Hostility in schizophrenia: An integrated analysis of the combined Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) and the European First Episode Schizophrenia Trial (EUFEST) studies

The efficacy and safety of cariprazine in the early and late stage of schizophrenia: a post hoc analysis of three randomized, placebo-controlled trials

BACKGROUND

The aim of the post hoc analysis was to better understand the efficacy and safety of cariprazine in patients with schizophrenia for less than 5 years (early stage) and for more than 15 years (late stage).

METHODS

Data from three phase II/III randomized, double-blind, placebo-controlled trials with similar design in patients with acute exacerbation of schizophrenia were pooled and patients with early and late stage of schizophrenia were determined. A mixed-effects model for repeated measures approach was applied and least square (LS) mean changes from baseline to week 6 on the Positive and Negative Syndrome Scale (PANSS) total and factor scores were reported. Descriptive statistics were used for safety analyses including treatment emergent adverse events (TEAEs) and discontinuation rates.

RESULTS

Overall, 460 patients were identified as being in the early and 414 in the late stage of schizophrenia. The pooled analysis evaluating mean change from baseline to week 6 in the PANSS total score indicated statistically significant difference between cariprazine and placebo in favor of cariprazine in both the early (LS mean difference [LSMD] -7.5 P < .001) and late stage (LSMD -6.7, P < .01) subpopulation. Early stage patients experienced similar amount of TEAEs (CAR 67.3%, PBO 54.1%) as patients in the late stage (CAR 69.6%, PBO 65.6%).

CONCLUSION

In conclusion, cariprazine, a potent D₃-D₂ partial agonist has been found to be safe and effective in the treatment of early and late stage schizophrenia.

Specific Anti-hostility Effects of Atypical Antipsychotics in Persons with Schizophrenia: From Clozapine to Cariprazine

LEARNING OBJECTIVE

After participating in this activity, learners should be better able to:• Evaluate the anti-hostility effects of available atypical antipsychotic agents.

ABSTRACT

In addition to hallucinations and delusions, persons with schizophrenia may exhibit hostility. In clinical trials of antipsychotics, hostility is routinely measured as part of rating scales such as the Brief Psychiatric Rating Scale or Positive and Negative Syndrome Scale. The availability of the atypical antipsychotic clozapine in 1989 led to the observation that it is possible to have a treatment effect on hostility that is independent of the treatment effect on hallucinations or delusions, and independent of general sedative effects. The data supporting this notion of a specific anti-hostility effect are the most robust for clozapine as the data include specifically designed randomized, controlled clinical trials. A specific anti-hostility effect is also observable to various degrees with most of the other atypical antipsychotics, as evidenced in post hoc analyses of clinical trials originally conducted for regulatory purposes, supplemented by post hoc analyses of large effectiveness trials. The generalizability of these studies, however, may be limited. Participants in these trials were not selected for aggressive and hostile behavior. Some of the studies also excluded patients with substance use disorders. The latter is particularly important because alcohol and substance use are well known to increase risk for hostility and aggression. Nevertheless, the repeated demonstrations of the specificity of an anti-hostility effect (in terms of statistical independence of effects on other positive symptoms and of sedation) are of potential clinical importance.

Hostility and aggressive behaviour in first episode psychosis: Results from the OPTiMiSE trial

AIM

The aim of this paper is to determine clinical factors related to hostility and disturbing and aggressive behaviour and to examine the effect of medication on these behaviours in FEP.

METHODS

Data from phase I and II of the OPTiMiSE trial are used. Outcome measures are the hostility item of the Positive and Negative Syndrome Scale (PANSS P7) and the disturbing and aggressive behaviour domain of the Personal and Social Performance scale (PSP-D).

