Subjective response to antipsychotic drugs

Initial response to active drug and placebo predicts outcome of antidepressant treatment

In this study we tested whether initial clinical change (ICC) and initial subjective response (ISR) predict the outcome of antidepressant pharmacotherapy and whether ICC and ISR as predictors reflect specific pharmacological actions or a placebo effect. Forty patients with major depression were treated with three different antidepressants for 4 weeks. Overall clinical change and final subjective response were taken as outcome criteria. The patients were randomly assigned to two subgroups in a double-blind design. Initially, one group received the active drug and the other placebo. Afterwards, all patients were given the active drug. Significant correlations were found between ICC and ISR and at least one of the outcome criteria in the total sample and in each subgroup. The findings show that ICC and ISR may be significant predictors of outcome. The predictive value of ICC and ISR is not due to initial pharmacological effects, but to non-specific treatment factors.

Subjective response to antipsychotics in bipolar disorders: A review of a neglected area

Background:

The term “subjective response to antipsychotic” (SRA) refers to changes in the subjective state experienced due to antipsychotic (AP) exposition that is independent of the therapeutic or physical side effects of these drugs. This dimension of analysis has been extensively explored in schizophrenic disorders, finding that negative SRA is an early and independent predictor of compliance as well as a successful pathway to construct current theoretical frameworks of these disorders. There is an increasing use of AP in bipolar disorders’ treatment (BD) but no reviews on the topic have been published to date in this population. The aim of this work is to review published data of SRA in BD patients and to discuss their clinical and theoretical implications.

Methods:

An extensive search in online databases was performed. Reports were reviewed and included if they described SRA in BD or included instruments aimed to assess it. Reports of cognitive, sexual, motor autonomic side effects were excluded. Findings were summarized in a narrative fashion.

Results:

Nine reports fulfilled the inclusion criteria and were included in the revision, reporting data from 1282 BD patients. Among these, three were prospective studies and three explored relations between SRA and treatment compliance.

Conclusions:

There is an asymmetry between the increase in the use of antipsychotics in BD and the lack of data regarding the SRA. Phenomenologically, SRA in BD is similar to that found in schizophrenic subjects. Some of these symptoms may be misdiagnosed as depressive symptoms. The existing data show that SRA has a strong correlation with treatment compliance as well as a promising way to develop theoretical paradigms for these disorders.

Revisiting the Concept of Subjective Tolerability to Antipsychotic Medications in Schizophrenia and its Clinical and Research Implications: 30 Years Later

Schizophrenia is a long-term psychiatric disorder that impacts important mental functions and requires indefinite treatment, as well as psychosocial and economic support. The introduction of chlorpromazine, the first antipsychotic, and the subsequent development of a long list of similar dopamine-blocking antipsychotic medications, has changed the treatment of schizophrenia as medications have become the cornerstone of clinical management. The enthusiasm that greeted the introduction of antipsychotics was soon tempered by the realisation that they induced significant side effects, such as extrapyramidal and autonomic symptoms. A less-recognized side effect at the time was the emergence of subtle subjective side effects that led patients to dislike medications and eventually discontinue them, with serious consequences of frequent relapses requiring hospitalization, poor outcomes and more health costs. The development of our dedicated programme for research into subjective tolerability to medications over the past 30 years has allowed us to establish the validity of the construct of 'subjective tolerability' to antipsychotics, applying research methodologies that are required for any scientific inquiry. We clarified definitions, developed reliable measuring tools, and constructed psychosocial and neurobiological conceptual models. We also documented the serious consequences of negative subjective tolerability to antipsychotics: poor medication adherence behaviour, impaired quality of life, and worse clinical and functional outcomes. More recently, using neuroimaging techniques, we and other international research groups were able to clearly elucidate the neurobiology of dysphoric negative subjective responses, linking it to low dopamine functioning in the striatal region of the brain. Such a discovery for the first time allowed us to also link the development of comorbid drug abuse in schizophrenia, which is a common occurrence, to the development of neuroleptic dysphoria, since both relate to the low dopamine function in the striatum. As an already validated scientific concept that has serious consequences, subjective tolerability to antipsychotics can serve as a model for patient-centered outcomes that really matter. Our long-serving research programme also illustrates the value of clinical observations to the development of important clinical research studies, i.e. from the bedside to the research bench, and back to the bedside.

[Subjective evaluation of the effect of single test doses of phenazepam and placebo in patients with anxiety disorders: a relationship with objective pharmaco-electroencephalography characteristics]

AIM

To study the relationship between subjective evaluation (SE) of the effect of single test doses of benzodiazepine anxiolytic phenazepam and placebo and objective electroencephalography (EEG) characteristics in patients with anxiety disorders.

MATERIAL AND METHODS

Forty patients, including 13 with generalized anxiety disorders (GAD, ICD-10 F41.1), 13 with anxiety-phobic disorders (AFD, ICD-10 F40.0) and 14 with anxiety-hypochondriac disorders (AHD, ICD-10 F45.2), were enrolled. The method of subjective evaluation of the effect of psychotropic drugs and EEG recording during wakeful rest and 2 hours after taking test doses of phenazepam (1 mg) and placebo were performed.

RESULTS AND CONCLUSION

A trend towards the higher SE indices (tolerability and a wish to continue treatment with the drug) of the test dose of phenazepam in patients with GAD, its decrease in AFD and AHD, no differences in SE indices of placebo between different psychopathological patterns of disorders were identified. The changes in EEG specific for benzodiazepines were revealed in patients treated with phenazepam. Insignificant changes in the beta rhythm after taking placebo were found. Correlations between subjective assessments of the effect of test doses of phenazepam and placebo and EEG were observed. The results suggest that subjective assessments of the effect of anxiolytic drugs and objective indices of anxiolytic drug action are interrelated.

Risperidone versus olanzapine among patients with schizophrenia participating in supported employment: Eighteen-month outcomes

This study compares the efficacy and tolerability of olanzapine versus risperidone among patients with schizophrenia who are established in outpatient psychiatric care and entering supported employment. A multicenter, randomized, double-blind trial was conducted among 107 outpatients with schizophrenia, who were cross-titrated to flexible dose risperidone or olanzapine over 2 weeks. Clinical endpoints included time to hospitalization and persistence on assigned medication. Weight, laboratory tests, psychopathology, neurologic side effects, social adjustment and role functioning were assessed at 3-6 month intervals. Data were analyzed first by randomized treatment, and then reassessed controlling for prior medication treatment. The proportion of patients on assigned medication at 18 months was 30.9% for risperidone and 37.3% for olanzapine. Mean doses were 6.4 ± 3.2 mg daily for risperidone, and 17.0 ± 5.0 mg daily for olanzapine. The groups did not differ significantly in time to medication discontinuation, first hospitalization or first employment. There were few differences in psychopathology, laboratory, or neurological assessments between groups at 18 months. Patients randomized to olanzapine gained modestly more weight. Controlling for pre-randomization medication suggested improvement in some aspects of psychopathology from switching medications; however, switching from olanzapine to risperidone was associated with more hospitalizations. Risperidone and olanzapine have similar efficacy and tolerability in patients with schizophrenia who are participating in supported employment. Randomization to olanzapine was associated with more weight gain, but randomization from olanzapine to risperidone appeared to be associated with a greater likelihood of hospitalization. Careful monitoring of metabolic effects and participation in supported employment may have contributed to minimal weight gain and metabolic effects.

