Olanzapine response in treatment-refractory schizophrenic patients with a history of substance abuse

Efficacy of Low-dose Olanzapine in Combination with Sertraline on Negative Symptoms and Psychosocial Functioning in Schizophrenia: A Randomized Controlled Trial

BACKGROUND

Evidence for the efficacy of a low dose of olanzapine (OLA) in combination with antidepressants has been limited and without positive trials in first-episode (FE) patients with schizophrenia (SCH). This study aimed to compare the efficacy in treating negative and depressive symptoms between those FE patients with SCH treated with a combination of OLA plus sertraline and those treated with OLA monotherapy.

METHODS

One hundred and ninety-six first-episode and drug naïve patients with SCH were randomized to receive low-dose OLA (7.5-10 mg/day) combined with sertraline (50-100 mg/day) (OS group) or normal-dose OLA monotherapy (12.5-20 mg/day) (NO group). Clinical symptoms were evaluated by the Positive and Negative Syndrome Scale (PANSS), and the depressive symptoms were evaluated by the Hamilton Depression Scale (HAMD). Psychosocial functioning was assessed by the Personal and Social Performance Scale (PSP).

RESULTS

In the intent-to-treat efficacy analysis, the OS group had greater decreases in negative and depressive symptoms (pall < 0.01) and a greater increase in PSP total score compared with the NO group (p < 0.01). Moreover, reductions in HAMD total score and PANSS negative subscore and sex were associated with the improvements in psychosocial functioning from baseline to week 24, after controlling for baseline psychosocial function, age, and onset age.

CONCLUSION

This study demonstrates that low-dose OLA in combination with sertraline had clinically meaningful improvements not only in the negative and depressive symptoms but also in psychosocial functioning in patients with FE-SCH, while not affecting positive symptoms.

Associations between antipsychotic use, substance use and relapse risk in patients with schizophrenia: real-world evidence from two national cohorts

BACKGROUND

Research on the effectiveness of pharmacotherapies for schizophrenia and comorbid substance use disorder (SUD) is very sparse, and non-existent on the prevention of the development of SUDs in patients with schizophrenia.

AIMS

To compare the real-world effectiveness of antipsychotics in schizophrenia in decreasing risk of developing an initial SUD, and psychiatric hospital admission and SUD-related hospital admission among patients with an SUD.

METHOD

Two independent national cohorts including all persons diagnosed with schizophrenia (N = 45 476) were followed up for 22 (Finland: 1996-2017) and 11 (Sweden: 2006-2016) years. Risk of developing an SUD was calculated with between-individual models, and risks of psychiatric and SUD-related hospital admission were calculated with within-individual models, using Cox regression and adjusted hazard ratios (aHRs) for using versus not using certain antipsychotics.

RESULTS

For patients with schizophrenia without an SUD, clozapine use (Finland: aHR 0.20, 95% CI 0.16-0.24, P < 0.001; Sweden: aHR 0.35, 95% CI 0.24-0.50, P < 0.001) was associated with lowest risk of developing an initial SUD in both countries. Antipsychotic polytherapy was associated with second lowest risk (aHR 0.54, 95% CI 0.44-0.66) in Sweden, and third lowest risk (aHR 0.47, 95% CI 0.42-0.53) in Finland. Risk of relapse (psychiatric hospital admission and SUD-related hospital admission) were lowest for clozapine, antipsychotic polytherapy and long-acting injectables in both countries. Results were consistent across both countries.

CONCLUSIONS

Clozapine and antipsychotic polytherapy are most strongly associated with reduced risk of developing SUDs among patients with schizophrenia, and with lower relapse rates among patients with both diagnoses.

Atypical antipsychotic drugs in dual disorders: current evidence and clinical guidelines

BACKGROUND

Concurrent disorder or dual diagnosis refers to a combination of substance use disorders and mental disorders that occur in the same patient simultaneously. These conditions pose significant clinical and healthcare impacts and are often underdiagnosed, undertreated, and complex to manage.

OBJECTIVE

We assessed the quality of current pharmacological recommendations for the management of dual diagnosis, particularly by evaluating the use of second-generation antipsychotics (SGA).

METHOD

A literature search was performed using the PubMed and Scopus databases for publications up to September 21, 2021, without any time restrictions. The following search strings were used: (aripiprazole OR brexpiprazole OR cariprazine OR paliperidone OR risperidone OR quetiapine OR clozapine OR olanzapine) AND (psychosis OR schizophrenia OR schizoaffective) AND ("substance use disorder" OR cocaine OR alcohol OR cannabis OR heroin OR "double diagnosis" OR "dual diagnosis")) NOT (animal OR rat OR mouse) NOT (review or meta-analysis).

RESULTS

The search produced a final set of 41 articles. Most patients were males and were affected by schizophrenia, with cannabis the most abused substance, followed by alcohol. Aripiprazole was the most used drug, either orally or by long-acting formulations, followed by risperidone with oral and long-acting formulations, clozapine, olanzapine, and quetiapine.

CONCLUSION

The findings highlight the use of SGA for the treatment of psychotic symptoms in comorbidity with substance use. Future studies on people with dual diagnosis and focused on long-term evaluations are warranted and need to investigate the efficacy of newly introduced molecules, such as partial D2 agonists and long-acting injectable antipsychotics.

