Comparison of Olanzapine and Risperidone in 367 First-Episode Patients with Non-Affective or Affective Psychosis: Results of an Open Retrospective Medical Record Study

Effectiveness, tolerability, and safety of ziprasidone in patients with schizophrenia or schizoaffective disorder: Results of a multi-centre observational trial

Purpose

The ZEISIG study (Ziprasidone Experience in Schizophrenia in Germany/Austria) investigated the effectiveness of ziprasidone as measured by discontinuation rates and mean changes of the BPRS total. Secondary objectives included quality of life, subjective well-being, tolerability, and safety.

Subjects and methods

Two hundred and seventy-six subjects with schizophrenia and schizoaffective disorder were treated within an open-label, 12-week, prospective, flexible-dose observational trial of ziprasidone (40–160 mg/day). Baseline and outcome assessments mainly included Brief Psychiatric Rating Scale (BPRS), Clinical Global Impressions Scale (CGI), Short-Form 12 (SF-12), and Subjective Well-being under Neuroleptic treatment (SWN-K).

Results

Study discontinuation due to any cause was evident in 58% of subjects, most of them within the first 4 weeks after study initiation. In study completers, ziprasidone was associated with improvements in BPRS total (44.8 to 33.6; p < 0.001), CGI, SF-12, and SWN-K total scores (80.5 to 89.5). Ziprasidone was related to reduction of weight, fasting glucose, and serum lipids. No cardiovascular adverse event or significant increase of the QTc interval was observed.

Discussion and conclusion

Approximately 60% of subjects discontinued ziprasidone prematurely, probably related to an initial and overall underdose. The present study confirmed previous tolerability and safety data of ziprasidone as well as results of its effectiveness. Independent from reason to switch, previous antipsychotic class, and severity of illness at baseline, the recommended starting dose of 80 mg/day as well as the maximum treatment dose of 160 mg/day may not be sufficient for a selected subgroup of patients.

Predictive Factors of Treatment Resistance in First Episode of Psychosis: A Systematic Review

Background: Clinical and functional outcome improvement in psychotic disorders is a challenge for the investigators. Recent advances offered opportunities for ameliorating the course of the illness during its early stages and for identifying treatment-resistant patients. Patients who had not response to two different antipsychotics, administered at correct doses for a sufficient period, can be operationally considered treatment-resistant. Available evidence suggested that the response's trajectory to the antipsychotic treatment revealed that a small proportion of subjects are poor responders (8.2%), the majority of patients have a moderate response (76.4%), and only 15.4% can be considered rapid responders with the greatest magnitude of response. Patients with first episode of psychosis generally obtain a more favorable response profile. Nevertheless, in around 25% of these patients symptoms of psychosis persist with a worse long-term course of illness. Objectives: The aim of this review is to report current evidences on the main predictors of treatment non-response in patients at early stage of psychosis. Methods: We used a specific string that guaranteed a high sensitive search in pubmed. We included the following types of publications: randomized-controlled trials, observational studies, longitudinal studies, retrospective studies, case-control studies, open-label investigations, cohort studies, and reviews. Publications must concern predictors of treatment resistance in early psychosis. Results: Forty-seven records were included: 5 reviews, 3 meta-analyses, 22 longitudinal studies, 2 retrospective studies, 1 naturalistic study, 6 randomized controlled trials, 2 open-label studies, 2 case-control studies, 4 cohort studies, 2 retrospective studies. Several factors were identified as predictors of treatment resistance: lower premorbid functioning; lower level of education; negative symptoms from first psychotic episode; comorbid substance use; younger age at onset; lack of early response; non-adherence to treatment; and longer duration of untreated psychosis. The role of gender and marital status is still controversial. More evidences are needed about neurobiological, genetic, and neuroimaging factors. Conclusions: The identification of specific predictive factors of treatment resistance in patients with first episode of psychosis ameliorates the quality of clinical management of these patients in the critical early phase of schizophrenia.

Treatment of the early stages of bipolar disorder

For many patients with bipolar disorder there is a long delay between the onset of illness and receiving a diagnosis and the initiation of treatment. This may have an adverse effect on the clinical outcome. Early intervention in bipolar disorder has received less attention than in schizophrenia, and there are relatively few specialist services in this area. This article reviews the literature on the early detection of bipolar disorder and on the effectiveness of pharmacological, psychological and psychosocial interventions in the early phase of the disorder.

