Persisting low use of antipsychotics in the treatment of major depressive disorder with psychotic features. Patterns of pharmacological maintenance treatment in a community mental health services bipolar disorder cohort study (SIN-DEPRES). Impact of prior pharmacotherapy on remission of psychotic depression in a randomized controlled trial. Effectiveness of switching from antipsychotic polypharmacy to monotherapy. Response of psychotic depression subtypes to pharmacotherapy. Psychotic vs. nonpsychotic depression: comparison of treatment response. Antidepressant monotherapy compared with combinations of antidepressants in the treatment of resistant depressive patients: A randomized, open-label study Use of combinations of antipsychotics: McLean Hospital inpatients, 2002. Antipsychotic combination using low-dose antipsychotics is as efficacious and safe as, but cheaper, than optimal-dose monotherapy in the treatment of schizophrenia: a randomized, double-blind study Antipsychotic switching: results from a one-year prospective, observational study of patients with schizophrenia The efficacy of drugs and psychotherapy in the treatment of acute depressive episodes. Antipsychotic drugs versus cognitive behavioural therapy versus a combination of both in people with psychosis: a randomised controlled pilot and feasibility study Combining psychotherapy and antidepressants in the treatment of depression. The expert consensus guideline series. Optimizing pharmacologic treatment of psychotic disorders. Introduction: methods, commentary, and summary. Implementing Psychopharmacology Rounds in a Nursing Facility to Improve Antipsychotic Usage. Evaluation of the Individual Safe Correction of Antipsychotic Agent Polypharmacy in Japanese Patients with Chronic Schizophrenia: Validation of Safe Corrections for Antipsychotic Polypharmacy and the High-Dose Method Time to discontinuation of atypical versus typical antipsychotics in the naturalistic treatment of schizophrenia
OBJECTIVE Practice guidelines recommend the use of a combination of an antidepressant and an antipsychotic for the pharmacologic treatment of major depressive disorder with psychotic features ( MD-Psy ) . We assessed the extent to which the  pharmacotherapy  received by patients with MD-Psy under usual care conforms to these recommendations . METHOD We assessed the  pharmacotherapy  received under usual care conditions by 100 patients with MD-Psy prior to enrollment in STOP-PD ( Study of the Pharmacotherapy of Psychotic Depression ) , a 12-week r and omized , controlled trial comparing olanzapine plus sertraline to olanzapine plus placebo . Our assessment took place from January 2003 to May 2004 . The strength of antidepressant trials was rated using the Antidepressant Treatment History Form ( ATHF ) . The strength of antipsychotic trials or combinations of antidepressants and antipsychotics was rated using a modified version of the ATHF . We also determined whether the strength of antipsychotic or combination trials was associated with age , the duration of the current depressive episode , medical burden , cognitive status , or the severity of depressive or psychotic symptoms . RESULTS Most patients with MD-Psy were treated with antidepressants ( N = 82 , 82 % ) or antipsychotics ( N = 65 , 65 % ) . About half of the patients ( N = 48 , 48 % ) received therapeutic doses of an antidepressant ; 10 % ( N = 10 ) received an intermediate dose of an antipsychotic , and 6 % ( N = 6 ) received a high dose . Overall , only 5 % ( N = 5 ) received a combination of an adequate dose of an antidepressant and a high dose of an  antipsychotic .  The strength of both antipsychotic trials ( p = .021 ) and combination trials ( p = .039 ) was significantly associated only with a longer duration of the current depressive episode . CONCLUSIONS These findings show a persisting low use of  antipsychotics  in the treatment of MD-Psy . Given the high morbidity rates associated with MD-Psy , it is important to continue to educate clinicians regarding its identification and treatment . CLINICAL TRIALS REGISTRATION Clinical Trials.gov identifier NCT00056472 Maintenance therapy in bipolar disorder ( BD ) is usually required to prevent relapses and improve residual symptoms . Therefore , in this study , we describe patterns of pharmacological maintenance treatment and identify associated clinical features . This prospect i ve multicentre epidemiological study recruited a cohort of 739 consecutive out- patients with clinical ly stable BD . Clinical stability was assessed at baseline with the Clinical Global Impression scale for BD and depressive symptoms with the Hamilton Depression Rating Scale .  