Pharmacotherapy in dual diagnosis

The prevalence of coexisting substance misuse and psychiatric disorder (dual diagnosis, comorbidity) has increased over the past decade, and the indications are that it will continue to rise. There have simultaneously been unprecedented developments in the pharmacological treatment of alcohol, opiate and nicotine misuse. Here we evaluate the evidence on the use of some of these treatments in dual diagnosis (with psychotic, mood and anxiety disorders). The evidence base is limited by the exclusion of mental illness when pharmacological agents for substance misuse are evaluated and vice versa. We set the available information within the context of the psychosocial management of comorbid substance misuse and mental illness, and the framework for service delivery recommended by UK national policy.

Antipsychotic efficacy in psychosis with co-morbid cannabis misuse: A systematic review

The prevalence of cannabis use in patients with psychotic mental illness is known to be high and is suspected to exacerbate symptoms and worsen prognosis. We aimed to evaluate evidence of antipsychotic efficacy in reducing the burden of psychotic symptoms and cannabis use in individuals with psychotic mental illness and co-morbid cannabis use. A systematic review was conducted of antipsychotic treatment in those with psychotic mental illness and co-morbid cannabis use. Quality of evidence for each study and outcomes were rated using the 'GRADE' approach. Twenty-two studies were identified: 13 experimental and 9 observational, including a total sample of 1543 patients, 761 of whom had a diagnosed cannabis use disorder. The most frequent antipsychotics compared were risperidone, olanzapine and clozapine with olanzapine, risperidone and haloperidol. No clear differences between antipsychotics were demonstrated. Future studies are needed to confirm whether clozapine is superior to other antipsychotics in reducing cannabis use.

Effectiveness of short-term olanzapine in patients with bipolar I disorder, with or without comorbidity with substance use disorder

OBJECTIVES

Prognosis of comorbid bipolar disorder (BD) and drug abuse is poor. We assessed the efficacy of olanzapine in manic or mixed BD patients, with (SUD) or without (N-SUD) comorbidity with substance use disorder (SUD) and its effect on drug abuse, days of abuse, and craving.

METHODS

Eighty patients with BD-I (40 SUD) were hospitalized for a manic or mixed episode and received add-on olanzapine. Assessments were conducted at admission, discharge, and 4 and 8 weeks after discharge. Primary outcome was the proportion of responders and remitters in each group. We used a logistic regression model to adjust for possible confounders. We assessed craving and drug-abuse days with a visual analog scale and the Timeline Follow-Back.

RESULTS

SUD and N-SUD were similar on response and remission, adjusted for sex, age, years ill, age at first episode, first episode depressive, number of hospitalizations, and duration of hospitalization (odds ratio, 1.09; 95% confidence interval, 1.02-2.29). Mood rating scores dropped significantly from baseline to end point in both groups. Timeline follow-back decreased in SUD from 22.5 to 7.3 at 8 weeks postdischarge, whereas craving dropped from 8.3 to 5.1 (P < 0.03).

CONCLUSIONS

The effectiveness of short-term olanzapine in BD-I mania or mixed mania did not differ according to SUD comorbidity. Treatment was followed by less substance use/abuse and craving in comorbid bipolar-SUD patients.

World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for Biological Treatment of Schizophrenia, part 1: update 2012 on the acute treatment of schizophrenia and the management of treatment resistance

These updated guidelines are based on a first edition of the World Federation of Societies of Biological Psychiatry Guidelines for Biological Treatment of Schizophrenia published in 2005. For this 2012 revision, all available publications pertaining to the biological treatment of schizophrenia were reviewed systematically to allow for an evidence-based update. These guidelines provide evidence-based practice recommendations that are clinically and scientifically meaningful and these guidelines are intended to be used by all physicians diagnosing and treating people suffering from schizophrenia. Based on the first version of these guidelines, a systematic review of the MEDLINE/PUBMED database and the Cochrane Library, in addition to data extraction from national treatment guidelines, has been performed for this update. The identified literature was evaluated with respect to the strength of evidence for its efficacy and then categorised into six levels of evidence (A-F; Bandelow et al. 2008b, World J Biol Psychiatry 9:242). This first part of the updated guidelines covers the general descriptions of antipsychotics and their side effects, the biological treatment of acute schizophrenia and the management of treatment-resistant schizophrenia.

The Potential Role of Long-acting Injectable Antipsychotics in People with Schizophrenia and Comorbid Substance Use

OBJECTIVE: Treatment of schizophrenia in patients with comorbid substance use (alcohol/illicit drug use, abuse or dependence) presents challenges for public health systems. Substance use in people with schizophrenia is up to four times greater than the general population and is associated with medication nonadherence and poor outcomes. Therefore, continuous antipsychotic treatment in this population may pose more of a challenge than for those with schizophrenia alone. Many clinical trials and treatment recommendations in schizophrenia do not take into consideration substance use as people with comorbid substance use have typically been excluded from most antipsychotic trials. Nonetheless, antipsychotic treatment appears to be as efficacious in this population, although treatment discontinuation remains high. The objective of this review was to highlight the importance and utility of considering long-acting injectable antipsychotics for patients with schizophrenia and comorbid substance use. METHODS: We did a literature search using PubMed with key words schizophrenia and substance use/abuse/dependence, nonadherence, antipsychotics, long acting injectables, relapse, and psychosocial interventions. We limited our search to human studies published in English and 4,971 articles were identified. We focused on clinical trials, case reports, case series, reviews and meta-analyses resulting in 125 articles from 1975-2011. RESULTS: Our review suggests the potential role of long-acting injectables for people with comorbid substance use and schizophrenia in leading to improvements in psychopathology, relapse prevention, fewer rehospitalizations, and better outcomes. CONCLUSIONS: While more research is needed, long-acting antipsychotics should be considered an important option in the management of people with schizophrenia and comorbid substance use.