Onset of action of atypical and typical antipsychotics in the treatment of acute psychosis

OBJECTIVE

Antipsychotic medications are the frontline treatment for the most psychotic disorders. The aim of this study is to compare the onset of action of the first and second generation antipsychotics and the rate of their side-effects in the treatment of acute psychosis.

METHODS

In a double-blind, controlled clinical trial, 40 acute psychotic patients were randomly allocated in four groups and treated with each of the four antipsychotics: olanzapine, risperidone, haloperidol or thiothixene. The onset of action of each drug was assessed by the Positive and Negative Symptoms Scale. The data were analyzed by Wilcoxon (Gehan) survival and Log Rank analysis, using SPSS version 20.0.

FINDINGS

Initial response was observed in 97.5% (N = 39) of subjects during 2 weeks of intervention. The mean time to the first response was 6.15 ± 2.9 days and this was significantly shorter for risperidone than others. The most common side-effects were sedation and drug induced Parkinsonism.

CONCLUSION

Risperidone represented shorter onset of action for the treatment of acute psychotic symptoms compared with olanzapine, haloperidol and thiothixene.

Differentiating schizoaffective and bipolar I disorder in first-episode psychotic mania

OBJECTIVE

This study aims to differentiate schizoaffective disorder (SAD) and bipolar-I-disorder (BD) in first-episode psychotic mania (FEPM).

METHODS

All 134 patients from an epidemiological first-episode psychosis cohort (N=786) with FEPM and an 18-month follow-up final diagnosis of SAD (n=36) or BD (n=98) were assessed with respect to pre-treatment, baseline and outcome differences. Second, patients with baseline BD who shifted (shifted BD) or did not shift to SAD (stable BD) over the follow-up period were compared regarding pre-treatment and baseline differences.

RESULTS

SAD patients displayed a significantly longer duration of untreated psychosis (DUP; effect size r=0.35), a higher illness-severity at baseline (r=0.20) and more traumatic events (Cramer-V=0.19). SAD patients displayed a significantly higher non-adherence rate (Cramer-V=0.19); controlling for time in treatment and respective baseline scores, SAD patients had significantly worse illness severity (CGI-S; partial η²=0.12) and psychosocial functioning (GAF; partial η(2)=0.07) at 18-months, while BD patients were more likely to achieve remission of positive symptoms (OR=4.9, 95% CI=1.8-13.3; p=0.002) and to be employed/occupied (OR=7.7, 95% CI=2.4-24.4, p=0.001). The main discriminator of stable and shifted BD was a longer DUP in patients shifting from BD to SAD.

CONCLUSIONS

It is difficult to distinguish BD with psychotic symptoms and SAD in patients presenting with FEPM. Longer DUP is related to SAD and to a shift from BD to SAD. Compared to BD, SAD had worse outcomes and higher rates of non-adherence with medication. Despite these differences, both diagnostic groups need careful dimensional assessment and monitoring of symptoms and functioning in order to choose the right treatment.

Early identification of non-remission in first-episode psychosis in a two-year outcome study

OBJECTIVE

To identify predictors of non-remission in first-episode, non-affective psychosis.

METHOD

During 4 years, we recruited 301 patients consecutively. Information about first remission at 3 months was available for 299 and at 2 years for 293 cases. Symptomatic and social outcomes were assessed at 3 months, 1 and 2 years.

RESULTS

One hundred and twenty-nine patients (43%) remained psychotic at 3 months and 48 patients (16.4%) remained psychotic over 2 years. When we compared premorbid and baseline data for the three groups, the non-remitted (n = 48), remitted for <6 months (n = 38) and for more than 6 months (n = 207), duration of untreated psychosis (DUP) was the only variable that significantly differentiated the groups (median DUP: 25.5, 14.4 and 6.0 weeks, respectively). Three months univariate predictors of non-remission were being single, longer DUP, core schizophrenia, and less excitative and more negative symptoms at baseline. Two-year predictors were younger age, being single and male, deteriorating premorbid social functioning, longer DUP and core schizophrenia. In multivariate analyses DUP, negative and excitative symptoms predicted non-remission at 3 months, but only DUP predicted at 2 years.

CONCLUSION

Long DUP predicted both 3 month and 2-year non-remission rates in first-episode psychosis.

Pretreatment and outcome correlates of sexual and physical trauma in an epidemiological cohort of first-episode psychosis patients

OBJECTIVES

High prevalence of trauma has been reported in psychosis. While role of trauma as a risk factor for developing psychosis is still debated, its negative impact on outcome has been described. Few studies have explored this issue in first-episode psychosis (FEP) patients. We assessed rate of stressful events, as well as premorbid and outcome correlates of past sexual and/or physical abuse (SPA) in an epidemiological FEP patients cohort.

