Outcome and risks of ultra-long-term treatment with an oral neuroleptic drug. Relationship between perazine serum levels and clinical variables in schizophrenic outpatients

Optimisation of pharmacotherapy in psychiatry through therapeutic drug monitoring, molecular brain imaging and pharmacogenetic tests: Focus on antipsychotics

BACKGROUND

For psychotic disorders (i.e. schizophrenia), pharmacotherapy plays a key role in controlling acute and long-term symptoms. To find the optimal individual dose and dosage strategy, specialised tools are used. Three tools have been proven useful to personalise drug treatments: therapeutic drug monitoring (TDM) of drug levels, pharmacogenetic testing (PG), and molecular neuroimaging.

METHODS

In these Guidelines, we provide an in-depth review of pharmacokinetics, pharmacodynamics, and pharmacogenetics for 45 antipsychotics. Over 30 international experts in psychiatry selected studies that have measured drug concentrations in the blood (TDM), gene polymorphisms of enzymes involved in drug metabolism, or receptor/transporter occupancies in the brain (positron emission tomography (PET)).

RESULTS

Study results strongly support the use of TDM and the cytochrome P450 (CYP) genotyping and/or phenotyping to guide drug therapies. Evidence-based target ranges are available for titrating drug doses that are often supported by PET findings.

CONCLUSION

All three tools discussed in these Guidelines are essential for drug treatment. TDM goes well beyond typical indications such as unclear compliance and polypharmacy. Despite its enormous potential to optimise treatment effects, minimise side effects and ultimately reduce the global burden of diseases, personalised drug treatment has not yet become the standard of care in psychiatry.

Perazine and carbamazepine in comparison to olanzapine in schizophrenia

Atypical antipsychotics like olanzapine are more efficacious in treating negative symptoms and have less side effects. Nevertheless, important adverse effects of olanzapine are, for example, weight gain and hyperglycemia. Perazine in combination with carbamazepine has shown satisfying results in several single-schizophrenia patients, leading to the hypothesis of being equal or even superior to atypical antipsychotic monotherapy. The aim of the present study was to survey the hypothesis that perazine in combination with carbamazepine have an outcome and risk of side effects comparable to olanzapine. Eleven patients with DSM-IV schizophrenia received 14.0 +/- 5.0 mg/day olanzapine and 12 patients received 360.0 +/- 196.0 mg/day perazine in combination with 404.0 +/- 229.0 mg/day carbamazepine. Symptoms and neuropsychological state were assessed 3 times (days 0, 7, 21) using the Positive and Negative Syndrome Scale and the Brief Psychiatric Rating Scale. The neuropsychological state was assessed by the following neuropsychological tests: Benton, d2, ZVT, VLMT and MWT-B. Data were analyzed of variance for multiple dependent variables and repeated-measures multivariate analysis of variance. Positive and Negative Syndrome Scale and Brief Psychiatric Rating Scale scores showed superior improvement in the group receiving olanzapine. Olanzapine offers a more favorable response in positive symptoms than does perazine in combination with carbamazepine. The effect on negative symptoms is favorable in both forms of therapy and no significant differences between the groups could be determined. In both groups, treatment was associated with improved performance in cognitive tests; however, no differences were determined in the effects of the drugs. Results suggest that olanzapine offers a better response in positive symptoms than perazine in combination with carbamazepine.

Auditory evoked potentials as possible predictors of outcome in schizophrenic outpatients

As part of a follow-up study on long-term neuroleptic treatment, 36 schizophrenic out-patients under neuroleptic treatment were studied in an 'auditory oddball' event-related potential paradigm after a 3-month stabilization phase following clinical discharge. In the first cross-sectional analysis, we evaluated the influences of age and gender and tried to find auditory evoked potential (AEP) variables, which might be promising as potential predictors of the course of illness. Compared with healthy age-matched controls, the patients showed smaller N1/P3-amplitudes. Males and females showed only minor AEP-differences, the amplitude N1/P2 being slightly higher in females. Age correlated positively with the latency P3 and negatively with the latency P2R. The interpeak latency P3-P2R showed the highest correlation with age. Test/re-test reliability was measured and variables with r less than 0.60 were rejected. The amplitudes N1/P2 and N1/P3 showed the highest test/re-test correlations. The more severely disturbed patients (global assessment scale [GAS]-score less than 65) had shorter interpeak latencies P2F-N1F than the less disturbed patients (GAS greater than or equal to 65). Patients with a high rate of relapse tended to have shorter interpeak latencies P2F-N1F than patients with low rates of relapse. Our results indicate that the interpeak latency P2F-N1F has an acceptable test/re-test reliability (C3: r = 0.72; C4: r = 0.80) and is related to clinical variables characterizing the course and outcome of illness. This leads to the hypothesis that a short interpeak latency, P2F-N1F, might be a predictor of poor prognosis.

Psychiatric clinic of the Free University of Berlin; Department of Clinical Psychiatry and Polyclinic

The Department of Psychiatry in its present form has developed since 1968, when the psychiatric branch of the Psychiatrische und Neurologische Klinik (Psychiatric and Neurological Clinic), the traditional type of a West German university hospital comprising psychiatry and neurology in one chair, became autonomous with the establishment of an independent chair of psychiatry. This was an early step in the separation of psychiatry and neurology, a situation which is now to be seen in all German universities. Moreover, during the last decade almost all psychiatric university departments have been more or less sub-divided into sub-specialities. This process has been carried to its furthest extreme in West Berlin which now has departments of clinical psychiatry, geronto-psychiatry, social psychiatry, psychosomatics, child and adolescent psychiatry, neuropsychopharmacology, psychophysiology, student mental health, and forensic psychiatry. The lines of demarcation have been drawn according to somewhat divergent (historical, personal, conceptual) criteria, so that the individual departments differ in size, research interests and research facilities. More than 10 professors, 15 senior doctors and about 50 assistants (physicians, psychologists, sociologists, mathematicians, chemists and engineers) make up a critical mass, but centrifugal forces are often dominant and restrain the optimal use of all facilities for real interdisciplinary collaboration in the sense of what has been described as the ‘agricultural’ approach to research (Shepherd, 1981).