The predictive value of early treatment response in antipsychotic-naive patients with first-episode psychosis: Haloperidol versus olanzapine

Early non-response as a predictor of later non-response to antipsychotics in schizophrenia: a randomized trial

BACKGROUND

It remains a challenge to predict the long-term response to antipsychotics in patients with schizophrenia who do not respond at an early stage. This study aimed to investigate the optimal predictive cut-off value for early non-response that would better predict later non-response to antipsychotics in patients with schizophrenia.

METHODS

This multicenter, 8-week, open-label, randomized trial was conducted at 19 psychiatric centers throughout China. All enrolled participants were assigned to olanzapine, risperidone, amisulpride, or aripiprazole monotherapy for 8 weeks. The positive and negative syndrome scale (PANSS) was evaluated at baseline, week 2, week 4, and week 8. The main outcome was the prediction of nonresponse. Nonresponse is defined as a < 20% reduction in the total scores of PANSS from baseline to endpoint. Severity ratings of mild, moderate, and severe illness corresponded to baseline PANSS total scores of 58, 75, and 95, respectively.

RESULTS

At week 2, a reduction of < 5% in the PANSS total score showed the highest total accuracy in the severe and mild schizophrenia patients (total accuracy, 75.0% and 80.8%, respectively), and patients who were treated with the risperidone and amisulpride groups (total accuracy, 82.4%, and 78.2%, respectively). A 10% decrease exhibited the best overall accuracy in the moderate schizophrenia patients (total accuracy, 84.0%), olanzapine (total accuracy, 79.2%), and aripiprazole group (total accuracy, 77.4%). At week 4, the best predictive cut-off value was < 20%, regardless of the antipsychotic or severity of illness (total accuracy ranging from 89.8 to 92.1%).

CONCLUSIONS

Symptom reduction at week 2 has acceptable discrimination in predicting later non-response to antipsychotics in schizophrenia, and a more accurate predictive cut-off value should be determined according to the medication regimen and baseline illness severity. The response to treatment during the next 2 weeks after week 2 could be further assessed to determine whether there is a need to change antipsychotic medication during the first four weeks.

TRIAL REGISTRATION

This study was registered on Clinicaltrials.gov (NCT03451734).

Prospects for Neurotrophic Factor-Based Early Intervention in Schizophrenia: Lessons Learned from the Effects of Antipsychotic Drugs on Cognition, Neurogenesis, and Neurotrophic Factors

Although reducing psychotic symptoms in schizophrenia has been a major focus of therapeutic interventions for decades, improving cognition is considered a better predictor of functional outcomes. However, the most commonly prescribed antipsychotic drugs (APDs) show only marginal beneficial effects on cognition in patients with schizophrenia. The neural mechanisms underlying cognitive disturbances in schizophrenia remain unknown that making drug development efforts very challenging. Since neurotrophic factors are the primary architects of neurogenesis, synaptic plasticity, learning, and memory, the findings from preclinical and clinical studies that assess changes in neurogenesis and neurotrophic factors and their relationship to cognitive performance in schizophrenia, and how these mechanisms might be impacted by APD treatment, may provide valuable clues in developing therapies to combat cognitive deficit in schizophrenia. Numerous evidence produced over the years suggests a deficit in a wide spectrum of neurotrophic factors in schizophrenia. Since schizophrenia is considered a neurodevelopmental disorder, early intervention with neurotrophic factors may be more effective in ameliorating the cognitive deficits and psychopathological symptoms associated with this pathology. In this context, results from initial clinical trials with neurotrophic factors and their future potential to improve cognition and psychosocial functioning in schizophrenia are discussed.

Homocysteine Levels and Clinical Outcomes in Schizophrenia—A Pilot Randomized Controlled Trial

Background:

There is an increasing need for proactive and individualized responses to various diseases in today’s progressive health-care fraternity. Accordingly, the approach to schizophrenia patients encompasses novel developments in the area of personalized medicine. Antipsychotic drugs in clinical practice necessitate biomarkers for the prediction of treatment outcomes and monitoring to ensure an appropriate choice of duration of chronic therapies. Hence, we studied the relation between homocysteine levels in peripheral blood and the effectiveness as well as the safety of haloperidol and olanzapine in schizophrenia treatment.

Materials and Methods:

A prospective randomized parallel-group open-label interventional clinical trial was conducted on 40 mild to moderate schizophrenia patients. To compare the efficacy of olanzapine and haloperidol Brief Psychiatric Rating Scale (BPRS) score was used. Homocysteine levels of peripheral blood and Abnormal Involuntary Movement Scale scores were evaluated.

Results:

BPRS score improved in both groups on day 14 and day 28. But significantly more with olanzapine ( P value =.001). The olanzapine group showed a higher reduction (13.91±0.47 to 9.74±0.5) in homocysteine levels than the haloperidol group. Also, the BPRS scores negatively correlated ( r = –0.66) to homocysteine levels.

Conclusion:

Therefore, our study shows that peripheral blood homocysteine levels can be used to predict and assess the treatment outcome in schizophrenia patients. Biomarker driven approach in schizophrenia will allow the patients to be treated promptly with the right drug. In this light, personalized treatment holds great potential in the future.

