A double-blind comparison of fluphenazine decanoate and flupenthixol decanoate in the treatment of acute schizophrenia

The impact of fluphenazine withdrawal: a mirror-image study

BACKGROUND

Fluphenazine decanoate licenced as a long-acting injectable (LAI) first-generation antipsychotic (FGA) was withdrawn from sale in 2018. This study evaluates if its withdrawal resulted in increased relapse rates of psychosis in an Irish patient cohort and examines which prescribed alternative antipsychotic medications were associated with more optimal outcomes.

METHODS

Fifteen participants diagnosed with a psychotic disorder were included. A mirror-image study over 24-months' pre-and post-withdrawal of fluphenazine was conducted. Kaplan-Meier survival and proportional hazards analyses were conducted. The impact of alternate antipsychotic agents (LAI flupenthixol compared to other antipsychotic medications) was evaluated. Semi-structured interviews with participants examined subjective opinions regarding the change in their treatment.

RESULTS

Seven participants (46.7%) relapsed in the 24-month period subsequent to fluphenazine discontinuation compared to one individual (6.7%) in the previous identical time-period (p = 0.035). Flupenthixol treatment was associated with reduced relapse rates compared to other antipsychotics (χ2 = 5.402, p = 0.02). Thematic analysis revealed that participants believed that the discontinuation of fluphenazine deleteriously impacted the stability of their mental disorder.

CONCLUSION

The withdrawal of fluphenazine was associated with increased relapse rate in individuals previously demonstrating stability of their psychotic disorder. While acknowledging the limitation of small sample size, preliminary evidence from this study suggests that treatment with the first-generation antipsychotic (FGA) flupenthixol was associated with a lower risk of relapse compared to SGAs. Reasons for this lower risk of relapse are not fully clear but could be related to dopamine hypersensitivity with this treatment change.

Is duration of illness really influencing outcome in major psychoses?

BACKGROUND

An increasing number of studies identifies the duration of illness (DI) as an important predictor of outcome in patients affected by major psychoses (MP). The aim of the present paper was to revise medical literature about DI and its effects on MP, focusing in particular on the relationship between DI and outcome with particular reference to treatment response, suicidal risk, cognitive impairment and social functioning.

METHODS

A search in the main database sources has been performed to obtain a comprehensive overview. Studies with different methodologies (open and double-blinded) have been included, while papers considering other variables such as duration of untreated episode/illness were excluded. MP included the diagnoses of schizophrenia, bipolar disorder and major depressive disorder.

RESULTS

Available data show that DI influences treatment response, suicidal risk and loss of social functioning in schizophrenic patients, while results are more controversial with regard to cognitive impairment. In bipolar disorder, a long DI has been associated with less treatment response, more suicidal risk and cognitive impairment, but more data are needed to draw definitive conclusions. Finally, studies, regarding DI of illness and its predictive value of outcome in major depressive disorder show contradictory results.

CONCLUSIONS

DI appears a negative outcome factor particularly for schizophrenia, while with regard to mood disorders, more data are needed to draw definitive sound conclusions.

Fluphenazine decanoate (depot) and enanthate for schizophrenia

BACKGROUND

Intramuscular injections (depot preparations) offer an advantage over oral medication for treating schizophrenia by reducing poor compliance. The benefits gained by long-acting preparations, however, may be offset by a higher incidence of adverse effects.

OBJECTIVES

To assess the effects of fluphenazine decanoate and enanthate versus oral anti-psychotics and other depot neuroleptic preparations for individuals with schizophrenia in terms of clinical, social and economic outcomes.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's Trials Register (February 2011 and October 16, 2013), which is based on regular searches of CINAHL, BIOSIS, AMED, EMBASE, PubMed, MEDLINE, PsycINFO, and registries of clinical trials.

SELECTION CRITERIA

We considered all relevant randomised controlled trials (RCTs) focusing on people with schizophrenia comparing fluphenazine decanoate or enanthate with placebo or oral anti-psychotics or other depot preparations.

DATA COLLECTION AND ANALYSIS

We reliably selected, assessed the quality, and extracted data of the included studies. For dichotomous data, we estimated risk ratio (RR) with 95% confidence intervals (CI). Analysis was by intention-to-treat. We used the mean difference (MD) for normal continuous data. We excluded continuous data if loss to follow-up was greater than 50%. Tests of heterogeneity and for publication bias were undertaken. We used a fixed-effect model for all analyses unless there was high heterogeneity. For this update. we assessed risk of bias of included studies and used the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach to create a 'Summary of findings' table.