Psychotropic medications were classified and analysed according to their mechanism as well as use . Logistic regression models were used to examine the associations between pharmacological strategies and clinical features . Longer time since last episode [ odds ratio ( OR ) 1.002 , p < 0.0001 ] and family history of psychiatric disorders ( OR 1.911 , p = 0.028 ) were associated with lithium in monotherapy ;  manic polarity of the most recent episode ( OR 3.300 , p = 0.006 ) and longer duration of clinical stability ( OR 1.009 , p = 0.034 ) with antipsychotic in monotherapy ;  depressive polarity of the most recent episode ( OR 2.567 , p = 0.003 ) and bipolar II disorder diagnosis ( OR 2.278 , p = 0.008 ) with antidepressant combination ;  no ongoing psychiatric co-morbidity ( OR 0.230 , p = 0.004 ) with lithium and anticonvulsant ;  manic polarity of the most recent episode ( OR 3.774 , p < 0.0001 ) with lithium and antipsychotic ;  manic polarity of the most recent episode ( OR 2.907 , p = 0.028 ) with lithium , anticonvulsant and antipsychotic . The pharmacological patterns followed published recommendations , except for the excessive use of antidepressants . This study reveals clinical factors closely related to prescription patterns Having failed to respond to an adequate antidepressant treatment course predicts poorer treatment outcomes in patients with major depression . However , little is known about the impact of prior treatment on the outcome of  major depression with psychotic features ( MDpsy ) . We examined the effect of prior treatment history on the outcome of pharmacotherapy  of MDpsy in patients who participated in the STOPD-PD study , a r and omized , double-blind , clinical trial comparing a combination of olanzapine plus sertraline vs. olanzapine plus placebo . The strength of treatment courses received prior to r and omization was classified using a vali date d method . A hierarchy of outcomes was hypothesized based on treatments received prior to r and omization and r and omized treatment . A high remission rate was observed in subjects with a history of no prior treatment or inadequate treatment who were treated with a combination of olanzapine and sertraline .  A low remission rate was observed in subjects who had previously failed to respond to an antidepressant alone and who were treated with olanzapine monotherapy . A low remission rate was also observed in subjects who had previously failed to respond to a combination of an antipsychotic and an antidepressant . Similar to patients with major depression , these results emphasize the impact of prior pharmacotherapy on treatment outcomes in patients with MDpsy OBJECTIVE This r and omized trial addressed the risks and benefits of staying on antipsychotic polypharmacy or switching to monotherapy . METHOD Adult out patients with schizophrenia taking two antipsychotics ( 127 participants across 19 sites ) were r and omly assigned to stay on polypharmacy or switch to monotherapy by discontinuing one antipsychotic . The trial lasted 6 months , with a 6-month naturalistic follow-up . Kaplan-Meier and Cox regression analyses examined time to discontinuation of assigned antipsychotic treatment , and r and om regression models examined additional outcomes over time . RESULTS Patients assigned to switch to monotherapy had shorter times to all-cause treatment discontinuation than those assigned to stay on polypharmacy . By month 6 , 86 % ( N=48 ) of those assigned to stay on polypharmacy were still taking both medications , whereas 69 % ( N=40 ) of those assigned to switch to monotherapy were still taking the same medication . Most monotherapy discontinuations entailed returning to the original polypharmacy . The two groups did not differ with respect to psychiatric symptoms or hospitalizations . On average , the monotherapy group lost weight , whereas the polypharmacy group gained weight . CONCLUSIONS Discontinuing one of two antipsychotics was followed by treatment discontinuation more often and more quickly than when both antipsychotics were continued . However , two-thirds of participants successfully switched , the groups did not differ with respect to symptom control , and switching to monotherapy result ed in weight loss . These results support the reasonableness of prescribing guidelines encouraging trials of antipsychotic monotherapy for individuals receiving antipsychotic polypharmacy , with the caveat that patients should be free to return to polypharmacy if an adequate trial on antipsychotic monotherapy proves unsatisfactory Patients with psychotic depression respond well when treated with a combination of an antidepressant