Individuals with physical comorbidities and polypharmacy may be at higher risk of depression relapse, however, they are not included in the ‘high risk of relapse’ group for whom longer antidepressant treatment durations are recommended.

In individuals with comorbid depression and type 2 diabetes (T2DM), we aimed to investigate the association and interaction between depression relapse and (a) polypharmacy, (b) previous duration of antidepressant treatment.

This was a cohort study using primary care data from the UK Clinical Practice Research Datalink (CPRD) from years 2000 to 2018. We used Cox regression models with penalised B-splines to describe the association between restarting antidepressants and our two exposures.

We identified 48 001 individuals with comorbid depression and T2DM, who started and discontinued antidepressant treatment during follow-up. Within 1 year of antidepressant discontinuation, 35% of participants restarted treatment indicating depression relapse. As polypharmacy increased, the rate of restarting antidepressants increased until a maximum of 18 concurrent medications, where individuals were more than twice as likely to restart antidepressants (hazard ratio (HR) = 2.15, 95% CI 1.32–3.51). As the duration of previous antidepressant treatment increased, the rate of restarting antidepressants increased – individuals with a previous duration of ≥25 months were more than twice as likely to restart antidepressants than those who previously discontinued in <7 months (HR = 2.36, 95% CI 2.25–2.48). We found no interaction between polypharmacy and previous antidepressant duration.

Polypharmacy and longer durations of previous antidepressant treatment may be associated with depression relapse following the discontinuation of antidepressant treatment.

Clozapine is commonly associated with hematological side effects. However, little research is available on the impact of adding other psychotropic medication on inducing blood dyscrasias.

The aim of the study was to explore the impact of associating psychotropic medication to clozapine in producing hematological abnormalities.

Our study was a longitudinal, retrospective chart review of adult psychiatric patients receiving clozapine treatment at our clozapine consultation between January 2000 and September 2020.

Our sample consisted of 15 women (23.5%) and 49 men (76.5%), mean age was 41.34 ±9.32 years. Polypharmacy was found in 70.3% of the cases. Association of clozapine to other psychotropic agents was found in 67.2% of the cases. Most prescribed add-on medication was valproic acid in 27 cases, benzodiazepines in 21 cases, promethazine and hydroxyzine in 16 cases, lithium in 8 cases and haloperidol in 6 cases. We found blood dyscrasias in 21 patients (32.8%). Hematological abnormalities were as follow: 2 cases of agranulocytosis, 8 cases of neutropenia, 13 cases of thrombocytopenia, 5 cases of leukocytosis, 5 cases of eosinophilia and 3 cases of anemia. In our sample we did not find a significant association between psychotropic polypharmacy and blood dyscrasias.

Many psychiatric patients on clozapine require polypharmacy to better stabilize their condition. Such co prescriptions may carry the risk of inducing more side effects especially blood dyscrasias. In our study, we did not find a significant association between psychotropic medication added to clozapine and hematological abnormalities. But further research is warranted to better explore this association.

No significant relationships.

Polypharmacy can be the cause of deliberate discontinuation of medication and consequent relapse of schizophrenia.

To establish the one-year rate of relapse in the patients with schizophrenia with regard to monotherapy or polypharmacy.

The sample of all hospitalized patients with schizophrenia in a five-year period was analyzed. Descriptive statistics were used.

Total of 87 participants (57 women), the median age was 43 years. Antipsychotic monotherapy was used in 31 (35.6%) of the participants. In one year period, 32 (36.8%) of all participants had a relapse. Prior to relapse, significantly more participants were treated with polypharmacy (p<0,05).

Antipsychotic polypharmacy is related to a higher rate of relapse in patients with schizophrenia.

No significant relationships.

Iatrogenic factors, such as polypharmacy and prescription cascade, are some of the main causes of delirium in the elderly. We present a case of delirium of months of evolution that improved after applying a pharmacological de-prescription strategy.

To report a case and review the available literature on the concepts of prescription cascade and de-prescription in delirium in the elderly.

A 92-year-old woman with a history of cerebrovascular accidents and no psychiatric history or dementia was admitted to a psychogeriatric clinic due to disorientation, delusions of harm and gait apraxia. Several months earlier she had required admission to the general hospital for agitation. In view of the suspicion of delirium, an exhaustive examination and complementary tests were performed, including a neuropsychological assessment and a brain scan (Image 1).

The patient had previously received multiple high-dose psychotropic drugs (Gabapentin, trazodone, Zolpidem, Quetiapine), which had reduced the agitation but had not resolved the problem. Organic causes were treated in a multidisciplinary team (pressure ulcers), together with a gradual tapering of medication. Although underlying vascular dementia was diagnosed, the patient’s gait and cognitive status improved, with a significant impact on her autonomy and quality of life.

Despite an extensive literature on the subject, delirium in the elderly remains an under-diagnosed medical condition, especially the hypoactive subtype, just as cascade prescribing remains common. It is important to raise awareness among specialists in training to prevent and diagnose it.

No significant relationships.

Research on the effectiveness of pharmacotherapies for schizophrenia and comorbid substance use disorder (SUD) is very sparse, and non-existent on the prevention of the development of SUDs in patients with schizophrenia.

To compare the real-world effectiveness of antipsychotics in schizophrenia in decreasing risk of developing an initial SUD, and psychiatric hospital admission and SUD-related hospital admission among patients with an SUD.

Two independent national cohorts including all persons diagnosed with schizophrenia (N = 45 476) were followed up for 22 (Finland: 1996–2017) and 11 (Sweden: 2006–2016) years. Risk of developing an SUD was calculated with between-individual models, and risks of psychiatric and SUD-related hospital admission were calculated with within-individual models, using Cox regression and adjusted hazard ratios (aHRs) for using versus not using certain antipsychotics.

For patients with schizophrenia without an SUD, clozapine use (Finland: aHR 0.20, 95% CI 0.16–0.24, P < 0.001; Sweden: aHR 0.35, 95% CI 0.24–0.50, P < 0.001) was associated with lowest risk of developing an initial SUD in both countries. Antipsychotic polytherapy was associated with second lowest risk (aHR 0.54, 95% CI 0.44–0.66) in Sweden, and third lowest risk (aHR 0.47, 95% CI 0.42–0.53) in Finland. Risk of relapse (psychiatric hospital admission and SUD-related hospital admission) were lowest for clozapine, antipsychotic polytherapy and long-acting injectables in both countries. Results were consistent across both countries.

Clozapine and antipsychotic polytherapy are most strongly associated with reduced risk of developing SUDs among patients with schizophrenia, and with lower relapse rates among patients with both diagnoses.