MAIN RESULTS

This review now includes 73 randomised studies, with 4870 participants. Overall, the quality of the evidence is low to very low.Compared with placebo, use of fluphenazine decanoate does not result in any significant differences in death, nor does it reduce relapse over six months to one year, but one longer-term study found that relapse was significantly reduced in the fluphenazine arm (n = 54, 1 RCT, RR 0.35, CI 0.19 to 0.64, very low quality evidence). A very similar number of people left the medium-term studies (six months to one year) early in the fluphenazine decanoate (24%) and placebo (19%) groups, however, a two-year study significantly favoured fluphenazine decanoate (n = 54, 1 RCT, RR 0.47, CI 0.23 to 0.96, very low quality evidence). No significant differences were found in mental state measured on the Brief Psychiatric Rating Scale (BPRS) or in extrapyramidal adverse effects, although these outcomes were only reported in one small study each. No study comparing fluphenazine decanoate with placebo reported clinically significant changes in global state or hospital admissions.Fluphenazine decanoate does not reduce relapse more than oral neuroleptics in the medium term (n = 419, 6 RCTs, RR 1.46 CI 0.75 to 2.83, very low quality evidence). A small study found no difference in clinically significant changes in global state. No difference in the number of participants leaving the study early was found between fluphenazine decanoate (17%) and oral neuroleptics (18%), and no significant differences were found in mental state measured on the BPRS. Extrapyramidal adverse effects were significantly less for people receiving fluphenazine decanoate compared with oral neuroleptics (n = 259, 3 RCTs, RR 0.47 CI 0.24 to 0.91, very low quality evidence). No study comparing fluphenazine decanoate with oral neuroleptics reported death or hospital admissions.No significant difference in relapse rates in the medium term between fluphenazine decanoate and fluphenazine enanthate was found (n = 49, 1 RCT, RR 2.43, CI 0.71 to 8.32, very low quality evidence), immediate- and short-term studies were also equivocal. One small study reported the number of participants leaving the study early (29% versus 12%) and mental state measured on the BPRS and found no significant difference for either outcome. No significant difference was found in extrapyramidal adverse effects between fluphenazine decanoate and fluphenazine enanthate. No study comparing fluphenazine decanoate with fluphenazine enanthate reported death, clinically significant changes in global state or hospital admissions.

AUTHORS' CONCLUSIONS

There are more data for fluphenazine decanoate than for the enanthate ester. Both are effective antipsychotic preparations. Fluphenazine decanoate produced fewer movement disorder effects than other oral antipsychotics but data were of low quality, and overall, adverse effect data were equivocal. In the context of trials, there is little advantage of these depots over oral medications in terms of compliance but this is unlikely to be applicable to everyday clinical practice.

Flupenthixol decanoate (depot) for schizophrenia or other similar psychotic disorders

BACKGROUND

Long-acting depot injections of drugs such as flupenthixol decanoate are extensively used as a means of long-term maintenance treatment for schizophrenia.

OBJECTIVES

To evaluate the effects of flupenthixol decanoate in comparison with placebo, oral antipsychotics and other depot neuroleptic preparations for people with schizophrenia and other severe mental illnesses, in terms of clinical, social and economic outcomes.

SEARCH METHODS

We identified relevant trials by searching the Cochrane Schizophrenia Group Trials Register in March 2009 and then for this update version, a search was run in April 2013. The register is based on regular searches of CINAHL, EMBASE, MEDLINE and PsycINFO. References of all identified studies were inspected for further trials. We contacted relevant pharmaceutical companies, drug approval agencies and authors of trials for additional information.

SELECTION CRITERIA

All randomised controlled trials that focused on people with schizophrenia or other similar psychotic disorders where flupenthixol decanoate had been compared with placebo or other antipsychotic drugs were included. All clinically relevant outcomes were sought.

DATA COLLECTION AND ANALYSIS

Review authors independently selected studies, assessed trial quality and extracted data. For dichotomous data we estimated risk ratios (RR) with 95% confidence intervals (CI) using a fixed-effect model. Analysis was by intention-to-treat. We summated normal continuous data using mean difference (MD), and 95% CIs using a fixed-effect model. We presented scale data only for those tools that had attained prespecified levels of quality. Using Grading of Recommendations Assessment, Development and Evaluation (GRADE) we created 'Summary of findings tables and assessed risk of bias for included studies.