The effect of the medicine administration route on health-related quality of life: Results from a time trade-off survey in patients with bipolar disorder or schizophrenia in 2 Nordic countries

BACKGROUND

Agitation episodes are common among patients with schizophrenia or bipolar disorder. Oral and intramuscular administration methods are commonly used in pharmacological treatment of acute agitation. Recently, an innovative inhalation product with loxapine(Adasuve®)has become available for treatment of acute agitation episodes associated with bipolar disorder or schizophrenia. The objective for the present study was to investigate the impact of the pharmacological treatment's administration methods on the health-related quality of life (HRQoL) in patients with bipolar disorder or schizophrenia in Denmark and Sweden using a time trade-off (TTO) approach.

METHODS

The TTO methodology was used to examine the HRQoL impact of administration method of pharmacological treatment of acute agitation. Data were collected via an internet-based survey, using an existing panel of respondents with schizophrenia or bipolar disorder.

RESULTS

Respondents considered living with schizophrenia/ bipolar disorder, having one yearly agitation episode treated with inhaler better than living with the same conditions and receiving treatment with tablet or injection. The utility value was 0.762 for inhalable treatment, 0.707 for injection and 0.734 for tablet treatment.

CONCLUSIONS

Patients' preference for treatment delivery options showed that inhalation was associated with a significant utility gain when compared to injection or tablets. Inhalable loxapine may be a new tool for control of agitation episodes for strengthening the patient provider alliance when taking patient's preference for delivery method into consideration.

Behavioral and emotional adverse events of drugs frequently used in the treatment of bipolar disorders: clinical and theoretical implications

BACKGROUND

Behavioral and emotional adverse events induced by drugs commonly prescribed to patients with bipolar disorders are of paramount importance to clinical practice and research. However, no reviews on the topic have been published so far.

METHODS

An extensive search was performed. Reports were reviewed if they described behavioral side effects related to pharmacological treatments for bipolar disorders in healthy subjects or patients with different neuropsychiatric disorders. For this review, lithium, antipsychotics, anticonvulsants and selective serotonin reuptake inhibitors were included.

RESULTS

Apathy or emotional blunting, diminished sexual desire, and inability to cry were reported to be associated with exposure to selective serotonin reuptake inhibitors. Neuroleptic-induced deficit syndrome/emotional detachment and obsessive-compulsive symptomatology and decision-making modifications. A lithium-related amotivational syndrome was also reported in the literature. Furthermore, hypersexuality and obsessive-compulsive symptoms have been noted in subjects treated with lamotrigine.

LIMITATIONS

Primary studies on drug-related adverse events are scant so far and most of the data currently available derive from case reports. Moreover, most of the evidence reviewed is based on studies performed on healthy subjects and patients with neuropsychiatric conditions other than bipolar disorders.

DISCUSSION

There is a remarkable dearth of data on behavioral adverse events of pharmacological treatment for bipolar disorders. However, the pieces of evidence available at present, though scant and scattered, suggest that different behavioral adverse events may be related to pharmacological treatment for these disorders. The implications of these findings for research and management of patients with mood disorders are discussed.

Development of the My Medicines and Me (M3Q) side effect questionnaire for mental health patients: a qualitative study

OBJECTIVE

The objective of this study was to assess the acceptability, content validity and usability of the My Medicines and Me (M3Q) self-report side effect questionnaire.

METHODS

Eight focus groups consisting of mental health patients, carers, general practitioners, psychiatrists, mental health nurses and pharmacists were conducted, involving 78 participants. Two researchers independently examined the transcriptions and analysed the data thematically using an inductive method.

RESULTS

The findings supported changes to the formatting, length and phrasing of questions in the original version of the questionnaire. Although the groups provided differing views on the usability of the M3Q in clinical practice, the patient and carer groups were unconditionally in favour of such a tool to be used systematically to describe patients' subjective experiences with side effects.

CONCLUSION

The differing contribution made by all groups involved in the administration and completion of the M3Q assisted with content validity of the questionnaire. The acceptability and usability of this novel side effect questionnaire was also explored, with many participants agreeing it was a necessary tool for a patient centred approach to treatment. Following implementation of the changes to the current format of the questionnaire, investigation into the uptake and use in clinical practice should be carried out.

Antipsychotic medication-induced dysphoria: its meaning, association with typical vs. atypical medications and impact on adherence

Antipsychotic medication-induced dysphoria is a relatively under-recognized and understudied effect of antipsychotic medication. Although the term is encountered in clinical practice and in the literature, there is no consensus regarding its exact meaning. This article is a narrative review of the literature on antipsychotic medication and dysphoria based on a pubmed database search. We found that antipsychotic medication-induced dysphoria is a term used to describe a negative and unpleasant affective state which seems to be more often associated with high potency first-generation antipsychotics and could potentially lead to medication non-adherence. Though it is plausible to expect antipsychotic medication-induced dysphoria to be related to extrapyramidal symptoms, most especially akathisia, the nature of the association remains unspecified. Furthermore, there is some evidence that dopamine blockade maybe involved in the pathogenesis of antipsychotic medication-induced dysphoria. However, the limited methods of the currently available studies make it impossible to conclusively address the question of which class of antipsychotic (first- or second-generation) has a higher prevalence and severity of the syndrome.

Revisiting the 'self-medication' hypothesis in light of the new data linking low striatal dopamine to comorbid addictive behavior

Persons with schizophrenia are at a high risk, almost 4.6 times more likely, of having drug abuse problems than persons without psychiatric illness. Among the influential proposals to explain such a high comorbidity rate, the 'self-medication hypothesis' proposed that persons with schizophrenia take to drugs in an effort to cope with the illness and medication side effects. In support of the self-medication hypothesis, data from our earlier clinical study confirmed the strong association between neuroleptic dysphoria and negative subjective responses and comorbid drug abuse. Though dopamine has been consistently suspected as one of the major culprits for the development of neuroleptic dysphoria, it is only recently our neuroimaging studies correlated the emergence of neuroleptic dysphoria to the low level of striatal dopamine functioning. Similarly, more evidence has recently emerged linking low striatal dopamine with the development of vulnerability for drug addictive states in schizophrenia. The convergence of evidence from both the dysphoria and comorbidity research, implicating the role of low striatal dopamine in both conditions, has led us to propose that the person with schizophrenia who develops dysphoria and comorbid addictive disorder is likely to be one and the same.

Critical involvement of 5-HT2C receptor function in amphetamine-induced 50-kHz ultrasonic vocalizations in rats

RATIONALE

Rats emit various distinct types of ultrasonic vocalizations (USV), with high-frequency 50-kHz USV typically occurring in appetitive situations being elicited by administering drugs of abuse, most notably amphetamine (AMPH), possibly reflecting drug wanting/craving and/or liking.

OBJECTIVES

Because 50-kHz USV emission is, at least in part, dopamine (DA) dependent and 5-HT2C agonists inhibit DA neurotransmission, we hypothesized that AMPH-induced 50-kHz USV can be attenuated by pretreatment with a 5-HT2C agonist.