Evolution of Substance use, Neurological and Psychiatric Symptoms in Schizophrenia and Substance use Disorder Patients: A 12-Week, Pilot, Case-Control Trial with Quetiapine

Neurological and psychiatric symptoms are consequences of substance abuse in schizophrenia and non-schizophrenia patients. The present case-control study examined changes in substance abuse/dependence, and neurological and psychiatric symptoms in substance abusers with [dual diagnosis (DD) group, n = 26] and without schizophrenia [substance use disorder (SUD) group, n = 24] and in non-abusing schizophrenia patients (SCZ group, n = 23) undergoing 12-week treatment with the atypical antipsychotic, quetiapine. Neurological and psychiatric symptoms were evaluated with the Positive and Negative Syndrome Scale, the Calgary Depression Scale for Schizophrenia, the Extrapyramidal Symptoms Rating Scale, and the Barnes Akathisia Rating Scale. At endpoint, DD and SCZ patients were receiving significantly higher doses of quetiapine (mean = 554 and 478 mg/day, respectively), relative to SUD patients (mean = 150 mg/day). We found that SUD patients showed greater improvement in weekly dollars spent on alcohol and drugs and SUD severity, compared to DD patients. At endpoint, there was no significant difference in dollars spent, but DD patients still had a higher mean SUD severity. Interestingly, DD patients had significantly higher parkinsonism and depression than SCZ patients at baseline and endpoint. On the other hand, we found that SUD patients had significantly more akathisia at baseline, improved more than SCZ patients, and this was related to cannabis abuse/dependence. Finally, SUD patients improved more in Positive and Negative Syndrome Scale positive scores than DD and SCZ patients. Taken together, our results provide evidence for increased vulnerability to the adverse effects of alcohol and drugs in schizophrenia patients. They also suggest that substance abuse/withdrawal may mimic some symptoms of schizophrenia. Future studies will need to determine the role quetiapine played in these improvements.

Substance abuse is associated with increased extrapyramidal symptoms in schizophrenia: a meta-analysis

BACKGROUND

Psychoactive substances (PAS) may interact with antipsychotics in the development of extrapyramidal symptoms (EPS) in schizophrenia. PAS exert acute and chronic impacts on the basal ganglia. Clinical data have been gathered about the effects of PAS on EPS in schizophrenia, producing inconsistent results. This meta-analysis sought to determine whether PAS enhance EPS in schizophrenia patients.

METHODS

A search of the literature using computerized engines was undertaken. Studies were retained in the analysis if: (i) they included schizophrenia patients with and without substance abuse; and (ii) they comprised a measure of EPS using valid instruments.

RESULTS

Sixteen studies available were identified, involving 3479 patients. The composite analysis revealed a small and positive effect size (g=0.260), suggesting increased EPS in substance-abusing patients. Cocaine was associated with the largest effect size estimate (g=0.613). Dual diagnosis patients were more frequently males than single diagnosis patients. Thus, we performed a sub-analysis of studies with no confounders (e.g. age, sex and/or symptoms). The pooling of these 10 studies produced a moderate and positive effect size (g=0.401).

DISCUSSION

Our results show that PAS negatively impact on EPS in schizophrenia, especially when potential confounding factors are controlled. Cocaine emerged as the PAS with the most deleterious effects on EPS in schizophrenia. Our results have implications for the prevention of EPS in schizophrenia and for the design of future studies on the topic.

Pharmacological treatment of schizophrenia and co-occurring substance use disorders

Substance abuse among individuals with schizophrenia is common and is often associated with poor clinical outcomes. Comprehensive, integrated pharmacological and psychosocial treatments have been shown to improve these outcomes. While a growing number of studies suggest that second-generation antipsychotic medications may have beneficial effects on the treatment of co-occurring substance use disorders, this review suggests that the literature is still in its infancy. Few existing well controlled trials support greater efficacy of second-generation antipsychotics compared with first-generation antipsychotics or any particular second-generation antipsychotic. This article focuses on and reviews studies involving US FDA-approved medications for co-occurring substance abuse problems among individuals with schizophrenia.Comprehensive treatment for individuals with schizophrenia and co-occurring substance use disorders must include specialized, integrated psychosocial intervention. Most approaches use some combination of cognitive-behavioural therapy, motivational enhancement therapy and assertive case management. The research on antipsychotic and other pharmacological treatments is also reviewed, as well as psychosocial treatments for individuals with schizophrenia and co-occurring substance use disorders, and clinical recommendations to optimize care for this population are offered.