RESULTS

Moderate, severe or extreme hostility (PANSS P7 > 3) was present in 42 patients (9.4%). The PANSS P7 and PSP-D were low to moderate but significantly associated with the selected PANSS items: delusions, hallucinatory behaviour, excitement, tension, uncooperativeness, unusual thought content, impulsivity, and lack of judgement and insight. In a subsample of 185 patients (41.5%) with baseline PANSS P7 > 1, the PANSS P7 and PSP-D scores improved in the first 4 weeks of amisulpride treatment. This effect remained significant after controlling for baseline positive symptoms (PANSS P1-P6). No significant differences were found between olanzapine and amisulpride in the second phase of the trial.

CONCLUSION

Clinical risk factors such as poor impulse control, uncooperativeness and excitement could help clinicians in detecting and treating hostile and aggressive behaviour in FEP. Amisulpride could be an effective antipsychotic choice in the treatment of FEP patients who express hostile or aggressive behaviour. Future research is needed to compare the effects of amisulpride and olanzapine on hostility in FEP during the first weeks of treatment.

Persistent cannabis use as an independent risk factor for violent behaviors in patients with schizophrenia

Although recent studies have shown a moderately strong association between cannabis use and violence among people with severe mental disorders, the direction of this association has not been investigated prospectively in a population with schizophrenia. Therefore, this study aims to determine, using cross-lag models, whether a temporal relationship between cumulative cannabis use and violence exists in a population with schizophrenia. The authors reported findings covering an 18-month period from a randomized, double-blind clinical trial of antipsychotic medications for schizophrenia treatment. Among the 1460 patients enrolled in the trial, 965 were followed longitudinally. Although persistent cannabis use predicted subsequent violence, violence did not predict cannabis use. The relationship was therefore unidirectional and persisted when controlling for stimulants and alcohol use. Finally, a significant body of evidence suggests a link between persistent cannabis use and violence among people with mental illnesses. Studies to further investigate the mechanisms underlying this association should be conducted.

Pharmacological treatment of violence in schizophrenia

Chronic aggression and violence in schizophrenia are rare, but receive disproportionate negative media coverage. This contributes to the stigma of mental illness and reduces accessibility to mental health services. Substance Use Disorders (SUD), antisocial behavior, non-adherence and recidivism are known risk factors for violence. Treatment with antipsychotic medication can reduce violence. Aside from clozapine, long-acting injectable antipsychotics (LAI) appear to be superior to oral antipsychotics for preventing violence, addressing adherence and recidivism. LAI also facilitate the implementation of functional skills training. For the high-risk recidivist target population with schizophrenia, better life skills have the potential to also reduce the risk for contact with the legal system, including an improved ability to live independently in supported environments and interact appropriately with others. High-risk patients who are resistant to treatment with other antipsychotics should receive treatment with clozapine due to its direct positive effects on impulsive violence, along with a reduction in comorbid risk factors such as SUDs.

Metacognitive Deficits Predict Impaired Insight in Schizophrenia Across Symptom Profiles: A Latent Class Analysis

The integrated model of insight in schizophrenia suggests that poor insight is the result of multiple factors which compromise persons' abilities to integrate streams of information into a personal awareness of psychiatric challenges, and make adaptive responses. This model hypothesizes that metacognitive deficits, or difficulties forming a complex and integrated understanding of the self and others, influence insight, regardless of other proximal causes including clinical profile. To explore this possibility, we performed a latent class analysis on 324 adults with schizophrenia or schizoaffective disorder. This analysis produced 4 groups on the basis of assessment of insight and Positive and Negative Syndrome Scale (PANSS) positive, negative, cognitive, and hostility symptoms. The resultant groups were characterized as: Good Insight/Low Symptoms (n = 71), Impaired Insight/High Negative Symptoms, (n = 43), Impaired Insight/High Positive Symptoms (n = 50) and Impaired Insight/Diffuse Symptoms (n = 160). When we compared metacognitive function as assessed with the Metacognition Assessment Scale - Abbreviated (MAS-A) across groups, we found that the good insight group had better overall metacognition as well as higher levels of self-reflectivity, awareness of the other and mastery as compared to all 3 groups with impaired insight. When controlling for total symptoms, all differences in metacognitive function between the good insight and the impaired insight groups remained significant. These results are consistent with the view that, independent of symptoms, impaired metacognition contributes to difficulties integrating information and hence impedes insight, or awareness of psychiatric challenges. Consistent with extant literature, results suggest that interventions focusing on metacognition as the target may lead to improved insight.