METHODS

The Early Psychosis Prevention and Intervention Centre admitted 786 FEP patients between 1998 and 2000. Data were collected from patients' files using a standardized questionnaire. A total of 704 files were available, 43 excluded because of a nonpsychotic diagnosis at end point and 3 due to missing data regarding past stressful events; 658 patients were analyzed.

RESULTS

A total of 83% patients had been exposed to at least one stressful event and 34% to SPA. SPA patients were more likely to have presented other psychiatric disorders before psychosis onset (posttraumatic stress disorder, substance use disorder), to have made suicide attempts in the past, and to have had poorer premorbid functional levels. Additionally, SPA patients had higher rate of comorbid diagnosis at program entry and were more likely to attempt suicide during treatment.

CONCLUSIONS

SPA prevalence is high in FEP patients and must be explored by clinicians considering its durable impact on psychological balance and link with long-lasting suicidal risk. More research is warranted to better understand mechanisms involved between trauma and its potential consequences, as well as to develop psychological interventions adapted to this very sensitive and complex issue.

Serotonin transporter polymorphisms and early response to antipsychotic treatment in first episode of psychosis

There is substantial evidence suggesting that individual variability in antipsychotic treatment response could be genetically determined. Variations in several serotonin transporter (5-HTT) gene polymorphisms have been associated with antipsychotic response among chronic patients with schizophrenia, although their implication in early response among first-episode patients remains unclear. Two polymorphisms in the 5-HTT gene (a 44 bp insertion/deletion in the promoter region and the functional polymorphism rs25531) were genotyped in a sample of 147 drug-naïve patients experiencing a first episode of a non-affective psychosis. Early (6 weeks) response to antipsychotic treatment with haloperidol, olanzapine or risperidone was assessed with the Brief Psychiatric Rating Scale, the Scale for the Assessment of Positive Symptoms, and the Scale for the Assessment of Negative Symptoms. No clear association was found between the rs25531 variant and treatment response. However, significant associations were observed between 5-HTT-LPR variants and early negative symptom response among first-episode patients with psychosis. Our results suggest a minor contribution to antipsychotic drug response of genetic alterations in the 5-HTT gene.

Metabolic profiles of second-generation antipsychotics in early psychosis: findings from the CAFE study

OBJECTIVE

To further define the metabolic profiles of second-generation antipsychotics during the treatment of young patients with early psychosis, with a view to better inform prescribing clinicians.

METHOD

Weight, body mass index (BMI), glucose, and serum lipids were measured in the 52-week Comparison of Atypicals for First Episode (CAFE) study, in which olanzapine, quetiapine, and risperidone were evaluated, and whose primary outcomes have been reported elsewhere. These metabolic data were analyzed using a mixed random coefficients model for continuous longitudinal measures and a logistic regression model for categorical responses.

RESULTS

Of the 400 patients recruited, 31% were overweight and 18% were obese at baseline, and 17 (4.3%) patients met criteria for metabolic syndrome. After 12 and 52 weeks of treatment, weight gain >or=7% from baseline was reported in 29.2% and 50.0% of quetiapine-treated patients, 59.8% and 80.0% of olanzapine-treated patients, and 32.5% and 57.6% of risperidone-treated patients, respectively. Weight gain after 12 and 52 weeks of treatment was estimated as [Least Squares Mean (SE)] 15.6 (+/-1.1) and 24.2 (+/-1.9) lb for olanzapine, 8.6 (+/-1.1) and 14.0 (+/-1.9) lb with risperidone and 7.9 (+/-1.1) and 12.1 (+/-1.8) lb for quetiapine respectively. In women, greater weight gain occurred during risperidone treatment compared with quetiapine treatment. By week 52, increases in BMI >or=1 unit occurred with significantly higher frequency in olanzapine-treated patients compared with quetiapine- or risperidone-treated patients. By 52 weeks, treatment-emergent metabolic syndrome was reported in 51 individuals (13.4% of the total population), of whom 22 were receiving olanzapine, 18 quetiapine, and 11 risperidone. Risperidone was associated with the smallest elevations in triglyceride and total cholesterol levels.

CONCLUSION

Weight gain and metabolic syndrome occur commonly even in young patients receiving antipsychotic treatment for early psychosis. Targeted interventions are therefore warranted from the onset of antipsychotic therapy.