METHODS

In experiments I and II, a dose-response curve for AMPH-induced 50-kHz USV was established, and the partial dependency of AMPH-induced 50-kHz USV on DA neurotransmission was validated by pretreatment with the D2-antagonist eticlopride. In experiment III, rats were pretreated with the 5-HT2C agonist CP 809,101 (0.0, 0.3, 1.0, 3.0, and 10 mg/kg), while in experiment IV, CP 809,101 (3.0 mg/kg), the 5-HT2C antagonist SB 242084 (1.0 mg/kg), or the combination of the two, was applied before AMPH administration (2.0 mg/kg). Finally, in experiment V, rats were treated with SB 242084 (0.0, 0.1, 0.3, and 1.0 mg/kg) only, i.e., in absence of AMPH.

RESULTS

The 5-HT2C agonist CP 809,101 dose-dependently blocked AMPH-induced 50-kHz USV, most notably trills, a call subtype that is considered to exclusively reflect a positive affective state, while the 5-HT2C antagonist SB 242084 induced opposite effects. Moreover, SB 242084 induced 50-kHz USV by its own.

CONCLUSIONS

5-HT2C receptors are critically involved in AMPH-induced 50-kHz USV, with 5-HT2C antagonism resulting in a stimulant-like effect. Attenuation of drug wanting/craving and/or liking by coadministration of a 5-HT2C agonist could be a translational pharmacodynamic biomarker.

Long-term efficacy and safety of blonanserin in patients with first-episode schizophrenia: a 1-year open-label trial

AIMS

The purpose of this study was to evaluate the long-term effectiveness and safety of blonanserin, a second-generation antipsychotic drug developed in Japan, in patients with first-episode schizophrenia.

METHODS

Twenty-three antipsychotic-naïve patients with first-episode schizophrenia were treated within an open-label, 1-year, prospective trial of blonanserin (2-24 mg/day). Clinical evaluations were conducted at baseline and 2, 6, and 12 months after the start of treatment. The main outcome measures were changes in subjective well-being and subjective quality of life, as assessed by the Subjective Well-being under Neuroleptic treatment scale Short form-Japanese version and the Schizophrenia Quality of Life Scale-Japanese version, respectively. Secondary outcome measures included the Positive and Negative Syndrome Scale, the Brief Assessment of Cognition in Schizophrenia-Japanese version, laboratory tests, bodyweight, and extrapyramidal symptoms.

RESULTS

Fourteen patients (60.9%) remained on the study at 1 year. In the intention-to-treat analysis, significant improvements were observed in several subscales on the Subjective Well-being under Neuroleptic treatment scale Short form-Japanese version, the Schizophrenia Quality of Life Scale-Japanese version, and the Brief Assessment of Cognition in Schizophrenia-Japanese version, and in all factor scores on the Positive and Negative Syndrome Scale. Improvement in depressive symptoms with blonanserin treatment was positively correlated with improvements in subjective well-being and subjective quality of life, as well as verbal memory. No significant changes were noted for any safety measure during the 1-year study period.

CONCLUSIONS

Blonanserin was well tolerated and effective for the treatment of first-episode schizophrenia in terms of subjective wellness, cognition, and a wide range of pathological symptoms. Further large-scale studies are warranted to confirm our findings.

Attitudes towards antipsychotics among patients with schizophrenia on first- or second-generation medications

BACKGROUND

Given the paucity of research in this area, this study attempted to assess attitudes toward antipsychotic medications and its correlates among patients with schizophrenia, either on first-generation antipsychotics (FGAs) or second-generation antipsychotics (SGAs) medications.

MATERIALS AND METHODS

Structured assessments of attitudes to antipsychotics, psychopathology, insight and side-effects were carried out in 120 patients with DSM-IV schizophrenia; 89 of these were on SGAs and 31 on FGAs.

RESULTS

Patients had predominantly positive attitudes toward antipsychotics. Severity of side-effects was the principal correlate of attitudes, explaining 19.5% of the variance, followed by greater insight (4.2% of the variance). Other factors such as younger age, male gender, employment, higher family income, urban residence and lower symptom-severity explained only a negligible proportion of the variance (0.2%) in attitudes. Patients on SGAs had more positive views of their medications than those on FGAs. They felt more normal on their medications, believed that their thoughts were clearer on medications, felt that good things about their medications outweighed the bad and believed that their medications helped them from falling ill again. In addition, they did not feel as tired and sluggish on their medications and did not believe that medications were unnatural or controlled their bodies.

CONCLUSIONS

Positive attitudes toward antipsychotics were common among patients with schizophrenia. Attitudes were principally determined by severity of side-effects and insight levels. Patients on SGAs had better attitudes, possibly because of less severe side-effects and greater insight among them. The importance of exploring patients' attitudes toward their antipsychotics is highlighted by this study.

Neural substrates underlying effort computation in schizophrenia

The lack of initiative, drive or effort in patients with schizophrenia is linked to marked functional impairments. However, our assessment of effort and motivation is crude, relying on clinical rating scales based largely on patient recall. In order to better understand the neurobiology of effort in schizophrenia, we need more rigorous measurements of this construct. In the behavioural neuroscience literature, decades of work has been carried out developing various paradigms to examine the neural underpinnings of an animal's willingness to expend effort for a reward. Here, we shall review this literature on the nature of paradigms used in rodents to assess effort, as well as those used in humans. Next, the neurobiology of these effort-based decisions will be discussed. We shall then review what is known about effort in schizophrenia, and what might be inferred from experiments done in other human populations. Lastly, we shall discuss future directions of research that may assist in shedding light on the neurobiology of effort cost computations in schizophrenia.

Attitude towards second-generation antipsychotics among patients with schizophrenia and their relatives

OBJECTIVE

Given the paucity of research in this area, this study attempted to assess attitudes towards second-generation antipsychotic medications and their correlates among the patients with schizophrenia and their relatives.

METHODS

Structured assessments of attitudes to medications, psychopathology, insight/knowledge, side effects, functioning and treatment satisfaction were carried out in a random sample of 50 patients with DSM-IV schizophrenia and their relatives. All, except one of the patients, were on second-generation antipsychotics.

RESULTS

Most patients had positive attitudes towards second-generation antipsychotics. Severity of positive symptoms and higher burden of side effects (e.g. sexual dysfunction, weight gain and sedation) emerged as the principal correlates of negative attitudes among patients. Greater awareness of illness, being employed, better social functioning and greater treatment satisfaction were all associated with positive attitudes among patients. Relatives had significantly more positive attitudes towards antipsychotics than patients and were more satisfied with the treatment. They were well informed about the illness, and their level of knowledge had a significant association with positive attitudes.

CONCLUSIONS

Effective antipsychotic treatment, which improves functioning and minimises side effects could lead to more favourable attitudes towards antipsychotics among patients. Increasing awareness of illness, enhancing treatment satisfaction and involving relatives in treatment could also be of help.