MAIN RESULTS

The review currently includes 15 randomised controlled trials with 626 participants. No trials compared flupenthixol decanoate with placebo.One small study compared flupenthixol decanoate with an oral antipsychotic (penfluridol). Only two outcomes were reported with this single study, and it demonstrated no clear differences between the two preparations as regards leaving the study early (n = 60, 1 RCT, RR 3.00, CI 0.33 to 27.23,very low quality evidence) and requiring anticholinergic medication (1 RCT, n = 60, RR 1.19, CI 0.77 to 1.83, very low quality evidence).Ten studies in total compared flupenthixol decanoate with other depot preparations, though not all studies reported on all outcomes of interest. There were no significant differences between depots for outcomes such as relapse at medium term (n = 221, 5 RCTs, RR 1.30, CI 0.87 to 1.93, low quality evidence), and no clinical improvement at short term (n = 36, 1 RCT, RR 0.67, CI 0.36 to 1.23, low quality evidence). There was no difference in numbers of participants leaving the study early at short/medium term (n = 161, 4 RCTs, RR 1.23, CI 0.76 to 1.99, low quality evidence) nor with numbers of people requiring anticholinergic medication at short/medium term (n = 102, 3 RCTs, RR 1.38, CI 0.75 to 2.25, low quality evidence).Three studies in total compared high doses (100 to 200 mg) of flupenthixol decanoate with the standard doses (˜40mg) per injection. Two trials found relapse at medium term (n = 18, 1 RCT, RR 1.00, CI 0.27 to 3.69, low quality evidence) to be similar between the groups. However people receiving a high dose had slightly more favourable medium term mental state results on the Brief Psychiatric Rating Scale (BPRS) (n = 18, 1 RCT, MD -10.44, CI -18.70 to -2.18, low quality evidence). There was also no significant difference in the use of anticholinergic medications to deal with side effects at short term (2 RCTs n = 47, RR 1.12, CI 0.83 to 1.52 very low quality evidence). One trial comparing a very low dose of flupenthixol decanoate (˜6 mg) with a low dose (˜9 mg) per injection reported no difference in relapse rates (n = 59, 1 RCT, RR 0.34, CI 0.10 to 1.15, low quality evidence).

AUTHORS' CONCLUSIONS

In the current state of evidence, there is nothing to choose between flupenthixol decanoate and other depot antipsychotics. From the data reported in clinical trials, it would be understandable to offer standard dose rather than the high dose depot flupenthixol as there is no difference in relapse. However, data reported are of low or very low quality and this review highlights the need for large, well-designed and reported randomised clinical trials to address the effects of flupenthixol decanoate.

Efficacy of flupentixol and risperidone in chronic schizophrenia with predominantly negative symptoms

The study investigated the non-inferiority of flupentixol compared to risperidone in the treatment of negative symptoms. In addition, the effects of flupentixol on mood and cognitive symptoms were explored. In a randomized, double-blind multicenter study, 144 non-acute schizophrenia patients with predominant negative symptoms were treated with a flexible dose of either flupentixol (4-12 mg/d) or risperidone (2-6 mg/d) for up to 25 weeks. In addition to a non-inferiority analysis, a principal component analysis (PCA) of the PANSS was performed post hoc. Regarding negative symptoms, flupentixol proved to be non-inferior to risperidone. Both drugs improved depressed mood with effect sizes favoring flupentixol. PCA suggested a five-factor structure. Effect sizes for the cognitive factor were up to 0.74 for flupentixol and up to 0.80 for risperidone. EPS scores were rather low and Parkinsonism improved in both groups, but anticholinergic drugs were prescribed significantly more frequently in the flupentixol group, which generally showed significantly more adverse events. Results indicate that the 1st generation antipsychotic flupentixol improves negative, affective and cognitive symptoms in chronic schizophrenia comparable to risperidone. Further studies should confirm the latter using neuropsychological performance tests and should investigate whether tolerability improves with a markedly lower dose range.

Depot fluphenazine decanoate and enanthate for schizophrenia

BACKGROUND

Intramuscular injections (depot preparations) offer an advantage over oral medication for treating schizophrenia by reducing poor compliance. The benefits gained by long acting preparations, however, may be offset by a higher incidence of adverse effects.

OBJECTIVES

To investigate the clinical effects of fluphenazine decanoate and enanthate.

SEARCH STRATEGY

For this update we searched the Cochrane Schizophrenia Group's Register (May 2002).

SELECTION CRITERIA

We considered all relevant randomised clinical controlled trials focusing on people with schizophrenia comparing fluphenazine decanoate or enanthate with placebo or oral anti-psychotics or other depot preparations.