Aggressive Behavior, Hostility, and Associated Care Needs in Patients With Psychotic Disorders: A 6-Year Follow-Up Study

Background: Hostility and aggressive behavior in patients with psychotic disorders are associated with demographic and clinical risk factors, as well as with childhood adversity and neglect. Care needs are an essential concept in clinical practice; care needs in the domain of safety for others reflect the actual problem the patient has. Hostility, aggressive behavior, and associated care needs, however, are often studied in retrospect. Method: In a sample of 1,119 patients with non-affective psychotic disorders, who were interviewed three times over a period of 6 years, we calculated the incidence of hostility, self-reported maltreatment to others and care needs associated with safety for other people (safety-to-others). Regression analysis was used to analyze the association between these outcomes and risk factors. The population attributable fraction (PAF) was used to calculate the proportion of the outcome that could potentially be prevented if previous expressions of adverse behavior were eliminated. Results: The yearly incidence of hostility was 2.8%, for safety-to-others 0.8% and for maltreatment this was 1.8%. Safety-to-others was associated with previous hostility and vice versa, but, assuming causality, only 18% of the safety-to-others needs was attributable to previous hostility while 26% was attributable to impulsivity. Hostility, maltreatment and safety-to-others were all associated with number of unmet needs, suicidal ideation and male sex. Hostility and maltreatment, but not safety-to-others, were associated with childhood adversity. Neither safety-to-others, maltreatment nor hostility were associated with premorbid adjustment problems. Conclusion: The incidence of hostility, self-reported aggressive behaviors, and associated care needs is low and linked to childhood adversity. Known risk factors for prevalence also apply to incidence and for care needs associated with safety for other people. Clinical symptoms can index aggressive behaviors years later, providing clinicians with some opportunity for preventing future incidents.

Insight in schizophrenia spectrum disorders: relationship with behavior, mood and perceived quality of life, underlying causes and emerging treatments

Poor insight in schizophrenia is prevalent across cultures and phases of illness. In this review, we examine the recent research on the relationship of insight with behavior, mood and perceived quality of life, on its complex roots, and on the effects of existing and emerging treatments. This research indicates that poor insight predicts poorer treatment adherence and therapeutic alliance, higher symptom severity and more impaired community function, while good insight predicts a higher frequency of depression and demoralization, especially when coupled with stigma and social disadvantage. This research also suggests that poor insight may arise in response to biological, experiential, neuropsychological, social-cognitive, metacognitive and socio-political factors. Studies of the effects of existing and developing treatments indicate that they may influence insight. In the context of earlier research and historical models, these findings support an integrative model of poor insight. This model suggests that insight requires the integration of information about changes in internal states, external circumstances, others' perspectives and life trajectory as well as the multifaceted consequences and causes of each of those changes. One implication is that treatments should, beyond providing education, seek to assist persons with schizophrenia to integrate the broad range of complex and potentially deeply painful experiences which are associated with mental illness into their own personally meaningful, coherent and adaptive picture.

Long-acting injectable antipsychotics for prevention and management of violent behaviour in psychotic patients

BACKGROUND AND AIMS

It has been well established that long-term antipsychotic treatment prevents relapse, lowers number of rehospitalisations, and also effectively reduces violent behaviour. Although violent behaviour is not a typical manifestation of schizophrenia or other psychotic disorders, the diagnosis of psychosis increases the overall risk of violence. One of the few modifiable factors of violence risk is adherence with medication. In contrast, non-adherence with drug treatment and subsequent relapse increases risk of violent acts. Non-adherence can be addressed partially by long-acting injectable antipsychotics (LAI). The aim of our review was to examine the role of antipsychotic drugs, especially LAI, in prevention and management of violent behaviour in psychosis.