The impact of newer atypical antipsychotics on patient-reported outcomes in schizophrenia

Over the past two decades there has been increasing interest in including patients' self-reports in the management of their illness. Among the many reasons for such recent interest has been a rising consumer movement over the past few decades, which has led patients, their caregivers and their families to press for more meaningful sharing with physicians in the clinical decision-making process, with the clear expectations of better therapies and improved outcomes. Patients as consumers of services, their views, attitudes towards healthcare, as well as their level of satisfaction with care, have become increasingly recognized. The recent interest by the US Food and Drug Administration (FDA), as well as other regulatory agencies, in patient-reported outcomes (PROs) in the process of developing and testing new antipsychotics, has also added more impetus. It is clear that including patients in the decision-making process about the management of their psychiatric conditions also broadens the concept of 'recovery', by empowering patients to be active participants and gives a clear message that successful treatment in schizophrenia is more than a symptomatic improvement, but also includes improved functional status. Additionally, the recent interest in personalized medicine puts the patient in the centre of such development. Since 2004, when we published our review about the impact of new antipsychotics on quality of life in CNS Drugs, a number of newer antipsychotics have been introduced and include ziprasidone, aripiprazole, paliperidone, asenapine, iloperidone and lurasidone. The current review is based on 31 selected publications that cover the years 2004-2012, and deals with the impact of such newer antipsychotics on specific domains of PROs, such as subjective tolerability, quality of life, medication preference, satisfaction and social functioning. Most of the available data deal with ziprasidone, aripiprazole and paliperidone. Though the great majority of the studies indicate the newer antipsychotics have favourably impacted on aspects of PROs, such a conclusion can only be considered a trend due to the many design and methodological limitations of many of these studies. It is interesting to note, as the field awaits more rigorous studies, that there seems to be a unifying core that exists among the various subjective outcomes and that tends to generalize from one subjective outcome to other subjective outcomes. The patient who experiences good subjective tolerability to medications tends generally to be more satisfied and has a strong medication preference. The identification of such a unifying core can prove helpful, not only in the development of appropriate scales, but also in informing and guiding the process of development of new antipsychotics.

Early perception of medication benefit predicts subsequent antipsychotic response in schizophrenia: "the consumer has a point" revisited

BACKGROUND

An easy-to-administer tool for predicting response to antipsychotic treatment could improve the acute management of patients with schizophrenia. We assessed whether a patient's perception of medication benefit early in treatment could predict subsequent response or nonresponse to continued use of the same treatment.

METHOD

This post hoc analysis used data from a randomized, open-label trial of antipsychotics for treatment of schizophrenia in which attitudes about medication adherence were assessed after two weeks of antipsychotic treatment using the Rating of Medication Influences (ROMI) scale. The analysis included 439 patients who had Positive and Negative Syndrome Scale (PANSS) and ROMI scale data at Weeks 2 and 8. Scores on the ROMI subscale Perceived Medication Benefit factor were used to predict subsequent antipsychotic response at Week 8, defined as a .20% reduction from baseline on the PANSS. Logistic regression was used to identify a cut-off score for the Perceived Medication Benefit factor that could accurately identify antipsychotic responders vs. nonresponders at Week 8.

RESULTS

A score of .2.75 (equal to a mean subscale score of .11.00) on the ROMI scale Perceived Medication Benefit factor at Week 2 predicted response at Week 8 with high specificity (72%) and negative predictive value (70%), moderate sensitivity (44%) and positive predictive value (47%), and with a 38% misclassification rate.

CONCLUSIONS

A brief assessment of the patient's perception of medication benefit at two weeks into treatment appears to be a good predictor of subsequent response and nonresponse after eight weeks of treatment with the same antipsychotic.

Symptom levels and initial appraisal of hospital treatment in patients with schizophrenia

The initial appraisal of treatment by inpatients with schizophrenia has been found to be a significant predictor of clinical outcomes. The study aim was to examine whether specific types of symptoms are associated with the initial appraisal of treatment after controlling other patient characteristics. Data of 2105 inpatients with schizophrenia (ICD-10 F20-9) were pooled from three national and international multi-centre studies. Patients were interviewed within the first week of their inpatient admission. Higher levels of manic and positive symptoms were significantly associated with a less favourable initial appraisal of treatment, whilst no association was found with depression/anxiety and negative symptoms. Detained patients had more negative initial treatment appraisals, and the association with manic symptoms was significantly stronger in detained patients compared to those admitted voluntarily. Whilst patient-reported outcomes in psychiatry are usually associated with mood symptoms, this appears not to be the case for the initial appraisal by inpatients with schizophrenia. The association with manic and positive symptoms may be explained by the influence of such symptoms on the hospital experience. Focusing on the initial management of mania and positive symptoms might improve patients' appraisal of treatment in the inpatient environment.

Schizophrenia as a disorder of too little dopamine: implications for symptoms and treatment

Antipsychotics represent the first effective therapy for schizophrenia, with their benefits linked to dopamine D2 blockade. Schizophrenia was soon identified as a hyperdopaminergic disorder, and antipsychotics proved to be reasonably effective in controlling positive symptoms. However, over the years, schizophrenia has been reconceptualized more broadly, now defined as a heterogeneous disorder with multiple symptom domains. Negative and cognitive features, not particularly responsive to antipsychotic therapy, have taken on increased importance--current thinking suggests that these domains predate the onset of positive symptoms and are more closely tied to functional outcome. That they are better understood in the context of decreased dopamine activity suggests that schizophrenia may fundamentally represent a hypodopaminergic disorder. This shift in thinking has important theoretical implications from the standpoint of etiology and pathophysiology, but also clinically in terms of treatment and drug development.

Dopamine sudden depletion as a model for mixed depression

Up to date research on Bipolar Disorders' phenomenology is in keeping with early descriptions made by E. Kraëpelin regarding the overlap in clinical presentation of both manic and depressive symptoms, namely, mixed states. The latter constitute a highly prevalent and characteristic clinical presentation of Bipolar Disorders' and entail therapeutic difficulties, prognostic implications and increased suicidal risk. Notwithstanding, mixed states', more specifically mixed depression, have been underestimated and bypassed to the point where currently neither diagnostic criteria nor specific therapeutic recommendations are provided. In addition to the lack of agreement on nosography and diagnostic criteria, mixed depression is usually excluded from Bipolar Disorders' neurobiological models. Furthermore, renewed interest in the role of dopamine in Bipolar Disorders' physiopathology has left aside hypothesis that may account for the aforementioned clinical presentation. Interestingly enough, other syndromes arising from sudden dopamine depletion such as neuroleptic dysphoria or withdrawal syndromes from dopaminergic drugs, bear remarkable clinical similarities with mixed depression. These syndromes have been subject of further research and may thus provide a model for mixed states' physiopathology. Indeed, this article accounts for clinical similarities between mixed depression, neuroleptic induced dysphoria, and other behavioural syndromes arising from sudden dopamine depletion. After reviewing neurochemical basis of such syndromes we present, to the best of our knowledge, the first neurobiological hypothesis for mixed depression. Specifically, such hypothesis regards over activation symptoms as auto regulatory attempts to compensate for sudden dopaminergic depletion. This hypothesis provides with a beginning step for the neglected problem of mixed depression, a non-antithetic link between the dopaminergic hypothesis for both manic and depressive symptoms, a plausible explanation regarding inter individual variability to mixed depression susceptibility, and suggests new approaches for the development of novel treatments in which dopamine dysregulation should be targeted.

Psychotic exacerbation and emotional dampening in the daily life of patients with schizophrenia switched to aripiprazole therapy: a collection of standardized case reports

BACKGROUND

Blockade of the dopamine D2 receptor is a key mechanism in the antipsychotic treatment of patients with a psychotic disorder, but may also induce emotional deficits. The partial D2 agonistic profile of aripiprazole has, therefore, been suggested to favor emotional wellbeing compared with the pure dopamine antagonistic properties of traditional antipsychotics.