and antipsychotic medication . We previously reported that they will respond in a similar fashion when treated with amoxapine monotherapy . There are few prospect i ve studies on the pharmacologic treatment response of psychotic depression subtypes . We treated 37 in patients , 21 with mood congruent ( MC ) psychotic depression and 16 with mood incongruent ( MI ) psychotic depression , in a r and omized double-blind fashion with either the combination of amitriptyline and perphenazine or with amoxapine for 4 weeks . Depression and psychosis ratings improved in a similar manner in both the MC or MI patients irrespective of medication treatment group . Global response rates were similar in the MI patients and MC patients . The data suggest that classifying psychotic depression into MC versus MI subtypes may have limited acute prognostic value in pharmacotherapy response rates This retrospective study compared the treatment responses of 34 primary , unipolar depressives without psychotic features and 30 with psychotic features . Patients were diagnosed by Research Diagnostic Criteria and received trials of tricyclic antidepressants , antipsychotics , the combination of the two , electroconvulsive therapy , or placebo and psychotherapy . Only three of 18 psychotic patients vs. 17 of 23 nonpsychotic patients responded to antidepressants alone . Electroconvulsive therapy and the combination of antipsychotic and antidepressant medication gave better responses . These data suggest that major depressive disorder with psychotic features is best considered as a distinct subtype rather than a severe variant of major depression Abstract Objective . This r and omized , 6-week , open-label study compared efficacy of CAD and antidepressant monotherapies ( ADM ) that had been chosen according to clinical judgment of the attending psychiatrist . Methods . A total of 60 in patients ( intent-to-treat analysis ) with depressive disorder ( ≥ 1 unsuccessful antidepressant treatment ) were r and omly assigned to the interventions . The responders who completed the acute phase of study , were evaluated for relapse within 2 months of follow-up treatment . The primary outcome measure was change in the Montgomery – Åsberg Depression Rating Scale ( MADRS ) and response was defined as a ≥ 50 % reduction of MADRS score . Results . Mean changes in total MADRS score from baseline to week 6 for patients in both treatment modalities were not different ( ADM = 13.2 ± 8.6 points ; CAD = 14.5 ± 9.5 points ; P = 0.58 ) . The analysis of covariance performed for significantly higher value of imipramine equivalent dose in CAD group showed only a non-significant between-group difference for total MADRS change ( P = 0.17 ) . There were also no differences between groups in response rate ( ADM = 48 % ; CAD = 58 % ) and number of drop-outs in acute treatment as well as proportion of responders ’ relapses in the follow-up . Conclusion . Both treatment modalities produced clinical ly relevant reduction of depressive symptomatology in acute treatment of patients with resistant depression and their effect was comparable BACKGROUND The empirical use of combinations of antipsychotic agents appears to be increasing with little research support for the relative efficacy , safety or cost-effectiveness of this practice . Such treatment was evaluated in hospitalized psychiatric patients . METHODS Sample s of consecutive in patients treated with > or = 2 ( ' polytherapy ' ) vs 1 antipsychotic ( ' monotherapy ' )  were matched on age , sex , diagnosis and admission clinical ratings , and these groups were compared on total daily chlorpromazine-equivalent doses , days in hospital , and changes in clinical ratings between admission and discharge . RESULTS The study sample included 69 polytherapy and 115 well-matched monotherapy subjects . Despite matching for initial CGI and GAF ratings , polytherapy was associated with high PANSS subscale scores of positive symptoms among affective psychosis , and relatively greater PANSS subscale ratings of excitement-agitation among patients diagnosed with schizophrenia . Estimated clinical improvement during hospitalization was similar among poly- and monotherapy patients , but total daily CPZ-eq doses at discharge averaged twice-greater with polytherapy , and hospitalization lasted 1.5 times longer . CONCLUSIONS Antipsychotic polytherapy as well as the types of agents combined may reflect clinician responses to particular symptom patterns . The value of specific combinations of antipsychotic agents and their comparison with monotherapies requires specific , prospect i ve , r and omized and well-controlled trials that consider