Detection of psychosis by mental health care services; a naturalistic cohort study

Background

Detection of psychotic disorders is an important issue, since early treatment might improve prognosis. Timely diagnosis of psychotic disorders depends on recognition of psychotic symptoms and their interpretation. The aim of this study is to examine to what extent reported psychotic symptoms are accounted for in clinical diagnosis.

Methods

The medical files of all patients who had a first contact with one of two mental health care services (N = 6477) were screened for reported psychotic symptoms and subsequent clinical diagnosis. Patients who reported psychotic symptoms and who were diagnosed with a psychotic disorder were followed-up for two years to register prescription of antipsychotic treatment and continuity of care.

Results

In the files of 242 (3.7%) patients specific psychotic symptoms were recorded. 37% of these patients were diagnosed with a non-affective psychotic disorder, 7% with other psychotic disorders and 56% with non-psychotic disorders or no diagnosis at all. About 90% of the patients diagnosed with a psychotic disorder did receive any prescription of antipsychotics, and about 50% were in continuous care during the first 2 years.

Conclusion

Relatively large proportions of patients presenting with psychotic symptoms were diagnosed with a non-psychotic diagnosis or not diagnosed at all. This applies also to patients reporting at least two or more psychotic symptoms. Although we did not verify the appropriateness of clinical diagnosis, these findings are an indication that psychotic disorders may be underdetected. Improving the diagnostic process in mental health care services may be the most obvious way to promote early intervention in psychosis.

The Italian guidelines for early intervention in schizophrenia: development and conclusions

AIM

The effectiveness of early intervention in schizophrenia is still under discussion. The guidelines described in the present paper were aimed at contributing to the current debate by providing Italian practitioners, families, patients and health managers with evidence-based information on early intervention. They also examined the diagnostic tools that are currently available for assessing different stages of psychotic disorders.

METHODS

A multidisciplinary panel of experts (the Guidelines Development Group) used a set of key-questions to develop an explicit search strategy to conduct a systematic review of the literature published from January 2000 to June 2006. Trained personnel then selected papers from those yielded by the literature search. The Guidelines Development Group's final recommendations were scaled according to the Italian National Guidelines System grading system.

RESULTS

The evidence available up to the time of the literature search does not allow for recommendation of early intervention targeting prodromal or at-risk patients to prevent progression from the prodromal phase to acute, full-blown psychosis, nor to improve prognosis. Conversely, identification and timely treatment of first-episode psychotic patients through specific early intervention programmes are highly recommended.

CONCLUSIONS

The Italian Guidelines on early intervention in schizophrenia are based on a comprehensive assessment of an updated, large-scale body of literature. They draw specific, evidence-based conclusions to assist clinicians and stakeholders in the planning and implementation of appropriate intervention programmes. Further research is needed to ascertain the effectiveness of early intervention in delaying or preventing the conversion to psychosis and improving prognosis in prodromal or at-risk patients. Further investigation is also required for first-episode and critical period patients.

Early intervention in bipolar disorder, part II: therapeutics

Recent evidence has shown that early pharmacological and psychosocial treatment dramatically ameliorates poor prognosis and outcome for individuals with psychotic disorders, reducing conversion rates to full-blown illness and decreasing symptom severity. In a companion paper, we discussed methodological issues pertaining to early intervention in bipolar disorder (BPD), reviewed clinical studies that focus on high-risk subjects as well as first-episode patients, and reviewed findings from brain imaging studies in the offspring of individuals with BPD as well as in first-episode patients. In this paper, we discuss how drugs that modulate cellular and neural plasticity cascades are likely to benefit patients in the very early stages of BPD, because they target some of the core pathophysiological mechanisms of this devastating illness. Cellular and molecular mechanisms of action of agents with neurotrophic and neuroplastic properties are discussed, with a particular emphasis on lithium and valproate. We also discuss their potential use as early intervention strategies for improving symptoms and functioning in patients in the earliest stages of BPD, as well as high-risk individuals.