METHOD

The current study used the experience sampling method (a structured diary technique) to assess the effects of switching from treatment with traditional dopamine antagonist antipsychotics to treatment with the partial dopamine agonist aripiprazole on emotional wellbeing in the daily life of 13 patients with a diagnosis of schizophrenia.

RESULTS

More than half of all patients experienced exacerbation of psychotic symptoms after they had switched to the aripiprazole medication regime, consequently resulting in dropout of the study. Furthermore, switching to aripiprazole treatment, when effective in terms of symptom reduction, was accompanied by decreased feelings of both positive and negative affect in daily life, suggestive of a general state of emotional dampening.

CONCLUSIONS

Although the scale of the current study and the 54% dropout rate call for careful interpretation of the data, implementation of ecological monitoring in psychopharmacological research may open up new avenues for untangling the working mechanisms of compounds with regard to their impact on mental states.

Predictors of clinical and social outcomes following involuntary hospital admission: a prospective observational study

The Study aimed to assess clinical and social outcomes following involuntary admissions over 1 year and identify socio-demographic and clinical patient characteristics associated with more or less favourable outcomes. Seven hundred and seventy-eight involuntary patients admitted to one of 22 hospitals in England were assessed within the first week after admission and at 1 month, 3 month and 12 month follow-ups. Outcome criteria were symptom levels, global functioning, objective social outcomes, and subjective quality of life (SQOL). Baseline characteristics and patients' initial experience were tested as predictors. Symptom levels and global functioning improved moderately. Objective social outcomes showed a small, but statistically significant deterioration, and SQOL a small, but significant improvement at 1 year. In multivariable analyses, admission due to risk to oneself and receiving benefits predicted poorer symptom outcomes. Female gender and higher perceived coercion were associated with better objective social outcomes, whilst higher initial satisfaction with treatment predicted more positive SQOL at follow-ups. Over a 1-year period following involuntary hospital admission, patients on average showed only limited health and social gains. Different types of outcomes are associated with different predictor variables. Patients' initial experience of treatment, in the form of perceived coercion or satisfaction with treatment, has predictive value for up to a year following the admission.

Why do some voluntary patients feel coerced into hospitalisation? A mixed-methods study

This study aimed to investigate factors linked to perceived coercion at admission and during treatment among voluntary inpatients. Quantitative and qualitative methods were used. Two hundred seventy patients were screened for perceived coercion at admission. Those who felt coerced into admission rated their perceived coercion during treatment a month after admission. Patient characteristics and experiences were tested as predictors of coercion. In-depth interviews on experiences leading to perceived coercion were conducted with 36 participants and analysed thematically. Thirty-four percent of patients felt coerced into admission and half of those still felt coerced a month later. No patient characteristics were associated with perceived coercion. Those whose satisfaction with treatment increased more markedly between baseline and a month later were less likely to feel coerced a month after admission. In the qualitative interviews three themes leading to perceived coercion were identified: viewing the hospital as ineffective and other treatments as more appropriate, not participating in the admission and treatment and not feeling respected. Involving patients in the decision-making and treating them with respect may reduce perceived coercion.

Subjective effects of antipsychotic drugs and their relevance for compliance and remission

Only recently, success criteria became more ambitious and include a more thorough consideration of negative symptoms and cognitive dysfunction. The most important change within the last decade is the long overdue consideration of the patient's perspective. His/her subjective well-being, often unchanged or even worsened by typical antipsychotics, was neglected for a long time. One reason was the prejudice that schizophrenic patients are not able to self-rate their quality of life. Another reason was the belief that such data are not necessary because the psychiatrists' perspective, “objective” psychopathology, includes these domains. Among other scales, a self-report instrument has been constructed to evaluate “subjective well-being under neuroleptics” (SWN). This scale was used in numerous open and controlled trials, indicating: a) patients, if no longer acutely psychotic or suffering from severe cognitive deficits, are able to reliably assess their subjective well-being, b) high SWN is correlated with high compliance, c) atypical antipsychotics increase SWN, and d) individual improvements of SWN and of PANSS are not strongly related. Moreover, several studies found that early improvement of subjective well-being is a major predictor for the chance of remission. All these data indicate that a better consideration of the patient's perspective is possible and necessary.

Subjective well-being in schizophrenia as measured with the Subjective Well-Being under Neuroleptic Treatment scale: a review

OBJECTIVE

The Subjective Well-being under Neuroleptic Treatment scale (SWN) is the most widely used self-rating scale in recent research of subjective well-being in schizophrenia. We reviewed all available publications on relevant research of subjective well-being using the SWN, in order to evaluate measurement of subjective well-being with a single instrument.

METHOD

A MEDLINE and Embase search was performed for studies published between January 1994 and August 2010, analysing controlled and open clinical trials using the SWN.

RESULTS

A total of 52 publications were identified covering 44 studies. Strong evidence exists for improvement of subjective well-being during treatment. Atypical antipsychotics are associated with a higher level of well-being. However, dosage is more important than the kind of medication. Striatal dopamine D(2) receptor occupancy is correlated with subjective well-being. Early positive response of subjective well-being is predictive of a better outcome. Research on determinants of subjective well-being is rapidly expanding, focusing mostly on the effects of medication.

CONCLUSIONS

Subjective well-being of schizophrenia patients is a valuable outcome measure. It can be improved by optimizing antipsychotic treatment. More research on psychological and genetic predictors of subjective well-being is needed.

Patients' subjective initial response and the outcome of inpatient and day hospital treatment

OBJECTIVE

This study aimed to establish whether psychiatric patients' subjective initial response (SIR) to hospital and day hospital treatment predicts outcomes over a one-year follow-up period.

METHOD

We analysed data from 765 patients who were randomised to acute psychiatric treatment in a hospital or day hospital. SIR was assessed on day 3 after admission. Outcomes were psychiatric symptom levels and social disability at discharge, and at 3 and 12 months after discharge.

RESULTS

After controlling for socio-demographic and clinical characteristics, a more positive SIR was significantly associated with lower symptom levels at discharge and 3 months after discharge and lower social disability at 3 months and 12 months after discharge.

CONCLUSION

SIR can predict outcomes of complex interventions over a one-year period. Patients' initial views of acute hospital and day treatment should be elicited and considered as important.

Cost-effectiveness simulation analysis of schizophrenia at the Instituto Mexicano del Seguro Social: Assessment of typical and atypical antipsychotics

INTRODUCTION

Estimation of the economic costs of schizophrenia is a fundamental tool for a better understanding of the magnitude of this health problem. The aim of this study was to estimate the costs and effectiveness of five antipsychotic treatments (ziprasidone, olanzapine, risperidone, haloperidol and clozapine), which are included in the national formulary at the Instituto Mexicano del Seguro Social, through a simulation model.

METHODS

Type of economic evaluation: complete economic evaluation of cost-effectiveness.

STUDY PERSPECTIVE

direct medical costs.

TIME HORIZON

1 year. Effectiveness measure: number of months free of psychotic symptoms.