METHODS

This is a non-systematic, narrative review of the data from open, naturalistic, retrospective, and population studies, case series, and post hoc analyses of randomised controlled trials. Search of electronic databases (PubMed, Embase) was performed to identify relevant papers.

RESULTS

Nine published papers (3 cross-sectional chart reviews, 4 retrospective studies, 2 prospective, randomised trials) were found. The results indicated positive clinical and antiaggressive effects of LAI in psychotic patients with high risk of violent behaviour.

DISCUSSION

Reviewed evidence suggests that secured drug treatment with LAI may have clinical benefit in schizophrenia patients with high risk of violent behaviour. LAI significantly reduced the severity of hostility, aggressivity, number of violent incidents, and criminal offences. These findings are supported further by the empirical evidence from clinical practice, high rates of prescribed LAI to schizophrenia patients in high-security and forensic psychiatric facilities.

CONCLUSIONS

Available data encourage the use of LAI in forensic psychiatry, especially during court-ordered commitment treatment.

Serotonin Dysfunction, Aggressive Behavior, and Mental Illness: Exploring the Link Using a Dimensional Approach

Aggressive individuals have higher rates of mental illness compared to non-aggressive individuals. Multiple factors, including psychosocial, genetic, and neurobiological determinants modulate the liability to both aggressive behavior and mental illness. Concerning the latter factors, multiple lines of evidence have shown a dysfunction in the serotonin (5-HT) system occurring in aggressive and in mentally ill individuals. In particular, reduced 5-HT activity has been associated with depression as well as with aggressive behavior, especially with impulsive aggression. Consistently, psychopharmacological interventions aimed at boosting the 5-HT system (e.g., with selective serotonin reuptake inhibitors) have demonstrated therapeutic efficacy in a high percentage of patients with either or both pathological conditions. Current knowledge does not yet allow to clearly disentangle whether 5-HT dysfunction, most often a 5-HT deficiency, is the cause or the consequence of the aggressive/violent behavior, of the underlying mental disease/s, or the expression of the comorbidity. Future studies are thus needed to clarify the association between changes in 5-HT levels, altered activity of 5-HT receptors and their intracellular signaling cascades, and modifications of 5-HT genes, and in particular the neurobiological link between the altered 5-HT machinery and aggressive behavior in the context or in the absence of mental illness. In this Review, we employ a dimensional approach to discuss the trivariate relationship among the 5-HT system, aggressive behavior, and mental illness, focusing our attention on 5-HT levels, 5-HT receptors, metabolic enzymes, and their genes. Emphasis is given to controversial findings, still unanswered questions, and future perspectives.

A longitudinal analysis of the overlap between violence and victimization among adults with mental illnesses

Prior research suggests considerable overlap of violence perpetration and victimization among adults with mental illnesses. However, there has been no examination of how the likelihood of being a victim and/or perpetrator of violence may change over time, nor consideration of clinically-relevant factors affecting these transitions. In a pooled sample of adults with mental illnesses (N=3,473) we employed latent transition analysis to: (a) determine prevalence of four violence and victimization classifications (i.e., non-victim/non-perpetrator, victim only, perpetrator only, and victim-perpetrator) over a 6-month period; (b) calculate the likelihood that adults with mental illnesses will remain in or transition between these classifications over time; and (c) assess the effects of recent substance use, psychiatric symptoms, and suicidal behaviors on transitions over time. At each time point, the majority of participants identified as non-victim/non-perpetrators, followed by victim-perpetrators, victims only, and perpetrators only. Analyses also revealed many individuals transitioned between classifications over time. These distinct pathways towards, and away from, violent outcomes were, in part, a function of recent violence and/or victimization, as well as substance use, psychiatric symptoms, and suicidal behaviors. Findings inform the identification of adults with mental illnesses at risk of violence and victimization and highlight points of intervention.