matching on clinical characteristics and truly comparable doses across regimens The use of antipsychotic combination has been increasing during the last decade . This study aim ed to compare the efficacy and safety of low-dose amisulpride plus low-dose sulpiride with full-dose amisulpride in the treatment of acute schizophrenia . In this 6-week , double-blind , fixed-dose study , patients were r and omized to antipsychotic combination ( 400 mg/day amisulpride plus 800 mg/day sulpiride , N=46 ) or monotherapy ( 800 mg/day amisulpride , N=46 ) groups . Efficacy measurements included the Positive and Negative Syndrome Scale ( PANSS ) and subscales , and other scales . Safety and quality of life were also assessed . Response was defined as a 30 % reduction in the PANSS total score . Both groups were similar in terms of the following : ( a ) clinical characteristics at baseline , ( b ) response rates , and ( c ) score changes in all psychopathology measures , quality of life , and all side-effect scales after 6 weeks of treatment . There were also no significant between-group differences in changes in other safety measurement . However , the combination strategy did reduce treatment costs . The current study suggests that an antipsychotic combination of low-dose antipsychotics is as efficacious and safe as , but cheaper than , optimal-dose monotherapy in the treatment of schizophrenia ABSTRACT Objective : The Health Outcomes of a Canadian Community Cohort ( HOCCC ) study is a 1-year prospect i ve observational study of out patients with schizophrenia or related psychotic disorders . The purpose of the study was to compare effectiveness of antipsychotic treatment as measured by 1-year treatment completion rates . Design and methods : Patients ( N = 929 ) were enrolled if in the course of usual clinical practice they switched to a second-generation antipsychotic ( SGA ) . Observational data were collected for up to 1 year . The primary analysis compared 1-year treatment-completion rates for the olanzapine cohort with the other SGA cohort ( quetiapine , risperidone , clozapine ) , using a chi-squared test . Results : Of 929 patients enrolled , 64.8 % ( 516/796 ) of evaluable patients completed 1 year of treatment . There was no statistically significant difference in the proportion of treatment completers between the olanzapine cohort ( 67.4 % , 256/380 ) and the other SGA cohort ( 62.5 % , 260/416 ) . Treatment-completion rates were risperidone 62.0 % ( 127/205 ) , quetiapine 63.7 % ( 123/193 ) and clozapine 55.6 % ( 10/18 ) . Antipsychotic polypharmacy was common . Patients treated with olanzapine or risperidone had significantly higher increases in BMI than quetiapine-treated patients . There were no major differences between olanzapine monotherapy and pooled other SGA monotherapy groups in status of extrapyramidal symptoms from baseline to endpoint . Conclusions : Olanzapine and other SGAs exhibited similar rates of 1-year treatment completion . Further study of medication combinations is needed , given their perceived clinical value , and the high frequency of antipsychotic polypharmacy in clinical practice . Limitations : As most patients received several psychotropics and power was reduced in monotherapy analyses , comparisons between cohorts must be interpreted cautiously . Comparisons between individual antipsychotics were post hoc and not powered a priori . Accuracy and completeness of adverse event information for drugs other than olanzapine is limited The efficacy of tricyclic antidepressants and various psychotherapies , in comparison with one another or in combination , has not been fully established in r and omized clinical trials . The authors present a r and omized controlled trial comparing the combination of amitriptyline and short-term interpersonal psychotherapy , either treatment alone , and nonscheduled supportive psychotherapy in ambulatory patients with acute depression . They found that pharmacotherapy and psychotherapy alone were equally efficacious and better than nonscheduled treatment . The combination treatment of  psychotherapy and pharmacotherapy was more effective than either treatment alone and delayed the onset of symptomatic failure Summary Background Little evidence is available for head-to-head comparisons of psychosocial interventions and pharmacological interventions in psychosis . We aim ed to establish whether a r and omised controlled trial of cognitive behavioural therapy ( CBT ) versus antipsychotic drugs versus a combination of both would be feasible in people with psychosis . Methods We did a single-site , single-blind pilot r and omised controlled trial in people with