Standard and higher dose of olanzapine in patients with schizophrenia or schizoaffective disorder: a randomized, double-blind, fixed-dose study

The objective of this study was to assess the dose-response relationship of standard and higher doses of olanzapine in a randomized, double-blind, 8-week, fixed-dose study comparing olanzapine 10 (n = 199), 20 (n = 200), and 40 mg/d (n = 200) for patients with schizophrenia or schizoaffective disorder and suboptimal response to current treatment. Patients meeting criteria for antipsychotic treatment resistance were excluded. Dose-response relationship was assessed by linear regression analysis with log-transformed dose (independent variable) and Positive and Negative Syndrome Scale (PANSS) total score (dependent variable). There were no significant dose group differences in patients completing the study (overall, 67.8%). All dose groups showed statistically significant improvement in PANSS total scores from baseline to end point without significant dose-response relationship (P = 0.295). Post hoc analysis of response showed significant interaction between baseline PANSS and dose (P = 0.023), indicating better response at higher doses for patients with higher baseline PANSS. There was a significant dose response for mean change in weight (P = 0.003) with significant difference between the 10- and 40-mg-dose groups (P = 0.002; 1.9 [10 mg/d], 2.3 [20 mg/d], and 3.0 kg [40 mg/d]). There was a significant dose response for change in prolactin (P < 0.001) with a significant difference between each group (-10.5 [10 mg/d], -1.7 [20 mg/d], and 4.9 ng/mL [40 mg/d]; P < or = 0.018). Over 8 weeks, non-treatment-resistant patients with schizophrenia or schizoaffective disorder responded to all 3 doses of olanzapine, without a statistically significant dose-response relationship, suggesting that for many patients with schizophrenia or schizoaffective disorder, particularly those who are mildly or moderately ill, 10 mg/d should be the initial dose of choice.

Pharmacotherapy of schizophrenia with comorbid substance use disorder--reviewing the evidence and clinical recommendations

Substance use disorder is the most common psychiatric comorbidity in schizophrenic patients, with prevalence rates of up to 65%. Recommendations for antipsychotic pharmacotherapy in schizophrenia are based on studies that excluded patients with this dual diagnosis. In the present comprehensive systematic review, the pharmacological studies performed in this subgroup of patients are summarised and discussed from the standpoint of evidence-based medicine. Unfortunately, randomized controlled studies, providing a high evidence level, in patients with this dual diagnosis are rare. Data, mainly based on open studies or case series, suggest superior efficacy for second generation antipsychotic agents (SGAs) (aripiprazole, clozapine, olanzapine, quetiapine, risperidone) with regard to improvement of distinct psychopathological symptoms, reduced craving and greater reduction of substance use compared with orally administered conventional antipsychotics (FGAs). Tricyclic antidepressants given adjunctive to antipsychotic maintenance therapy showed efficacy in reducing substance use and craving. The administration of anti-craving agents (naltrexone) led to a decrease of drug intake. Unfortunately, there is no clinical experience with acamprosate in schizophrenic patients with comorbid alcoholism. In conclusion, there are more theoretically based arguments for the preferential use of SGAs in schizophrenic patients with comorbid substance use disorder while the empirical evidence is weak. The early initiation of treatment with antidepressants, depending on the patient's psychopathology, as well as add-on medication with anti-craving agents should be considered.

Time to rehospitalization of clozapine versus risperidone in the naturalistic treatment of comorbid alcohol use disorder and schizophrenia

Clozapine is known to be effective in treating schizophrenia patients with comorbid alcohol use disorders (AUD). However, few prospective studies have examined the effect of clozapine on community survival of the patient, which is one of the most important indicators of success for patients with schizophrenia. In this prospective, naturalistic, observational, community-survival-analysis study, we compared the effect of clozapine and risperidone on two-year psychiatric hospitalization rate and time to hospitalization in the treatment of patients with schizophrenia and comorbid AUD. We found that the clozapine treated patients were readmitted to hospital significantly later (mean survival=526.5 days, n=25 patients) than the risperidone treated patients (mean survival=420.4 days, n=36 patients). The survival curve for the clozapine-treated patients was significantly different from that of the risperidone treated patients (log-rank test, df=1, p=.045). At the end of the two-year study period, 75% of the risperidone treated patients had been admitted to the hospital, compared to only 48% of the clozapine treated patients. These findings suggest that clozapine should be considered for the treatment of schizophrenia patients with comorbid AUD. However, due to the limitations of this study, further studies will be required to confirm these findings.

Clozapine and "high-dose" olanzapine in refractory early-onset schizophrenia: a 12-week randomized and double-blind comparison

BACKGROUND

The present study evaluated the effectiveness and safety of clozapine versus "high-dose" olanzapine in treatment-refractory adolescents with schizophrenia.

METHODS

Children, ages 10-18 years, who met DSM-IV criteria for schizophrenia and who were resistant or intolerant to at least two antipsychotic drugs were randomized to receive 12 weeks of double-blind flexibly dosed treatment with clozapine (n = 18) or "high-dose" olanzapine (up to 30 mg/day) (n = 21). The primary efficacy measure was response (improvement), defined as a decrease of 30% or more in total Brief Psychiatric Rating Scale score from baseline and a Clinical Global Impression Scale improvement rating of "1" (very much improved) or "2" (much improved).

RESULTS

Significantly more clozapine-treated adolescents met response criteria (66%) compared with olanzapine-treated subjects (33%). Clozapine was superior to olanzapine in terms of reduction of the psychosis cluster scores and negative symptoms from baseline to end point. However, both treatments were associated with significant weight-gain and related metabolic abnormalities.