Physical health interventions for patients who have experienced a first episode of psychosis: a narrative review

Objectives:

Service users with severe psychiatric illnesses, such as schizophrenia, major depressive disorder and bipolar disorder, are more likely to suffer from ill health. There is evidence that lifestyle interventions, for example, exercise, dietary advice and smoking cessation programmes for service users with severe mental illness can be of health benefit. This review was carried out to identify the literature pertaining to physical health interventions for service users who have experienced a first-episode psychosis (FEP), to examine the nature of the interventions which were carried out and to assess these interventions in terms of feasibility and efficacy.

Methods:

A narrative review was conducted in August 2019 by searching ‘Pubmed’ and ‘Embase’ electronic databases. Studies investigating the effect a physical health intervention had on service users who had experienced a FEP were included in the review.

Results:

Fifteen studies met inclusion criteria: 12 quantitative studies and 3 qualitative. Exercise, dietary advice, smoking cessation and motivational coaching were some of the physical health interventions utilised in the identified studies. Positive effects were seen in terms of physical health markers wherever they were investigated, particularly when the intervention was delivered early. The impact on psychiatric symptoms and longer-term impacts on health were less frequently assessed.

Conclusions:

Physical health interventions have a positive impact on service users who have experienced a FEP. More research is warranted in this area in Ireland. These studies should include controls, have longer follow-up periods and should assess the impact on psychiatric health.

Does early antipsychotic response predict long-term treatment outcome?

OBJECTIVE

Early antipsychotic response within the first 2-3 weeks of treatment can predict short-term outcomes after several months. We conducted the current study to determine whether the predictive value of early antipsychotic response persists throughout long-term treatment over multiple years.

METHODS

In this observational study, we conducted follow-up assessments of 64 patients with first-episode psychosis an average of 25 months after they began antipsychotic treatment. Patients were initially randomized to receive haloperidol or olanzapine, but treatment after the acute hospitalization period was not controlled. Regression analyses were used to determine whether early improvement on the Brief Psychiatric Rating Scale at 2 or 3 weeks predicted longer term improvement at follow-up. We conducted secondary analyses to determine whether early response could predict extrapyramidal side effects at follow-up.

RESULTS

Early response to haloperidol at 2 weeks predicted Brief Psychiatric Rating Scale improvement on longer term follow-up (p = .002). Longer term improvement was not predicted by early response to olanzapine at 2 weeks (p = .726) or 3 weeks (p = .541). Rates of extrapyramidal side effects did not differ between treatment groups and were not predicted by early response.

CONCLUSION

These results demonstrate the long-term prognostic value of early haloperidol response. The predictive value of early olanzapine response may be less robust.

Current and potential pharmacological and psychosocial interventions for anxiety symptoms and disorders in patients with schizophrenia: structured review

OBJECTIVE

Between 30% and 62% of patients with schizophrenia present with co-morbid anxiety disorders that are associated with increased overall burden. Our aim was to summarize current and potential interventions for anxiety in schizophrenia.

DESIGN

Structured review, summarizing pharmacological and psychosocial interventions used to reduce anxiety in schizophrenia and psychosis.

RESULTS

Antipsychotics have been shown to reduce anxiety, increase anxiety, or have no effect. These may be augmented with another antipsychotic, anxiolytic, or antidepressant. Novel agents, such as L-theanine, pregabalin, and cycloserine, show promise in attenuating anxiety in schizophrenia. Psychosocial therapies have been developed to reduce the distress of schizophrenia. Cognitive behavioural therapy (CBT) has shown that benefit and refinements in the therapy have been successful, for example, for managing worry in schizophrenia. CBT usually involves more than 16 sessions, as short courses of CBT do not attenuate the presentation of anxiety in schizophrenia. To address time and cost, the development of manualized CBT to address anxiety in schizophrenia is being developed.

CONCLUSIONS

The presence of coexisting anxiety symptoms and co-morbid anxiety disorders should be ascertained when assessing patients with schizophrenia or other psychoses as a range of pharmacological and psychosocial treatments are available.

The Relationship Between Early Haloperidol Response and Associated Extrapyramidal Side Effects

BACKGROUND

Early response to antipsychotic medication within 2 weeks of initiating treatment can predict psychiatric outcomes. However, it is unclear whether early response is also predictive of extrapyramidal side effects (EPSs) associated with antipsychotic medications.

METHODS

In this study, we investigated 136 consecutive antipsychotic-naive, first-episode psychosis patients naturalistically treated with haloperidol. Patients were assessed at baseline and weekly after treatment initiation using the Brief Psychiatric Rating Scale, Hamilton Depression Rating Scale, and Hamilton Anxiety Rating Scale. Dystonia, parkinsonism, akathisia, and dyskinesia were also assessed weekly using standardized rating scales. Regression analyses were used to determine whether early response at week 2 of treatment predicted the incidence of EPS at any point during hospitalization. A secondary analysis was conducted to determine whether early response continued to predict EPS in patients who experienced no EPS within the first 2 weeks of treatment.

RESULTS

The analyses demonstrated that greater Brief Psychiatric Rating Scale percent improvement at week 2 predicted a decreased risk of EPSs (P = 0.004), even in patients who did not show any EPSs within the first 2 weeks of treatment (P = 0.005). For specific EPS, early response predicted decreased incidences of parkinsonism (P = 0.028) and dyskinesia (P = 0.025), but not akathisia or dystonia. Hamilton Depression Rating Scale and Hamilton Anxiety Rating Scale improvement at week 2 did not predict EPSs. In addition, EPSs were not predicted by the maximum antipsychotic dose received during hospitalization.

CONCLUSIONS

These results indicate that early antipsychotic response is valuable not only for predicting psychiatric outcomes, but also for predicting the risk of EPSs.