psychosis who used services in National Health Service trusts across Greater Manchester , UK . Eligible participants were aged 16 years or older ; met ICD-10 criteria for schizophrenia , schizoaffective disorder , or delusional disorder , or met the entry criteria for an early intervention for psychosis service ; were in contact with mental health services , under the care of a consultant psychiatrist ; scored at least 4 on delusions or hallucinations items , or at least 5 on suspiciousness , persecution , or gr and iosity items on the Positive and Negative Syndrome Scale ( PANSS ) ; had capacity to consent ; and were help-seeking . Participants were assigned ( 1:1:1 ) to antipsychotics , CBT , or antipsychotics plus CBT . R and omisation was done via a secure web-based r and omisation system ( Sealed Envelope ) , with r and omised permuted blocks of 4 and 6 , stratified by gender and first episode status . CBT incorporated up to 26 sessions over 6 months plus up to four booster sessions . Choice and dose of antipsychotic were at the discretion of the treating consultant . Participants were followed up for 1 year . The primary outcome was feasibility ( ie , data about recruitment , retention , and acceptability ) , and the primary efficacy outcome was the PANSS total score ( assessed at baseline , 6 , 12 , 24 , and 52 weeks ) . Non-neurological side-effects were assessed systemically with the Antipsychotic Non-neurological Side Effects Rating Scale . Primary analyses were done by intention to treat ; safety analyses were done on an as-treated basis . The study was prospect ively registered with IS RCT N , number IS RCT N06022197 . Findings Of 138 patients referred to the study , 75 were recruited and r and omly assigned—26 to CBT , 24 to antipsychotics , and 25 to antipsychotics plus CBT .  Attrition was low , and retention high , with only four withdrawals across all groups . 40 ( 78 % ) of 51 participants allocated to CBT attended six or more sessions . Of the 49 participants r and omised to antipsychotics , 11 ( 22 % ) were not prescribed a regular antipsychotic . Median duration of total antipsychotic treatment was 44·5 weeks ( IQR 26–51 ) . PANSS total score was significantly reduced in the combined intervention group compared with the CBT group ( –5·65 [ 95 % CI −10·37 to −0·93 ] ; p=0·019 ) . PANSS total scores did not differ significantly between the combined group and the antipsychotics group ( –4·52 [ 95 % CI −9·30 to 0·26 ] ; p=0·064 ) or between the antipsychotics and CBT groups ( –1·13 [ 95 % CI −5·81 to 3·55 ] ; p=0·637 ) . Significantly fewer side-effects , as measured with the Antipsychotic Non-neurological Side Effects Rating Scale , were noted in the CBT group than in the antipsychotics ( 3·22 [ 95 % CI 0·58 to 5·87 ] ; p=0·017 ) or antipsychotics plus CBT ( 3·99 [ 95 % CI 1·36 to 6·64 ] ; p=0·003 ) groups . Only one serious adverse event was thought to be related to the trial ( an overdose of three paracetamol tablets in the CBT group ) . Interpretation A head-to-head clinical trial of CBT versus antipsychotics versus the combination of the two is feasible and safe in people with first-episode psychosis . Funding National Institute for Health Research OBJECTIVE To compare the efficacy of antidepressants with that of antidepressants plus psychotherapy ( " combined therapy " ) in the treatment of depression . METHODS 6 month r and omised clinical trial of  antidepressants ( N=84 ) and  combined therapy ( N=83 ) in ambulatory patients with Major Depression and a 17-item HDRS baseline score of at least 14 points . The antidepressant protocol provides for three successive steps in case of intolerance or inefficacy : fluoxetine , amitriptyline and moclobemide . The combined therapy condition consists , in addition to pharmacotherapy , of 16 sessions of Short Psychodynamic Supportive Psychotherapy .  Efficacy is assessed using the 17-item HDRS , the CGI of Severity and of Improvement , the depression subscale of the SCL-90 , and the Quality of Life Depression Scale . The data analysis is conducted on three sample s : the intention-to-treat sample , the per protocol sample and the observed cases sample . RESULTS After r and omisation , 32 % of the patients refused the proposed pharmacotherapy while 13 % refused the proposed combined therapy . In 24 weeks , 40 % of the patients who started with the pharmacotherapy stopped medication ; 22 % of those receiving the combined therapy did so . The difference in success rates is statistically significant , favouring combined therapy , in 23 % , 31 % and 62 % of the patients after 8 , 16 and 24 weeks of treatment , respectively . At week 24 , the mean success rate is 40.7 % in the pharmacotherapy group and 59.2 % in the combined therapy group . CONCLUSION Patients found combined treatment significantly more acceptable , they were significantly less likely to drop out of combined therapy and , ultimately , significantly more likely to recover .  