CONCLUSIONS

This double-blind randomized comparison of two second-generation antipsychotic drugs for treatment-refractory adolescents with schizophrenia supports clozapine as the agent of choice. The development of interventions to limit weight gain and metabolic side effects are needed to enhance the risk-benefit profile for both study treatments.

Pharmakotherapie bei Schizophrenie und komorbider Substanzstörung

Substance use disorder is the most common psychiatric comorbidity in patients with schizophrenia, revealing prevalence rates of up to 65%. Recommendations of antipsychotic pharmacotherapy in schizophrenia are based on studies excluding patients with this double diagnosis. In this systematic review the available pharmacological studies in this subgroup of patients are summarised and discussed with regard to evidence-based medicine. Most available studies concern small sample sizes, and the level of evidence in those studies was low. Data suggest efficacy for second-generation antipsychotics (SGAs) (aripiprazole, clozapine, olanzapine, quetiapine, and risperidone) superior to orally administered conventional antipsychotics. Treatment with SGAs revealed superior improvement of distinct psychopathological symptoms, similarly to those studies excluding patients with comorbid substance abuse. In some studies reduced craving and increased reduction of substance abuse could be demonstrated. Tricyclic antidepressants (TCAs) added to antipsychotic maintenance therapy showed efficacy in reducing substance abuse and craving, whereas studies with other antidepressive agents (e.g. selective serotonin reuptake inhibitors) are lacking. Administration of the anti-craving agents naltrexone and disulfiram led to a decrease of drug intake in a few studies. Unfortunately no studies are available using acamprosate in patients with schizophrenia and comorbid alcoholism. In conclusion the preferential use of SGAs in patients with schizophrenia and comorbid substance use disorder is suggested, and the early initiation of concomitant treatment with TCAs (depending on current psychopathological status) and anti-craving agents has to be considered.

Substance abuse and schizophrenia: pharmacotherapeutic intervention

Substance use disorder is common in patients with schizophrenia and dramatically worsens their outcome. The typical antipsychotic medications, introduced more than 50 years ago, are effective for the treatment of psychosis but may have only limited efficacy in patients with these co-occurring disorders because patients continue to use substances while taking them. In preliminary studies, however, several of the atypical antipsychotic medications have shown promise for reducing alcohol and drug use in patients with schizophrenia. A neurobiological formulation is discussed, suggesting that the use of substances in patients with schizophrenia may be based on a dysfunction within the dopamine-mediated brain reward circuitry and that clozapine, in particular, may potentially ameliorate this dysfunction and lessen the desire for substance use. Medications for the treatment of alcohol use disorders, such as disulfiram, naltrexone, and acamprosate, as well as other adjunctive medications, may also be useful. Further studies are required to establish a solid evidence base of best practices for the use of medications in these patients.

Pharmacotherapy for schizophrenia and co-occurring substance use disorders

Substance use disorder (SUD) occurs commonly in patients with schizophrenia and is associated with a poor outcome. Despite this common co-morbid occurrence (and its negative impact on the course of schizophrenia), there have been very few studies assessing pharmacological strategies for optimal treatment of these patients. A number of theories have been advanced to help explain the high rate of substance use disorder in patients with schizophrenia. Our group has suggested that the brain reward circuit dysfunction model, which may incorporate aspects of all of these models, may help direct research aimed at developing new pharmacological treatments for patients with schizophrenia and co-occurring SUD. Although typical antipsychotic medications appear to be of limited value in these patients, emerging, but preliminary, data suggest that the atypical antipsychotics, particularly clozapine, may be particularly helpful. The role of adjunctive medications, such as those medications that have recently been shown to be useful for the treatment of alcoholism, may have a role in the treatment of these patients, although only naltrexone has, thusfar, been carefully tested in these comorbid patients. Further studies are indicated to assess the role of novel pharmacologic treatment strategies for these patients. Ultimately, any medication given to these patients will need to be prescribed within psychosocial treatment programs aimed at assisting these patients in limiting and ultimately ceasing substance use.

Antipsychotic drug treatment of schizophrenic patients with substance abuse disorders

BACKGROUND/AIM

In recent years, there has been a growing interest in developing adequate treatments for patients with a diagnosis of schizophrenia and a comorbid substance use disorder (SUD). In the present paper we aim to critically review published reports on the use of conventional and second-generation antipsychotics in the treatment of patients with schizophrenia and comorbid SUD, to provide clinicians with a clearer view of the pharmacological treatment of this highly prevalent dual diagnosis based upon the evidence arising from the scientific literature.

METHODS

A search of the relevant literature from Medline, PsycLIT and EMBASE databases, included in the Science Citation Index, and available up to November 2006 was conducted using the terms: 'schizophrenia', 'substance use disorder' and 'antipsychotics'.

RESULTS

While research on the use of conventional antipsychotics has remained limited, the majority of studies suggest the effectiveness of second-generation antipsychotics, particularly clozapine, for patients with schizophrenia and a comorbid substance use disorder.

CONCLUSION

In the absence of randomized controlled trials that could provide more reliable information, clinical decisions may need to rely on indirect data provided by the increasing number of case reports, open trials and retrospective studies showing a decrease in cigarette smoking, alcohol, cocaine or cannabis use and an improvement of overall psychiatric symptoms.