ANALYSIS

to estimate cost-effectiveness, a Markov model was constructed and a Monte Carlo simulation was carried out.

RESULTS

Effectiveness: the results of the Markov model showed that the antipsychotic with the highest number months free of psychotic symptoms was ziprasidone (mean 9.2 months). The median annual costs for patients using ziprasidone included in the hypothetical cohort was 194,766.6 Mexican pesos (MXP) (95% CI, 26,515.6-363,017.6 MXP), with an exchange rate of 1 € = 17.36 MXP. The highest costs in the probabilistic analysis were estimated for clozapine treatment (260,236.9 MXP).

CONCLUSIONS

Through a probabilistic analysis, ziprasidone showed the lowest costs and the highest number of months free of psychotic symptoms and was also the most costeffective antipsychotic observed in acceptability curves and net monetary benefits.

Depot and oral antipsychotics: patient preferences and attitudes are not the same thing

Some clinicians believe that antipsychotic depot injections are unacceptable to patients. This cross-sectional study investigated patients' attitudes regarding antipsychotics, and included within-participant comparisons. Two hundred and twenty-two out-patients with schizophrenia/schizoaffective disorder completed the Drug Attitude Inventory (DAI-10), scales on insight, side effects and treatment preferences. Formulation preference was associated with current medication formulation: depots were preferred by 43% (33/76) on depot vs 6% (8/146) on orals (P < 0.001). Attitudes (DAI scores) regarding current formulation were influenced by illness duration, extrapyramidal symptoms and insight but not by formulation (depot vs oral). For those with experience of both formulations, participants currently on tablets scored depots less favourably than oral (4.27 vs 6.89, P < 0.001); those on depot did not differentiate. When voluntary patients on maintenance antipsychotics are asked about their attitudes to their current medication, those on depot respond similarly to those on oral. However, when asked to state a preference for formulation (depot vs oral), patients tend to favour their current formulation. Whatever leads some to switch from depot to oral, leaves a lasting negative impression of the depot and this may limit uptake of newer depots.

Non-motor cognitive-perceptual dysfunction associated with drug-induced parkinsonism

OBJECTIVE

The purpose of the present study was to examine the relationship between drug-induced parkinsonism (DIP) and subjective non-motor cognitive impairments in schizophrenia by performing comprehensive assessments of extrapyramidal side effects (EPS) and the subjective cognitive-perceptual functioning.

METHODS

Ninety-one outpatients with schizophrenia were evaluated for DIP and other EPS. Subjective cognitive-perceptual dysfunction was comprehensively assessed using the Frankfurt Complaint Questionnaire (FCQ). To examine the association between DIP and non-motor cognitive-perceptual dysfunction, Pearson's partial correlation analysis was performed between the FCQ scores and the severity of DIP, controlling for relevant variables.

RESULTS

The analysis revealed that the severity of DIP had a significant correlation with the total FCQ score (p < 0.05). In phenomenological subscales, the severity of DIP showed significant correlations with "deterioration of discrimination," "psychomotor disorder," "perceptual disorder," "cognitive floating," and "automatic behavior disorder" (p < 0.05).

CONCLUSIONS

The results of our study suggest that DIP is significantly associated with a wide range of subjective non-motor cognitive impairments. Clinicians should be careful of the appearance of DIP and the associated non-motor cognitive-perceptual symptoms, which may cause considerable distress and reduce the quality of life in an already vulnerable group of patients.

Patients' views and readmissions 1 year after involuntary hospitalisation

BACKGROUND

Little is known about the long-term outcome of involuntary admissions to psychiatric hospitals.

AIMS

To assess involuntary readmissions and patients' retrospective views of the justification of the admission as 1-year outcomes and to identify factors associated with these outcomes.

METHOD

Socio-demographic data and readmissions were collected for 1570 involuntarily admitted patients. Within the first week after admission 50% were interviewed, and of these 51% were re-interviewed after 1 year.

RESULTS

At 1 year, 15% of patients had been readmitted involuntarily, and 40% considered their original admission justified. Lower initial treatment satisfaction, being on benefits, living with others and being of African and/or Caribbean origin were associated with higher involuntary readmission rates. Higher initial treatment satisfaction, poorer initial global functioning and living alone were linked with more positive retrospective views of the admission.

CONCLUSIONS

Patients' views of treatment within the first week are a relevant indicator for the long-term prognosis of involuntarily admitted patients.

Psychiatric nurses' attitudes to antipsychotic depots in Hong Kong and comparison with London

Psychiatric nurses' attitudes to depots have only been explored in the UK. We conducted a cross-sectional attitudinal study for Hong Kong psychiatric nurses and also conducted international comparisons for nurses' views about depots. A pre-existing UK questionnaire on clinicians' attitudes and knowledge regarding depots was updated for the present study. Participants were 98 psychiatric nurses who attended an academic meeting. The majority of respondents had positive views regarding their role in depot administration; most reported that they had sufficient training (84%). However, many did not feel involved in treatment decision making (60%) and other negative views were expressed including: (1) most patients always prefer to have oral (vs. depot) (80%); and (2) force is sometimes required when administering a depot (40%). Interestingly, most reported that patients' friends and family were more accepting of depot (vs. oral) (69%). When compared with a former sample of London community psychiatric nurses, Hong Kong nurses had less favourable patient-focussed attitudes (mean 56% vs. 60%, P = 0.051) and depot-specific attitudes regarding depots (mean 63% vs. 69%, P < 0.001). In conclusion, therefore, international variation exists and encompasses clinical practice aspects for both the patient and the depot formulation per se. Our participants wanted more involvement in treatment decision making.

Effect of olanzapine and risperidone on subjective well-being and craving for cannabis in patients with schizophrenia or related disorders: a double-blind randomized controlled trial

OBJECTIVE

To examine whether subjective well-being and craving for cannabis were different in patients with schizophrenia or related disorders treated with either olanzapine or risperidone.

METHOD

A 6-week, double-blind, randomized trial of olanzapine and risperidone was carried out in 128 young adults with recent onset schizophrenia or related disorders. Primary efficacy measures were the mean baseline-to-endpoint change in total scores on the Subjective Well-Being under Neuroleptics scale, the Obsessive-Compulsive Drug Use Scale, the Drug Desire Questionnaire, and the cannabis use self-report. An analysis of covariance was used to test between-group differences.

RESULTS

Estimated D(2) receptor occupancy did not differ between olanzapine (n = 63) and risperidone (n = 65). Similar improvements in subjective well-being were found in both groups. In the comorbid cannabis-using group (n = 41, 32%), a similar decrease in craving for cannabis was found in both treatment conditions.

CONCLUSIONS

Both olanzapine and risperidone were associated with improved subjective well-being. No evidence was found for a differential effect of olanzapine or risperidone on subjective experience or on craving for cannabis in dosages leading to comparable dopamine D(2) occupancy.

CLINICAL TRIAL REGISTRATION NUMBER

ISRCTN46365995.

Is antipsychotic medication stigmatizing for people with mental illness?

