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Ethnic Differences in Dose and Levels of Clozapine: Exploring Need for Any Specific Monitoring Needs
- Stephen Jiwanmall, Nilamadhab Kar, Akua Obuobie, Tanay Maiti, Deborah Lester, Kerry Mclaughlin, Thomas Hanson
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- Journal:
- BJPsych Open / Volume 9 / Issue S1 / July 2023
- Published online by Cambridge University Press:
- 07 July 2023, p. S136
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Aims
Clinical research shows that compared to Caucasian patients, Asian patients appear to have a lower clozapine dose requirement for clinical efficacy. Hence, appropriate dose adjustment should be considered in Asian patients receiving maintenance clozapine therapy. Secondly, studies in the UK report that Asian patients with treatment-resistant schizophrenia were less likely to receive clozapine than Caucasian patients. The objectives of this study were to find out the ethnic difference in dose and levels of clozapine in ethnic minority patient (BME (Black and minority ethnic) populations and to explore if there is a need for any specific monitoring.
MethodsDemographic (age, gender, and ethnicity) and clinical variables (diagnosis, clozapine dose, plasma level of clozapine and nor-clozapine, smoking status, side effect profile, and physical comorbidities) were collected from the electronic patient records and analysed.
ResultsThe sample consisted of 66 (56.4%) Caucasians, 22 (18.8%) Asians, 21 (17.9%) African-Caribbean, and 8 (6.8%) mixed ethnicity patients. Their age range was 19-80, with an average of 46.9 ±11.9 years.
Among the ethnic groups, age, clozapine, nor-clozapine level and QTc were comparable, except for the dose of clozapine; Caucasian had the highest dose (414.8±140.0 mg), followed by African-Caribbean (373.8±163.7 mg), Asian (333.8±121.2 mg) and mixed (260.7±110.7 mg) (F3.68, p<0.05). The difference remained significant when all the BME groups were combined as well.
Side effects such as hypersalivation, drowsiness, blurred vision, polyuria, sore throat, headache, vomiting (none), dizziness, difficulty passing urine, urine incontinence, flu-like symptoms, nausea, were comparable among ethnic groups.
There was no difference in smoking among the groups. Considering comorbidities compared to BME, Caucasians had significantly lower rate of hypertension (27.1% vs 9.1%, p<0.01); diabetes (18.6% vs 4.5%, p<0.05), however dyslipidemia (5.1% vs 3.0%) was comparable.
In addition to the above, the dose of clozapine was positively correlated with clozapine and norclozapine levels (p<0.05). Clozapine and norclozapine levels correlated significantly (p<0.001). Age was negatively correlated with norclozapine assay (p<0.05) and positively with the number of cigarettes. It appears as the age increases, the number of cigarettes goes up, and norclozapine levels come down.
ConclusionThere are a few variations of clozapine prescribing in different ethnic groups. Although the Caucasians had higher doses, they had comparable blood levels. A higher proportion of BME patients on clozapine had hypertension and diabetes, emphasizing metabolic risk. Our study findings suggest clozapine monitoring should look into ethnicity related risk factors.
Remote Clinical Assessments and Management During COVID-19: Views of the Patients and Clinicians About the Future Preferences
- Nilamadhab Kar, Lai-Ting Cheung, Stephen Jiwanmall
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- Journal:
- BJPsych Open / Volume 8 / Issue S1 / June 2022
- Published online by Cambridge University Press:
- 20 June 2022, p. S130
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Aims
During the COVID-19 pandemic most clinical services changed to remote consultation and management to minimise virus transmission by direct contact. As the social distancing and restrictions have eased with greater control of the pandemic, the nature of consultations is going to change. At this juncture we intended to understand the perception and satisfaction of patients and clinicians on remote consultations and management during COVID-19 and to determine their preference about clinical engagement in the future.
MethodsThis was a trust-wide anonymous survey conducted through surveymonkey. It involved both patients and mental healthcare staff (MHS) and explored about the quality and satisfaction in remote consultations, option to patients, and use of remote consultations in future. Clinicians were sent the online link to complete, with a reminder two weeks later. The patients were explained during their appointments about the survey, those who agreed to participate and gave informed consent, their responses to the questions were recorded.