Treatment-refractory schizophrenia in children and adolescents: an update on clozapine and other pharmacologic interventions

Treatment-refractory early-onset schizophrenia is a rare but severe form of the disorder associated with poor premorbid function and long-term disability. The currently available evidence suggests that clozapine remains the most efficacious treatment for the amelioration of both positive and negative symptoms of the disorder and problematic aggressive behaviors. Clozapine use in children and adolescents, however, is limited by its association with hematologic adverse events and an increased frequency of seizure activity. Further studies are needed to examine the usefulness of antipsychotic combinations and of augmentation therapies to antipsychotic medications in order to treat persistent residual psychotic symptoms in children and adolescents who have schizophrenia and who have not responded to several sequential trials of antipsychotic monotherapy.

World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of schizophrenia, Part 1: acute treatment of schizophrenia

These guide lines for the biological treatment of schizophrenia were developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBO). The goal during the development of these guidelines was to review systematically all available evidence pertaining to the treatment of schizophrenia, and to reach a consensus on a series of practice recommendations that are clinically and scientifically meaningful based on the available evidence. These guidelines are intended for use by all physicians seeing and treating people with schizophrenia. The data used for developing these guidelines have been extracted primarily from various national treatment guidelines and panels for schizophrenia, as well as from meta-analyses, reviews and randomised clinical trials on the efficacy of pharmacological and other biological treatment interventions identified by a search of the MEDLINE database and Cochrane Library. The identified literature was evaluated with respect to the strength of evidence for its efficacy and then categorised into four levels of evidence (A-D). This first part of the guidelines covers disease definition, classification, epidemiology and course of schizophrenia, as well as the management of the acute phase treatment. These guidelines are primarily concerned with the biological treatment (including antipsychotic medication, other pharmacological treatment options, electroconvulsive therapy, adjunctive and novel therapeutic strategies) of adults suffering from schizophrenia.

Improving the care of individuals with schizophrenia and substance use disorders: consensus recommendations

National attention continues to focus on the need to improve care for individuals with co-occurring mental illnesses and substance use disorders, as emphasized in the 2003 President's New Freedom Commission Report on Mental Health and recent publications from the Substance Abuse and Mental Health Services Administration (SAMHSA). These reports document the need for best practice recommendations that can be translated into routine clinical care. Although efforts are underway to synthesize literature in this area, few focused recommendations are available that include expert opinion and evidence-based findings on the management of specific co-occurring disorders, such as schizophrenia and addiction. In response to the need for user-friendly recommendations on the treatment of schizophrenia and addiction, a consensus conference of experts from academic institutions and state mental health systems was organized to 1) frame the problem from clinical and systems-level perspectives; 2) identify effective and problematic psychosocial, pharmacological, and systems practices; and 3) develop a summary publication with recommendations for improving current practice. The results of the consensus meeting served as the foundation for this publication, which presents a broad set of recommendations for clinicians who treat individuals with schizophrenia. "Integrated treatment" is the new standard for evidence-based treatment for this population and recommendations are given to help clinicians implement such integrated treatment. Specific recommendations are provided concerning screening for substance use disorders in patients with schizophrenia, assessing motivation for change, managing medical conditions that commonly occur in patients with dual diagnoses (e.g., cardiovascular disease, liver complications, lung cancer, HIV, and hepatitis B or C infections) and selecting the most appropriate medications for such patients to maximize safety and minimize drug interactions, use of evidence-based psychosocial interventions for patients with dual diagnoses (e.g., Dual Recovery Therapy, modified cognitive-behavioral therapy, modified motivational enhancement therapy, and the Substance Abuse Management Module), and key pharmacotherapy principles for treating schizophrenia, substance use disorders, and comorbid anxiety, depression, and sleep problems in this population. Finally the article reviews programmatic and systemic changes needed to overcome treatment barriers and promote the best outcomes for this patient population. An algorithm summarizing the consensus recommendations is provided in an appendix.

Cocaine abuse in schizophrenic patients treated with olanzapine versus haloperidol

Comorbid cocaine abuse adversely affects clinical outcomes in schizophrenia. Using a prospective, randomized, parallel group design (N = 24), we tested the hypothesis that patients with schizophrenia treated with olanzapine have reduced cocaine craving and abuse compared with those treated with haloperidol. In addition, we examined whether this differential effect correlated with reductions in extrapyramidal symptoms, positive and negative symptoms, and/or depression. There were no significant differences overall in proportions of positive drug screens between treatment groups; no differences in positive, negative, or depressive symptoms; and few differences between treatment conditions in extrapyramidal symptoms. However, craving for cocaine was rated significantly lower by patients treated with haloperidol compared with patients treated with olanzapine. Important study limitations include a small sample size and high attrition rates. Larger controlled studies are necessary to determine optimal antipsychotic therapy for patients with schizophrenia and comorbid cocaine abuse.

The impact of European regulatory policies on psychotropic drug prescribing patterns

Thanks to their alleged better tolerability atypical or second-generation antipsychotic drugs (SGA) have gained a considerable fraction of the market at the expense of the classical antipsychotics. The massive advertising of SGA focussed the doubtful reduction of extra-pyramidal side effects (EPS) overlooking the information about the cardiovascular risk induced by SGA. This also led to extensive off-label use as the control of behavioural symptoms associated with dementia in elderly patients. Although the European Medicine Agency (EMEA) eventually warned physicians and patients of the risk associated with SGA use in this area, the regulatory system has some responsibility in this situation. No added therapeutic value is required for new drugs to be approved for the market. They are only evaluated for their own quality, efficacy and safety with no comparison with available alternative treatments. This implies that new drugs may, in fact, be potentially less effective or less safe than other drugs currently in use.