Real-world use of quetiapine in early psychosis: An acute inpatient and community follow-up effectiveness study

Objective. To evaluate the use of quetiapine in first episode psychosis in adolescents and adults in a 26-week open-label trial. Methods. Consenting patients were recruited from consecutive acute psychiatric admissions. Quetiapine was increased stepwise to 750 mg. Baseline, 2, 4, 12, 16, 20 and 26 week measurement included: BPRS, PANSS, CGI, and indices of tolerability and safety. Change was assessed using repeated measures ANOVA. Results. Of 73 first admission patients with psychosis, 15 entered the study. Loss of otherwise eligible patients was mainly related to prospective consent, which appeared to cause selection bias. All 15 patients were retained for 4-week Intention-to-Treat Analysis; nine completed the 26-week protocol (Completers Analysis). Non-completers dropped out shortly after 4 weeks. In the ITT Analysis, there was significant improvement on BPRS Total (P<0.01), PANSS Positive (P<0.05), and CGI (P<0.01) scores. No change in the 2-week BPRS Total score predicted subsequent non-response to quetiapine. In the Completers Analysis, onset of significant PANSS Negative score reduction did not occur until week 12. By 26 weeks all efficacy measures had substantially improved; and substance abuse was markedly less prevalent (P=0.02). Adverse events included postural hypotension, drowsiness, and significant weight gain (P=0.001).

CONCLUSIONS

This uncontrolled trial suggests quetiapine is an effective first-line treatment in young early psychosis patients. Prospective consent is a major barrier to evaluating acute care for psychotic disorder.

Atypische Neuroleptika und metabolisches Syndrom

The introduction of atypical antipsychotics in psychopharmacology represented a major advance in the treatment of psychotic disorders. However, there have been numerous studies that certain atypical antipsychotics may be associated with a greater risk of metabolic abnormalities than others, including weight gain, hyperlipidemia and new-onset typ 2 diabetes mellitus. A G-Protein beta3 subunit Gen (C825T) polymorphism, an increased carbohydrate metabolism and dyshormonism are discussed as pathogenetic mechanisms. High risk patients (adiposity, hyperlipidaemia, hyperglycaemia, preexisting diabetes) should maintain an antipsychotic agent with a favourable side effect profile. In these cases a periodical diabetes screening and blood lipid controls are required. Clinicans must balance the significant benefits of atypical antipsychotics against the risk of metabolic disturbances. In this article recent findings are reviewed.

Switching to risperidone after unsuccessful treatment of olanzapine in the first-episode schizophrenia: an open trial

The purpose of this study was to assess the effect of switching to risperidone in the treatment of first-episode schizophrenia who had failed to respond to an initial-prescribed antipsychotic, olanzapine. Fifty-one patients with first-episode schizophrenia after unsuccessful treatment of olanzapine (the mean (S.D.) dosage: 16.4 (4.4) mg/day) were included in this switching study. Of the 51 patients, 43 (84.3%) completed the full 12-week trial and 8 (15.7%) dropped out. The mean dosage of risperidone at the endpoint (last observation) was 3.1 (2.0) mg/day. The total scores of Brief Psychiatric Rating Scales (BPRS) were significantly reduced from baseline to endpoint, especially in the positive and excitement factors (p<0.001). Responder rate (at least 20% decrease in BPRS total score plus final Clinical Global Impression score of 3 or less) was 35.3%. These findings indicate that the switching to risperidone could be one of the useful treatment options in this population.

Treatment of schizophrenia patients: comparing new-generation antipsychotics to each other

PURPOSE OF REVIEW

Although the debate on whether new antipsychotics have advantages over the old neuroleptics has recently been refueled by the first publication of the Clinical Antipsychotic Trials of Intervention Effectiveness results, one of the new challenges in the pharmacological management of schizophrenia patients is to choose among the new-generation drugs.

RECENT FINDINGS

Earlier work has compared these medications primarily to traditional antipsychotics and until very recently there was little published information on the relative efficacy/safety of new-generation antipsychotics.

SUMMARY

This review covers studies wherein therapeutic effects and adverse events of these drugs in schizophrenia patients were compared in head-to-head studies and that were published in 2005. Information is clearly more homogenous on the safety profile side, while the available evidence still offers little help for the clinicians' daily struggles to find the optimally effective antipsychotic for an individual schizophrenia patient.

Pharmacological treatment in the early phase of bipolar disorders: what stage are we at?

OBJECTIVE

To review available guidelines, explore treatment strategies currently applied, identify critical issues and propose direction for new developments.

METHOD

Literature review based on Medline search and hand search of relevant literature.

RESULTS

Pharmacological treatment of the early phase of bipolar disorders lacks specific guidelines. Mood stabilizers are often prescribed after many years of illness, antipsychotic medications are frequently prescribed and often for extensive periods of time, and adherence to medication is relatively poor. In addition, mania is frequently misdiagnosed, and there is limited knowledge on which to base identification of bipolar depression and identification of the initial prodrome to bipolar disorders.

CONCLUSIONS

There is an urgent need for more research in the early phases of bipolar disorders to develop means to identify patients earlier and to develop approaches that would address the specific needs of this population in a more adequate manner.