Combined therapy is preferable to pharmacotherapy in the treatment of ambulatory patients with major depression OBJECTIVES A growing number of atypical antipsychotics are available for clinicians to choose from in the treatment of psychotic disorders . However , a number of important questions concerning medication selection , dosing and dose equivalence , and the management of inadequate response , compliance problems , and relapse have not been adequately addressed by clinical trials . To aid clinical decision-making , a consensus survey of expert opinion on the pharmacologic treatment of psychotic disorders was undertaken to address questions not definitively answered in the research literature . METHOD Based on a literature review , a written survey was developed with 60 questions and 994 options . Approximately half of the options were scored using a modified version of the R AND 9-point scale for rating the appropriateness of medical decisions . For the other options , the experts were asked to write in answers ( e.g. , average doses ) or check a box to indicate their preferred answer . The survey was sent to 50 national experts on the pharmacologic treatment of psychotic disorders , 47 ( 94 % ) of whom completed it . In analyzing the responses to items rated on the 9-point scale , consensus on each option was defined as a non r and om distribution of scores by chi-square " goodness-of-fit"test . We assigned a categorical rank ( first line/preferred choice , second line/alternate choice , third line/usually inappropriate ) to each option based on the 95 % confidence interval around the mean rating . Guideline tables indicating preferred treatment strategies were then developed for key clinical situations . RESULTS The expert panel reached consensus on 88 % of the options rated on the 9-point scale . The experts overwhelmingly endorsed the atypical antipsychotics for the treatment of psychotic disorders . Risperidone was the top choice for first-episode and multi-episode patients , with the other newer atypicals rated first line or high second line depending on the clinical situation . Clozapine and a long-acting injectable atypical ( when available)were other high second line options for multi-episode patients . The expert 's dosing recommendations agreed closely with the package inserts for the drugs , and their estimates of dose equivalence among the antipsychotics followed a linear pattern . The experts considered 3 - 6 weeks an adequate antipsychotic trial , but would wait a little longer ( 4 - 10 weeks ) before making a major change in treatment regimen if there is a partial response . The experts recommended trying to improve response by increasing the dose of atypical and depot antipsychotics before switching to a different agent ; there was less agreement about increasing the dose of conventional antipsychotics before switching , probably because of concern about side effects at higher doses . If it is decided to switch because of inadequate response , risperidone was the expert 's first choice to switch to , no matter what drug was initially tried . Although there was some disparity in the expert 's recommendations concerning how many agents to try before switching to clozapine , the expert 's responses suggest that switching to clozapine should be Clozapine was also the antipsychotic of choice for patients with suicidal behavior . When switching oral antipsychotics , the experts considered cross-titration the preferred strategy . When switching to an injectable antipsychotic , the experts stressed the importance of continuing the oral antipsychotic until therapeutic levels of the injectable agent are achieved . The experts considered psychosocial interventions the first choice strategy for partially compliant patients , with pharmacologic interventions the first choice for patients with clear evidence of noncompliance . However , because it can be difficult to distinguish partially compliant from noncompliant patients , the editors recommended combining psychosocial and pharmacologic interventions to improve compliance whenever possible . When patients relapse because of compliance problems or if there is any doubt about compliance , the experts recommended the use of a long-acting injectable antipsychotic and would select an injectable atypical when this option becomes available . The experts would also