Risk:benefit assessment of old medicines

Any meaningful discussion about the present value of old drugs requires appropriate comparisons with new drugs. While there is noisy propaganda claiming the superiority of new drugs, the evidence supporting these claims is often scanty and poor. Therefore, the database utilizable to evaluate old and new drugs is incomplete and fragile. There are several reasons, including the poor dossiers presented for the approval of new drugs, the lack of comparisons aimed at showing superiority of new drugs, the bias frequently involved in clinical trials and the conflict of interests. This brief discussion reviews these questions and gives some examples by comparing diuretics and new antihypertensive agents, ticlopidine and clopidogrel, and atypical and classical antipsychotic agents.

Clozapine, quetiapine and olanzapine among addicted schizophrenic patients: towards testable hypotheses

Although life prevalence of substance use disorders among patients with schizophrenia is close to 50%, few studies have been carried out to date to identify an integrated pharmacological treatment for this comorbidity. So far, the most promising results, that we report here, have been obtained with clozapine. To a lesser extent, quetiapine and olanzapine, both clozapine analogues, have also shown promising results. Further to these observations, the present paper critically reviews the advantages associated with clozapine, quetiapine and olanzapine, and their relevance to the treatment of addiction among schizophrenic patients. Six characteristics seem to distinguish clozapine, quetiapine and olanzapine from the first-generation antipsychotics: (1) acting preferentially on the reward system, these second-generation antipsychotics (mainly clozapine and quetiapine) induce almost no extrapyramidal symptoms; (2) quickly dissociating from D(2), theses drugs (mainly clozapine and quetiapine) seem not to induce dysphoria, unlike conventional antipsychotics like haloperidol;(3) these drugs (mainly clozapine) seem more effective in the treatment of negative symptoms than conventional antipsychotics; (4) because of a diversified activity on several serotoninergic and noradrenergic receptors, these drugs positively alter mood, which does not seem to be the case with conventional antipsychotics, except for flupenthixol; (5) these drugs have a positive impact on cognition, which is not the case with the first-generation antipsychotics; (6) unlike conventional antipsychotics, these drugs seem to have a moderate affinity for 5-HT(3), the receptor on which ondansetron, an anti-craving medication, acts.

Clozapine treatment in patients with prior substance abuse

OBJECTIVE

This study examined outcomes following discharge on clozapine for treatment-resistant schizophrenia patients with and without diagnosed substance abuse histories.

METHODS

Those discharged on clozapine from a research unit between April 1991 and March 1996 were followed with respect to hospitalization status. Of the treatment-resistant patients with schizophrenia, 19 were diagnosed as individuals with substance abuse, while 26 patients had no history of abuse. Patients were openly treated with clozapine and were included in the study if they were stabilized and discharged on the medication.

RESULTS

Patients who had histories of abuse exhibited a better treatment response and a lower total Brief Psychiatric Rating Scale (BPRS) score at discharge, compared with the non-substance abuse group. One-year readmission rates were 21% and 23% in patients with and without prior substance abuse histories, respectively (P = ns).

CONCLUSIONS

Clozapine may be a therapeutic option for the dually diagnosed population and may offer benefits to patients with schizophrenia who have a history of substance abuse.

Treatment with the atypical antipsychotic, olanzapine, prevents the expression of amphetamine-induced place conditioning in the rat

Place conditioning (PC) experiments were conducted as a means to further elaborate the treatment potential of the atypical antipsychotic, olanzapine (OLZ), for stimulant abuse. The resulting preference/aversion provides an indirect measure of the incentive salience (i.e., euphoria/dysphoria) produced by a drug. Male Sprague-Dawley rats (n=48) were conditioned in two unique environments (i.e., vertical vs. horizontal stripped walls, large vs. small grid flooring) using injections (1.0 mg/kg ip) of either amphetamine (AMPH) or saline (SAL). On average, animals displayed a significant preference for the AMPH-paired location after 2.5 weeks of conditioning (five pairings each of AMPH and SAL). Once the preference was established, animals were pretreated (60 min) with a single dose of OLZ (0.0, 0.56, 1.0 or 1.5 mg/kg sc) given on the test (AMPH-free) day. For the following week's test, animals were injected with SAL (1.0 mg/kg ip) in an attempt to recapture the side preference exhibited before OLZ treatment. OLZ treatment prevented the expression of the AMPH-conditioned preference and reduced locomotor activity. Inhibition of preference resulted from the highest dose of OLZ (1.5 mg/kg), while the inhibition of locomotor activity occurred across all three doses. Additionally, while the effects on preference were no longer apparent by the SAL test the following week (reversible), the activity was still depressed during the SAL tests in animals that had experienced the highest dose of OLZ (1.5 mg/kg). Control experiments, in which OLZ was used as the conditioning drug, suggest that OLZ itself possesses no aversive effects in the PC paradigm, and may even produce a preference for the drug-paired chamber. Because the AMPH preference is dependent on dopamine (DA) release in the nucleus accumbens (NAcc), these experiments suggest that OLZ pretreatment interferes with the rewarding, as well as the subjective effects of AMPH.