Antipsychotic medications are clearly identified as important in the treatment of individuals with schizophrenia and with bipolar disorder. However, negative societal reaction related to having a serious mental illness and the socially undesirable side effects associated with antipsychotic medication treatment may combine to worsen stigma associated with treatment for mental illness. Specific stigmatizing effects of antipsychotic therapy may be difficult to evaluate independently from factors such as symptoms, insight into illness and side effects. Attitudes towards antipsychotic medication may be positive in individuals who recognize therapeutic drug effects, however other individuals may view medications negatively due to a sense of stigma. Stigma among individuals with bipolar disorder in relation to treatment with antipsychotic medication has not been well addressed in the literature. An additional concern among individuals with bipolar disorder who receive antipsychotic medications may be the notion that antipsychotics are 'schizophrenia drugs', and thus an inappropriate treatment for their condition. Antipsychotic medications can be stigmatizing for patients with serious mental illness, however the roots of stigma are extensive, and efforts to minimize stigma can only be successful when addressed by the individual with illness, their families and loved ones, treatment providers and society at large.

Management of acutely ill patients in the hospital setting: focus on quetiapine

We have considered published work and clinical experience focusing on the atypical antipsychotic quetiapine in order to form a consensus on the most appropriate treatment strategies for hospitalised patients with acute schizophrenia or bipolar disorder. It is important to consider the specific treatment needs of these patients and these are discussed in the context of current treatment guidelines. We will review the efficacy and tolerability of atypical antipsychotics versus conventional antipsychotics and/or benzodiazepines as a first-line treatment, and examine the suitability of oral versus intramuscular formulations in the acute setting. The potentially beneficial properties of specific atypical agents are also considered. Appropriate dosing is particularly important in acutely ill patients as it can help achieve rapid improvement. We will discuss emerging data which show that rapid initiation of quetiapine in patients with acute psychosis or mania is not only as effective as standard initiation, but is also well tolerated. This may be important for treatment in the long term as a positive initial treatment experience can determine patient compliance and treatment adherence. In conclusion, this review recommends that oral atypical antipsychotics should be a first-choice medication for acutely ill cooperative patients in the hospital setting.

Subjective and behavioural consequences of striatal dopamine depletion in schizophrenia--findings from an in vivo SPECT study

Dysphoria is an integral part of the symptomatology of a variety of clinical states, though there is little empirical data available on the qualitative and quantitative aspects of this phenomenon. The purpose of the study was to administer alphamethyl paratyrosine (AMPT), a catecholamine depleting agent as a chemical probe to induce dysphoria, and document the ensuing changes in mental status. AMPT (4-5 g/day) was administered to a group of medication-free schizophrenic patients (n=13) over a 48 hour period, and changes in their mental status were monitored at 12 hour intervals with the Profile of Mood States (POMS), Addiction Research Center Inventory (ARCI), Drug Attitude Inventory (DAI) and other standardized rating scales. All of the subjects experienced dysphoric responses of variable severity. The profile of changes included blunted pleasure responsivity, clouded thinking, loss of motivation and lowered vigilance. Subtle subjective changes were experienced soon after the first dose of AMPT and the dysphoria steadily worsened, resulting in social withdrawal and personal distress. Subjective responses were the earliest to manifest, followed by akathisia, akinesia and rigidity. We conclude that AMPT induced dopamine depletion is a safe, rapid, reliable and reversible method of studying dysphoric states in humans. The technique is helpful in examining the phenomenology of dysphoria, the temporal relationship between subjective and behavioural consequences of dopamine depletion, and the role of dopamine in mediating subtle aspects of pleasure responsivity, which is in turn crucial to the understanding of treatment non-adherence in schizophrenia and the origins of comorbid substance abuse.

Pharmakotherapie der Schizophrenie

The management of schizophrenia patients remains one of the great challenges in psychiatry. Despite the undisputed effectiveness of antipsychotic drugs, patients and their physicians still face considerable difficulties mainly related to incomplete or lacking treatment response and the inability to predict the individual efficacy and tolerability. In this manuscript we review the key elements of pharmacological treatment of this disorder, encompassing acute and long-term management as well as specific management problems ranging from acutely violent patients to treatment-resistant subjects. Along with general treatment principles, the document provides specific information regarding efficacy and safety features of antipsychotics. Many of the currently available treatment recommendations/guidelines are based on the evidence reviewed here. This review is meant to serve as a guide for clinicians involved in managing schizophrenia, whether in a psychiatric hospital setting or as family physicians in private practice.

Improvement of patient compliance after switching from conventional neuroleptics to the atypical neuroleptic amisulpride

Medication noncompliance of schizophrenic outpatients is an important problem in clinical practice, causing relapse and illness deterioration. Because atypical neuroleptics have, in controlled clinical studies, been shown to be better tolerated and accepted by patients, the question is whether switching from conventional to atypical neuroleptics such as amisulpride can increase patient compliance also under conditions of routine care. In a drug utilization observation study 570 schizophrenic outpatients, who had been pretreated with conventional neuroleptics and then been switched for individual clinical reasons to amisulpride, were observed for 3 months. Sociodemographic, illness and treatment related variables (e.g. Positive and Negative Symptom Scale, side effects), patients' subjective attitudes, and premedication and treatment compliance were assessed using standardized instruments. A total of 43.7% were rated as being noncompliant with the premedication, while 85.8% were rated as compliant after being switched to amisulpride, including 82.7% of the former noncompliant patients. Patients who had become compliant showed a signicantly better psychopathological status after 3 months as compared to still noncompliant patients, including a lower rate of inpatient stays. Switching noncompliant patients from conventional to atypical neuroleptics like amisulpride can improve patient compliance and psychopathology under conditions of routine treatment.

Does smoking reduce akathisia? Testing a narrow version of the self-medication hypothesis

BACKGROUND

The self-medication hypothesis proposes that schizophrenia patients smoke to decrease their schizophrenia symptoms or antipsychotic side effects, but they usually start smoking before their illness and heavy smoking is not consistently associated with fewer symptoms or side effects. A narrow version of the self-medication hypothesis, heavy smoking reduces akathisia, is explored.

METHOD

The sample included 250 outpatients with DSM-IV schizophrenia assessed with the Positive and Negative Syndrome Scale (PANSS) and the Barnes Akathisia Scale. Prevalences were 69% (173/250) for smoking, 39% (98/250) for heavy smoking (> or =30 cigarettes/day), 7% (17/250) for akathisia (Barnes Global score>1), 14% (35/250) for a broader akathisia definition (Barnes Global score>0) and 20% for excited symptoms (>1 on the PANSS factor score).

RESULTS

Heavy smoking was not associated with akathisia (41% of patients with akathisia were heavy smokers versus 39% of patients without akathisia; chi2=0.3, df=1, p=0.86), even after correcting for confounding factors and/or using a broader akathisia definition. Heavy smoking was associated with excited schizophrenia symptoms (possibly reflecting agitation). Particularly in patients taking lower doses of typical antipsychotics, excited symptoms, with or without akathisia, were strongly associated with heavy smoking and appear to interact with patients' reports of smoking's calming effect as the main reason for smoking.

CONCLUSION

The self-medication hypothesis does not explain increased smoking and heavy smoking in schizophrenia. Moreover, heavy smoking may be associated with more disturbed brain homeostatic mechanisms. Prospective studies need to explore whether temporary increases in cigarette smoking may be associated with periods of higher agitation, with or without akathisia.

