Schizophrenia in older adults

Abhilash K. Desai, MD, FAPA, Associate professor, Director Center for Healthy Brain Aging, Department of neurology and psychiatry, Division of geriatric psychiatry, Associate professor, Department of internal medicine, Division of geriatric medicine, St. Louis University School of Medicine, St. Louis, MO

Mehrzad Seraji, MD, Fellow, Department of neurology and psychiatry, Division of geriatric psychiatry, St. Louis University School of Medicine, St. Louis, MO

Maurice Redden, MD, Instructor, Department of neurology and psychiatry, Division of geriatric psychiatry, St. Louis University School of Medicine, St. Louis, MO

Ramasubba Tatini, MD, Private practice, St. Louis, MO

The number of older adults (age ≥65) who developed schizophrenia before age 45 is expected to double in the next 2 decades; the 1-year prevalence of schizophrenia among older adults is approximately 0.6%. This article reviews how positive, negative, and cognitive symptoms and social functioning change over decades and discusses strategies for reducing the impact of long-term antipsychotic use on neurologic and physical health. Although some patients experience schizophrenia onset later in life, in this article we focus on older adults who developed the illness before age 45.

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New algorithm for pediatric bipolar mania

Robert A. Kowatch, MD, PhD, Professor of psychiatry and pediatrics, Director of psychiatry research, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH

Jeffrey R. Strawn, MD, Clinical fellow, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH

Michael T. Sorter, MD, Associate professor of psychiatry and pediatrics, Director, division of psychiatry, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH

Five recent randomized controlled trials (RCTs) have demonstrated the efficacy of atypical antipsychotics for treating bipolar disorder in children and adolescents, but 4 of these 5 trials remain unpublished. The lag time between the completion of these trials and publication of their results—typically 4 to 5 years—leaves psychiatrists without important evidence to explain to families and critics why they might recommend using these powerful medications in children with mental illness.

This article previews the preliminary results of these 5 RCTs of atypical antipsychotics, offers a treatment algorithm supported by this evidence, and discusses how to manage potentially serious risks when using antipsychotics to treat children and adolescents with bipolar disorder (BPD).

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Worried about high-dose prescribing? Manage risk for you and your patient

Neil S. Kaye, MD, DFAPA
Assistant clinical professor of psychiatry and human behavior, Assistant clinical professor of family medicine, Jefferson Medical College, Philadelphia, PA

Jacqueline M. Melonas, RN, MS, JD
Vice president, risk management, Professional Risk Management Services, Inc., Arlington, VA

Mr. B, age 35, is admitted for the fourth time to the inpatient service with hallucinations and delusions related to chronic schizophrenia. After appropriate attempts to control his symptoms, he has begun to respond to usual treatment with an atypical antipsychotic. He remains a “partial responder,” however, at the maximum FDA-approved dosage listed in the package insert (PI). What do you do next?

Because of this author’s (NSK) dual training in medicine and forensic psychiatry, other clinicians often ask me about patients such as Mr. B. Prescribing for patients who do not respond to standard dosages can create anxiety about going “off-label.” This article describes how to manage potential risk to yourself and your patient by communicating effectively and documenting informed consent.

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When clozapine is not enough: Augment with lamotrigine?

Stabilizing glutamate transmission may benefit some patients with treatment-resistant schizophrenia.

John A. Gray, MD, PhD
Resident, department of psychiatry, postdoctoral fellow, department of cellular and molecular pharmacology, University of California, San Francisco

Samuel C. Risch, MD
Professor, department of psychiatry, University of California, San Francisco

Current antipsychotics are reasonably effective in treating positive symptoms, but they do less to improve the negative and cognitive symptoms that contribute to patients’ long-term poor functional capacity and quality of life. So what do psychiatrists do in clinical practice to mitigate antipsychotics’ limitations? We augment.

Schizophrenia patients routinely are treated with polypharmacy—often with antidepressants or anticonvulsants—in attempts to improve negative symptoms, aggression, and impulsivity. Most adjuncts, however—including divalproex, antidepressants, and lithium—have shown very small, inconsistent, or no effects. The only agent with a recent meta-analysis supporting its use as augmentation in treatment-resistant schizophrenia is lamotrigine, an anticonvulsant approved for use in epilepsy.

This article examines the evidence supporting off-label use of lamotrigine as an augmenting agent in schizophrenia and explains the rationale, based on lamotrigine’s probable mechanism of action as a stabilizer of glutamate neurotransmission.

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