An economic assessment of quetiapine and haloperidol in patients with schizophrenia only partially responsive to conventional antipsychotics

BACKGROUND

Many patients with schizophrenia exhibit only a partial response to conventional antipsychotic agents, making them difficult to treat adequately.

OBJECTIVE

This analysis models the cost-effectiveness of quetiapine compared with haloperidol in partial responders with schizophrenia.

METHODS

Outcome data from the Partial Responders International schiZophrenia Evaluation (PRIZE) clinical trial comparing quetiapine and haloperidol in partial responders with schizophrenia as defined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition were combined with data from the literature to construct a Markov model. The model was used to calculate treatment outcomes and total direct treatment costs from the perspective of the United Kingdom National Health Service over 5 years.

RESULTS

The PRIZE study showed that quetiapine treatment resulted in a higher response rate and better tolerability than haloperidol treatment. These benefits have the potential to improve compliance and reduce relapse rates. The model showed that the higher acquisition cost of quetiapine was offset by lower costs for other medications, hospitalization, and other medical services. The total treatment cost over 5 years was 38,106 pounds for quetiapine and 38,350 pounds for haloperidol, a cost saving of 244 pounds in favor of quetiapine. Quetiapine-treated patients also spent longer in response states and experienced fewer relapses. Sensitivity analysis showed these results to be robust across a range of conditions.

CONCLUSIONS

Quetiapine has the potential to improve outcomes compared with haloperidol in partial responders with schizophrenia, at a slightly lower total cost. The higher acquisition cost of quetiapine was offset by savings in other medical costs. Quetiapine could significantly improve the management of this patient group, without increasing the economic burden on the health service.

Substance abuse among patients with schizophrenia

Substance use in the general population is a significant public health problem. Problems associated with substance use are aggravated by concomitant psychiatric illness, particularly schizophrenia and schizoaffective disorder. Although there is a general agreement on the need to address this problem, a wide range of opinions exists on exactly what is the best modality. In this article, we provide a brief overview of the etiology and consequences of substance use in individuals with schizophrenia, followed by a more detailed review of pharmacological and psychotherapeutic trends in the treatment of this population. Research studies indicate that, while some evidence supports the self-medication hypothesis, individuals with schizophrenia or schizoaffective disorder frequently use substances for the same reasons and in the same manner as the general population. In the pharmacotherapy section, we briefly discuss the rationale for current medication strategies, their efficacy, and directions for future research. This is followed by an assessment of current psychotherapeutic interventions, their limitations, and potential modifications to improve treatment outcome. The research literature suggests that integrated treatment and well-tailored interventions that take into account psychosocial factors and motivation offer the most promise for the future. More controlled trials are necessary to validate this hypothesis.

Olanzapine treatment for patients with schizophrenia and substance abuse

The objective of this study was to evaluate the efficacy and safety of olanzapine in patients with schizophrenia and comorbid substance abuse disorders. Thirty patients who met DSM-IV criteria for schizophrenia or schizoaffective disorder as well as criteria for substance abuse or substance dependence, were treated in a 12-month prospective, open-label trial of olanzapine. Patients were evaluated with multiple efficacy and safety measures at baseline and then monthly thereafter. Statistically significant improvement was noted in psychopathology, levels of hope, and safety measures. Seventy percent (n = 21) of the patients achieved early full substance abuse remission at the end of the study period, while 30% (n = 9) achieved early partial substance abuse remission. Our results indicate that olanzapine treatment improved psychopathology, increased hopefulness, and reduced antipsychotic-associated side effects. The benefits observed with olanzapine treatment may contribute to the patients' substance abuse remission.

Treatment of the special patient with schizophrenia

Special patient populations with schizophrenia have received little attention. These populations include adolescents, the elderly, substance abusers, and patients who are considered treatment-resistant. Interest in these populations is rapidly growing, especially with regard to their treatment with second-generation antipsychotics. This article describes the treatment of special patient populations and summarizes the research that has been done in this field.

Addiction and schizophrenia

Epidemiologic studies in the general population and those based on the clinical assessment of schizophrenic populations have revealed a high degree of overlap between schizophrenia and addictive disorders. The abuse of psychoactive substances (including alcohol) throughout life is so frequent (50%) that the possibility of a specific link inevitably arises. Various hypotheses have been suggested to explain the high co-morbidity between schizophrenia and addiction: 1) The social-environmental hypothesis has been developed but studies have provided poor evidence to validate it. 2) The possible shared biological vulnerability between schizophrenia and addictions led researchers to explore common genetic determinants and study the involvement of the dopaminergic and opioid systems in the aetiology of both schizophrenia and the abuse of and dependence on psychoactive drugs. 3) Finally, the theory of self-medication suggests that schizophrenics may be attempting to counter the deficit linked to their disorders by using the substances they take or their dependency-type behaviour to cope with their emotional problems. The clinical profile of schizophrenic addicts does seem to display some distinctive features, such as the high level of depressive co-morbidity, very high nicotine and alcohol dependence, with a very poor prognosis. These patients are difficult to manage; the possibility of pharmacologic interactions between the substances they are taking and neuroleptic medication calls for prudence, and their compliance is also poor. Addictive disorders in schizophrenics are currently a topic of active research intended to lead to identifying specific treatments. The early identification of addictive disorders in schizophrenics should make it possible to limit their development and improve the prognosis.