consider using an injectable atypical antipsychotic ( when available ) in many clinical situations that do not involve compliance problems . The experts stressed the importance of monitoring for health problems-especially obesity , diabetes , cardiovascular problems , HIV risk behaviors , medical complications of substance abuse , heavy smoking and its effects , hypertension , and amenorrhea-in patients being treated with antipsychotics . Although many patients are prescribed adjunctive treatments , multiple antipsychotics , and combinations of different classes of drugs ( e.g. , antipsychotics plus mood stabilizers or antidepressants ) in an effort to enhance response , the experts gave little support to any of these strategies , with the exception of antidepressants for patients with  dysphoria/depression  , antidepressants or ECT for patients with suicidal behavior , and mood stabilizers for patients with aggression/violence . When asked about indicators of remission and recovery , the experts considered acute improvement in psychotic symptoms the most important indicator of remission , whereas they considered more sustained improvement in multiple outcome domains ( e.g. , occupational/educational functioning , peer relationships , independent living ) important in assessing recovery . CONCLUSIONS The experts reached a high level of consensus on many of the key treatment questions in the survey . Within the limits of expert opinion and with the expectation that future research data will take precedence , these guidelines provide direction for addressing common clinical dilemmas that arise in the pharmacologic treatment of psychotic disorders . They can be used to inform clinicians and educate patients regarding the relative merits of a variety of interventions . Clinicians should keep in mind that no guidelines can address the complexities involved in the care of each individual patient and that sound clinical judgment based on clinical experience should be used in applying these recommendations OBJECTIVES Evaluate whether implementing of pharmacy-led psychopharmacology rounds in a nursing facility will improve the rate of antipsychotic use . DESIGN Single-center , prospect i ve ; medication use evaluation ( MUE ) . SETTING Rutl and Nursing Home , Brooklyn , New York . PARTICIPANTS Nursing facility residents , excluding the pediatric unit . INTERVENTIONS Weekly interdisciplinary psychopharmacology rounds that include : clinical pharmacists , nurse managers , medical director , social workers , and administration . Antipsychotics were analyzed for all residents for appropriateness of use , proper documentation , and adequate monitoring . MAIN OUTCOME MEASURE Assess the overall rate of reduction of antipsychotic use after implementation of psychopharmacology rounds . Secondary outcomes assessed improvements in monitoring and documentation for residents on antipsychotics . RESULTS A total of 81 residents were evaluated over the six-month MUE . Of those residents , 20 had their antipsychotics discontinued , and 11 had their antipsychotics tapered . The overall use of antipsychotics decreased from 14.6 % ( 62/422 ) to 12.2 % ( 50/411 ) ( P = 0.285 ) . Compliance with indications generally approved by the Centers for Medicare & Medicaid Services improved from 65 % ( 37/57 ) to 85 % ( 46/54 ) ( P = 0.008 ) . Matching indications on the psychiatry consult and the medication order improved from 58 % ( 33/57 ) to 80 % ( 43/54 ) ( P = 0.015 ) . Metabolic laboratory monitoring improved from 58 % ( 33/57 ) to 83 % ( 45/54 ) ( P = 0.003 ) . Improvements in timeliness of psychiatry and ophthalmology consults were not statistically significant . CONCLUSION Implementing interdisciplinary psycho-pharmacology rounds in a nursing facility result ed in a reduction of inappropriate antipsychotic use and improved monitoring and documentation Background : Polypharmacy for schizophrenia treatment is not justified by the available clinical evidence . We evaluated a treatment reduction approach that reduces the dose and number of antipsychotic medications simultaneously prescribed to patients . Methods : In a r and omized open study of the Safe Correction of Antipsychotic Polypharmacy and High-Dose Prescriptions program funded by the Japanese Ministry of Health , Labour , and Welfare , we evaluated a drug reduction method consisting of a  dose reduction intervention performed on 163 patients with schizophrenia for twelve or 24 weeks . One antipsychotic medication was removed each week from each patient ’s treatment regimen by reducing the dose by 0 to 50 chlorpromazine equivalents .  