Prescribing Antidepressants and Antipsychotics? There’s an App for That

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A web-based application to aid in selection of antidepressants and antipsychotics through ranked matching of adverse-effect profiles with patient preference and tolerance will facilitate evidence-based and personalized prescribing of these agents, according to the investigator-developers.

Lead author Toby Pillinger, MRCPsych, PhD, of the Institute of Psychiatry, Psychology, and Neuroscience at King’s College London, and principle investigator Robert McCutcheon, MRCPsych, PhD, of the Department of Psychiatry at the University of Oxford, and colleagues described the digital application in an award-winning poster presented at the 2023 summer meeting of the British Association of Psychopharmacology (BAP) in Manchester, United Kingdom,¹ and in a detailed report in the November issue of Lancet Psychiatry.²

“Helping an individual choose a medication that is right for them is absolutely crucial, and optimizing the balance of side effects is key to helping people stick with treatments that help their symptoms,” McCutcheon remarked in the announcement of the new web-based application issued by the University of Oxford Department of Psychiatry.³

Pillinger commented that the application can help achieve this outcome because it “allows patients and their doctors to easily establish which side effects the patient is most worried about, allowing both parties to quickly highlight which medication is likely to work best.”

To establish signature adverse-effect profiles for each agent, Pillinger and colleagues conducted an umbrella review of meta-analyses of trials assessing drugs with a common comparator, as well as a review of national and international guidelines and consensus statements. Pillinger and McCutcheon established the relative risks and magnitude of effects from the meta-analytic, ordinal, and imputed data.

“To our knowledge, a comprehensive synthesis of meta-analyses examining side effects of antidepressants and antipsychotics in the adult population has not been done,” Pillinger and colleagues wrote.

A second umbrella review was conducted on the efficacy of the agents, and results were incorporated into the application along with the adverse-effect data. Patient preferences and tolerance can be input onto sliding scales of relative concern with selected adverse effects. The agents are matched in order of preference, using the TOPSIS multicriteria decision analysis method.

“Meta-analytic data were complemented by imputed results that were based on ordinal ranking scores, providing a compromise between the superior accuracy of meta-analytic results and broader drug coverage guidelines,” Pillinger and colleagues reported.

The application, now available at https://www.psymatik.com for desktop and mobile platforms, is built on data from 68 meta-analyses of trials comprising more than 65,000 participants, in addition to a synthesis of ordinal data from 7 national and international guidelines. Selection can be made from 32 antipsychotics and 37 antidepressants, with the app computing up to 10,993 pairwise adverse-effect comparisons in a fraction of a second.

Pillinger and colleagues pointed out that most national guidelines, including those from the American Psychiatric Association, emphasize the importance of discussing adverse effects as part of antipsychotic and antidepressant prescription decisions. They claimed that the application “supports care delivery that is consistent with regulatory guidance for the treatment of schizophrenia and depression.”

Computing, But With Caveats

The investigators noted that the application does not address uses of these agents outside major depression and schizophrenia, and they described a range of limitations in addition to omissions inherent in meta-analyses. The application does not, for example, account for the influence of medication dose, polypharmacy, or lifestyle factors such as smoking.

“Pragmatically, we focused on side effects that accompany large proportions of antipsychotics and antidepressants, but in doing so, we did not gather data on rarer but serious side-effects such as neuroleptic malignant syndrome and the side-effects typically associated with clozapine,” Pillinger and colleagues related. “Additionally, by focusing on monotherapy, we were unable to comment on potential drug-drug interactions that might translate into synergistic or antagonistic adverse or efficacy effects.”

In an accompanying editorial,⁴ Laila Asmal, MD, MMed, of the Department of Psychiatry at Stellenbosch University, and Tamara Kredo, MD, MMed, of the Division of Clinical Pharmacology, Department of Medicine, at Stellenbosch University, welcomed the “no-cost and user-friendly platform” for its utility in transforming evidence into actionable information for both clinicians and patients.

“This shift from complex datasets to a comprehensible and intuitive tool is a commendable effort to bridge the gap between rigorous scientific findings and practical clinical decision making,” Asmal and Kredo indicated.

They also agreed with the limitations described by the investigators, however, and suggested that several other issues warrant examination. They pointed out, for example, that the absence of patient data on variables such as age, gender, and genetic factors limits the utility of the application in tailoring personalized treatment.

Although agreeing that the application is based upon best available evidence and does provide confidence intervals as part of its quality process, Asmal and Kredo questioned how much confidence a user should place in the guidance.

“The confidence we have in evidence is affected not only by precision, but also by the degree of consistency of results, the applicability of the findings to the health decision at hand, and the potential risk of publication bias,” they observed.

In balance, Asmal and Kredo shared that they consider the application a promising, user-friendly approach to enhance clinical decision-making, while cautioning that it should be considered as a guide “to be used in conjunction with clinical expertise and experience and alongside patient preferences and choices.”

Dr Bender reports on medical innovations and advances in practice and edits presentations for news and professional education publications. He previously taught and mentored pharmacy and medical students, and he provided and managed pharmacy care and drug information services.

References

1. Pillinger T, Howes OD, Correll CU, et al. Psymatik: a digital tool to facilitate personalized and evidence-based psychotropic prescribing. Poster B29. Presented at the 2023 Summer Meeting of the British Association for Psychopharmacology, Manchester, UK, July 23-26, 2023.

2. Pillinger T, Howes OD, Correll CU, et al. Antidepressant and antipsychotic side-effects and personalized prescribing: a systematic review and digital tool development. Lancet. 2023;10:860-876.

3. New tool to streamline prescribing of antidepressants. University of Oxford Department of Psychiatry. News release. September 27, 2023. Accessed October 15, 2023. https://www.psych.ox.ac.uk/news/new-tool-to-streamline-prescribing-of-antidepressants

4. Asmal L, Kredo T. Balancing complexity and accessibility with the Psymatik Treatment Optimizer. Lancet. 2023;10:821-823.