ResultsThe sample consisted of 78 patients and 107 MHS representing adult, old age, children and adolescent and intellectual disability subspecialties. Most (92.4%) participants had participated in remote consultations and understood the reason behind it. Around a third (32.7%) of MHS and 46.2% of patients felt strongly satisfied in remote consultations, and together with satisfaction these were 56.1% v 71.8% respectively (p < 0.05). The quality of the remote consultations were considered somewhat (11.2% v 23.1%) or a lot better (8.4% v 15.4%) by MHS and patients respectively (p < 0.05). Majority (82.7%) felt that an option should be given to patients for the type of consultation, face to face or remote. After the pandemic, the preference for psychiatric consultations were primarily face to face (30.3%), primarily remote (8.6%) and a mixture of the two (61.1%); there were no difference between patients and MHS. However while 71.4% doctors, 70.8% other clinicians (occupational therapists and psychologists) and 75.0% of clinical managers opted for mixture of face to face and remote, 26.9% of nurses opted for that. Background subspecialty, age group, ethnicity, experience of remote consultation with GP or hospital doctors, attendance or admission to general or psychiatric hospitals during pandemic, disabilities, or having COVID-19 did not influence the suggestion for the future consultation type.
ConclusionFollowing the pandemic, both clinicians and patients express a preference for a mixture of face to face and remote consultations; and an option regarding that should be given to the patients.
Changing Patient Profile in a Psychiatric Hospital During COVID Pandemic: A Comparison With Pre-COVID State
- Nilamadhab Kar, Stephen Amarjeet Jiwanmall
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- Journal:
- BJPsych Open / Volume 8 / Issue S1 / June 2022
- Published online by Cambridge University Press:
- 20 June 2022, p. S136
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- Article
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Aims
COVID-19 pandemic has a massively adverse mental health impact and people with pre-existing psychiatric illnesses are one of the most severely affected groups. We intended to study the changes in the patient profile in a psychiatric hospital during the COVID-19 pandemic, comparing it to the period just before the pandemic.
MethodsConsecutive patients (n = 210) admitted to psychiatric ward under one team during COVID-19 pandemic (February 2020 to January 2022) were compared with patients (n = 234) admitted in the immediate pre-pandemic period (January 2017 to January 2020). Demographic (age, gender, and ethnicity) and clinical variables (diagnosis, admission days, Mental Health Act status, risk to self and others) were collected from the electronic patient records and analysed.
ResultsDuring the pandemic monthly admission rates have gone up by 38.1% over the base rate of 6.32/month. There was no difference in the mean age at admission; or the proportion of patients aged 18–40 years or above in the pre-pandemic and pandemic groups. Similarly the gender composition of patients in the two periods was comparable. Proportion of patients from Asian background increased from 7.7% to 16.8% during pandemic period (p < 0.05). The number of hospital days decreased from 31.97 ± 45.8 days in the pre-pandemic period to 22.44 ± 25.1 days during pandemic (p < 0.05). Along with increased admission rates, it suggested a rapid flow of the admission and discharge during the pandemic. Considering diagnostic composition between pre-COVID-19 and COVID-19 periods, psychotic (27.8% v 26.7%) and mood disorders (18.8% v 23.3%) were the predominant; and substance related disorders (20.5% v 16.7%) were the most common comorbidities. Risk to self was associated with 84.3% admissions during the pandemic compared to 78.6% in the pre-pandemic period; however, risk to others was noted in 13.8% v 22.2% (p < 0.01) respectively. There was no difference in proportions getting admitted under Mental Health Act or being discharged with Community Treatment Order. Interestingly, proportions of patients getting discharged under the care of Home Treatment Team decreased from 31.1% pre-pandemic to 16.5% during pandemic period (p < 0.005).
ConclusionThere is an increase in admission rate and decrease in the number of admission days, suggestive of increased demand of clinical resources during pandemic. This could be reflective of the stressful situation and adverse impact on mental health in the pandemic period. As the impact on mental health is expected to continue, there is a need for greater resources both in community and inpatient psychiatric services.