Data on health-related indices of quality of life , clinical symptoms , and risk of side effects were analyzed using a two-way repeated- measures mixed linear model . Results : Despite a 23 % reduction in antipsychotic dose , no differences in outcomes were observed between the dose reduction and observation groups ( effect size = 0.001 – 0.085 , P = .24–.97 ) , despite high statistical power ( 1-β = 0.48–0.97 ) . The findings are limited by the nonuniformity of the participants ’ treatment history , duration , and dose reduction amount . Dose reduction protocol patients exhibited no difference in psychotic symptoms or adverse events compared with the observation group . Conclusions : Importantly , the low dropout rate in our study ( 6.9 % of participants withdrew because of patient factors and 23.8 % for all secondary reasons ) indicates that our “ slowly ” method is well tolerated . We hope that this approach will result in therapeutic improvements Background There is an ongoing debate over whether atypical antipsychotics are more effective than typical antipsychotics in the treatment of schizophrenia . This naturalistic study compares atypical and typical antipsychotics on time to all-cause medication discontinuation , a recognized index of medication effectiveness in the treatment of schizophrenia . Methods We used data from a large , 3-year , observational , non-r and omized , multisite study of schizophrenia , conducted in the U.S. between 7/1997 and 9/2003 . Patients who were initiated on oral atypical antipsychotics ( clozapine , olanzapine , risperidone , quetiapine , or ziprasidone ) or oral typical antipsychotics ( low , medium , or high potency ) were compared on time to all-cause medication discontinuation for 1 year following initiation . Treatment group comparisons were based on treatment episodes using 3 statistical approaches ( Kaplan-Meier survival analysis , Cox Proportional Hazards regression model , and propensity score-adjusted bootstrap resampling methods ) . To further assess the robustness of the findings , sensitivity analyses were performed , including the use of ( a ) only 1 medication episode for each patient , the one with which the patient was treated first , and ( b ) all medication episodes , including those simultaneously initiated on more than 1 antipsychotic . Results Mean time to all-cause medication discontinuation was longer on atypical ( N = 1132 , 256.3 days ) compared to typical antipsychotics ( N = 534 , 197.2 days ; p < .01 ) , and longer on atypicals compared to typicals of high potency ( N = 320 , 187.5 days ; p < .01 ) , medium potency ( N = 140 , 213.5 days ; p < .01 ) , and low potency ( N = 74 , 208.7 days ; p < .01 ) . Among the atypicals , only clozapine , olanzapine , and risperidone had significantly longer time to all-cause medication discontinuation compared to typicals , regardless of potency level , and compared to haloperidol with prophylactic anticholinergic treatment . When compared to perphenazine , a medium-potency typical antipsychotic , only clozapine and olanzapine had a consistently and significantly longer time to all-cause medication discontinuation . Results were confirmed by sensitivity analyses . Conclusion In the usual care of schizophrenia patients , time to medication discontinuation for any cause appears significantly longer for atypical than typical antipsychotics regardless of the typical antipsychotic potency level . Findings were primarily driven by clozapine and olanzapine , and to a lesser extent by risperidone . Furthermore , only clozapine and olanzapine therapy showed consistently and significantly longer treatment duration compared to perphenazine , a medium-potency typical antipsychotic
Some evidence indicates that combination therapy with an antidepressant plus an antipsychotic is more effective than either treatment alone or placebo .
Evidence is limited for treatment with an antidepressant alone or with an antipsychotic alone
BACKGROUND Evidence is limited regarding the most effective pharmacological treatment for psychotic depression :  combination of an antidepressant plus an antipsychotic , monotherapy with an antidepressant or monotherapy with an antipsychotic .
This is an up date of a review first published in 2005 and last up date d in 2009 .
OBJECTIVES 1 .
To compare the clinical efficacy of pharmacological treatments for patients with an acute psychotic depression :  antidepressant monotherapy , antipsychotic monotherapy and the combination of an antidepressant plus an antipsychotic , compared with each other and /or with placebo.2 .
To assess whether differences in response to treatment in the current episode are related to non-response to prior treatment .