The impact of subjective well-being under neuroleptic treatment on compliance and remission

The patients' perspective of antipsychotic treatment was largely neglected for a long period. It has only been during the last 10 years, with the development of atypical antipsychotics, that scientific interest in this issue has markedly increased. Numerous studies have shown that the majority of schizophrenic patients are able to fill out a self-rating scale in a meaningful way, and several self-report scales with sufficient internal consistency and good construct validity have been developed. The effects of antipsychotic treatment on psychopathology and on subjective well-being (SW) are not strongly related; the perspectives of the patient and his/her psychiatrist markedly differ. Recent research indicates that SW/quality of life, much more improved by atypical than by typical antipsychotics, has a strong impact on compliance, as well as on the chance of achieving remission. The data strongly suggest that a systematic evaluation of the patient's perspective of antipsychotic treatment is meaningful and necessary to increase compliance, functional outcome, and long-term prognosis.

Classical as well as novel antipsychotic drugs increase self-stimulation threshold in the rat--similar mechanism of action?

Antipsychotic drugs given acutely increase the threshold for intracranial self-stimulation elicited from the ventral tegmental area. As all the antipsychotic drugs share the dopamine D2-receptor antagonism it is reasonable to believe that this is the cause for suppression of intracranial self-stimulation behaviour. The objective of this investigation was to examine the effect of classical (haloperidol) as well as novel antipsychotic drugs (clozapine, olanzapine and sertindole) on intracranial self-stimulation behaviour. Furthermore, the effects of different specific receptor antagonists on intracranial self-stimulation behaviour were examined. Our results showed that both the classical (haloperidol) and the three novel antipsychotic drugs increase the threshold for intracranial self-stimulation. The results obtained with the receptor specific antagonists showed that dopamine D2, alpha1-adrenoceptor and serotonin 5-HT2A receptor antagonisms inhibit intracranial self-stimulation behaviour and that muscarinic receptor antagonism is without effect. Even though all the tested antipsychotic drugs inhibited intracranial self-stimulation behaviour, there seems to be a difference in their ratio between doses that inhibits intracranial self-stimulation behaviour and those that produce antipsychotic effect in a preclinical model (amphetamine hyperactivity). Sertindole was the only antipsychotic drug able to produce antipsychotic effect without significant inhibition of intracranial self-stimulation behaviour at a narrow dose interval. The remaining antipsychotic drugs all inhibited intracranial self-stimulation behaviour at equal or lower doses than those producing antipsychotic effect.

Attitude towards antipsychotics among out-patients with schizophrenia in Nigeria

OBJECTIVE

The study aim to assess the attitude of patients with schizophrenia attending out-patient clinics in Nigeria towards antipsychotic medication and examine the factors associated with such attitude.

METHOD

Out-patients with schizophrenia (n = 312) completed the 10-item Drug Attitude Inventory. They were also evaluated for sociodemographic details, illness-related and drug-related variables.

RESULTS

Overall, the patients had a good attitude towards antipsychotic medication. The factors significantly associated with poor attitude towards medication include presence of symptoms, presence of side-effects like dyskinesia and sedation, lack of insight into the illness, and being employed.

CONCLUSION

Special attention should be paid to patients with these factors while designing programmes to improve overall compliance in patients with schizophrenia.

Critical assessment of how to study addiction and its treatment: human and non-human animal models

Laboratory models, both animal and human, have made enormous contributions to our understanding of addiction. For addictive disorders, animal models have the great advantage of possessing both face validity and a significant degree of predictive validity, already demonstrated. Another important advantage to this field is the ability of reciprocal interplay between preclinical and clinical experiments. These models have made important contributions to the development of medications to treat addictive disorders and will likely result in even more advances in the future. Human laboratory models have gone beyond data obtained from patient histories and enabled investigators to make direct observations of human drug self-administration and test the effects of putative medications on this behavior. This review examines in detail some animal and human models that have led not only to important theories of addiction mechanisms but also to medications shown to be effective in the clinic.

How antipsychotics work-from receptors to reality

How does a small molecule blocking a few receptors change a patients' passionately held paranoid belief that the FBI is out to get him? To address this central puzzle of antipsychotic action, we review a framework linking dopamine neurochemistry to psychosis, and then link this framework to the mechanism of action of antipsychotics. Normal dopamine transmission has a role in predicting novel rewards and in marking and responding to motivationally salient stimuli. Abnormal dopamine transmission alters these processes and results in an aberrant sense of novelty and inappropriate assignment of salience leading to the experience of psychosis. Antipsychotics improve psychosis by diminishing this abnormal transmission by blocking the dopamine D2/3 receptor (not D1 or D4), and although several brain regions may be involved, it is suggested that the ventral striatal regions (analog of the nucleus accumbens in animals) may have a particularly critical role. Contrary to popular belief, the antipsychotic effect is not delayed in its onset, but starts within the first few days. There is more improvement in the first 2 weeks, than in any subsequent 2-week period thereafter. However, a simple organic molecule cannot target the complex phenomenology of the individual psychotic experience. Antipsychotics diminish dopamine transmission and thereby dampen the salience of the pre-occupying symptoms. Therefore, in the initial stage of an antipsychotic response, the patients experience a detachment from symptoms, a relegation of the delusions and hallucinations to the back of their minds, rather than a complete erasure of the symptoms. Only with time, and only in some, via the mediation of new learning and plasticity, is there a complete resolution of symptoms. The implications of these findings for clinical care, animal models, future target discovery and drug development are discussed.

Evaluation of the subjects' response to antipsychotics questionnaire

The present study reports on the development of a new self-administered instrument to assess patients' responses to antipsychotic medication. The Subjects' Response to Antipsychotics (SRA) Questionnaire is a 74-item instrument with eight scales (Recovery, Weight Gain, Sexual Anhedonia, Sedation, Affective Flattening, Extrapyramidal Side-Effects, Diminished Sociability and Increased Sleep), and a total adverse responses score including additional items. Psychometric aspects were examined in a study of 320 inpatients and outpatients showing good internal consistency, reproducibility and external validity. Concordance with other instruments claiming to measure the subjective response is low, suggesting that the instruments measure different concepts. The SRA Questionnaire appears to be a reliable and efficient way of measuring patients' subjective responses to antipsychotic medication.

From dopamine to salience to psychosis--linking biology, pharmacology and phenomenology of psychosis

How does an excess in a neurochemical lead someone to being paranoid about the intentions of their neighbour? And why does blocking a dopamine receptor improve this symptom? In this article we present a heuristic framework which attempts to link the biology, phenomenology and pharmacology of psychosis. Focussing on dopamine's role in reward prediction and motivational salience we propose that psychosis arises from an aberrant assignment of novelty and salience to objects and associations. Antipsychotics block dopamine receptors and decrease dopamine transmission, which leads to the attenuation of aberrant novelty and salience. This 'salience' framework accounts for existing data and questions several current assumptions about the speed of onset phenomenological effects of antipsychotics and their behavioral effects in animal models. We review new data to show that in contrast to the prevailing idea of a "delayed onset" of antipsychotic action, the improvement is evident in the first few days. Antipsychotics do not eradicate symptoms, but create a state of "detachment" from them. And the actions of antipsychotics in the conditioned avoidance response model, one of the best established animal models for identifying antipsychotic action, are consistent with the idea that they dampen aberrant as well as normal motivational salience. The article discusses the caveats, limitations as well as the clinical implications of the salience framework.