DATA COLLECTION AND ANALYSIS

We reliably selected, quality rated and data extracted studies. For dichotomous data we estimated relative risk (RR) with 95% confidence intervals (CI), and, where possible, the number needed to treat/harm (NNT/H). Analysis was by intention-to-treat. We used the weighted mean difference (WMD) for normal continuous data. Tests of heterogeneity and for publication bias were undertaken.

MAIN RESULTS

This review now includes 70 randomised studies. Compared with placebo, fluphenazine decanoate did not reduce relapse over 6 months to 1 year, but one longer term study found that relapse was significantly reduced in the fluphenazine arm (n=54, RR 0.35, CI 0.2 to 0.6, NNT 2 CI 2 to 4). Fluphenazine decanoate does not reduce relapse more than oral neuroleptics (n=419, 6 RCTs, RR relapse 26-52 weeks 1.46 CI 0.8 to 2.8) or other depot antipsychotics (n=581, 11 RCTs, RR relapse 26-52 weeks 0.82 CI 0.6 to 1.2). Relapse rates over 6 months to 1 year were not significantly different between standard dosage of fluphenazine decanoate over a low dose group (n=523, 4 RCTs, RR 2.09 CI 0.6 to 7.1). Movement disorders were significantly less for people receiving fluphenazine decanoate compared with oral neuroleptics (n=259, 3 RCTs, RR 0.47 CI 0.2 to 0.9, NNT 14 CI 10 to 82). For fluphenazine enanthate there were limited data but no clear difference in global change (0 to 5 weeks) when compared with oral neuroleptics (n=31, 1 RCTs, RR 0.67 CI 0.3 to 1.7), and in relapse rates over 6-26 weeks between fluphenazine enanthate and other depots. Compared with placebo, giving the enanthate caused no more people to need need anticholinergic drugs (n=25, 1 RCT, RR 9.69 CI 0.6 to 163.0) and movement disorders, tardive dyskinesia, tremor, blurred vision and dry mouth were equally prevalent when enanthate was compared with other depot neuroleptics.

AUTHORS' CONCLUSIONS

There are more data for fluphenazine decanoate than for the enanthate ester. Both are effective antipsychotic preparations. In the context of trials, there is little advantage of these depots over oral medications in terms of compliance but this is unlikely to be applicable to everyday clinical practice.

Depot flupenthixol decanoate for schizophrenia or other similar psychotic disorders

BACKGROUND

Anti-psychotic drugs are the mainstay treatment for schizophrenia and similar psychotic disorders. Long-acting depot injections of drugs such as flupenthixol decanoate are extensively used as a means of long-term maintenance treatment.

OBJECTIVES

To evaluate the effects flupenthixol decanoate in comparison with placebo, oral antipsychotics and other depot neuroleptic preparations for people with schizophrenia and other severe mental illnesses, in terms of clinical, social and economic outcomes.

SEARCH STRATEGY

Relevant trials were identified by searching Biological Abstracts (1982-1998), Cochrane Library (Issue 2, 1998), Cochrane Schizophrenia Group's Register (December 1998), EMBASE (1980-1998), MEDLINE (1966-1998) and PsycLIT (1974-1998). The references of all identified trials were inspected for more studies and the first author of each included trial and relevant pharmaceutical companies were contacted.

SELECTION CRITERIA

All randomised controlled trials that focused on people with schizophrenia or other similar psychotic disorders where flupenthixol decanoate had been compared to placebo or other antipsychotic drugs. All clinically relevant outcomes were sought.

DATA COLLECTION AND ANALYSIS

Studies were reliably selected, quality rated and data extracted. For dichotomous data Peto odds ratios (OR) with 95% confidence intervals (CI) were estimated. Where possible, the number needed to treat statistic (NNT) was also calculated. Analysis was by intention-to-treat. Normal continuous data were summated using the weighted mean difference (WMD). Scale data were presented only for those tools that had attained pre-specified levels of quality.

MAIN RESULTS

No trials compared flupenthixol decanoate to placebo. One small study compared flupenthixol decanoate with an oral antipsychotic (penfluridol). There were no clear differences between the two preparations. When flupenthixol decanoate was compared to other depot preparations, there were no differences between depots for outcomes such as death, global impression, relapse (OR 1.16 CI 0.7-1.9) or leaving the study early (OR 1.00 CI 0.6-1.7). Two small studies suggest that flupenthixol decanoate is responsible for less movement disorders than other depot antipsychotic drugs (OR 0.23 CI 0.08-0.7, NNT 5). This finding did not hold for specific side effects, such as tremor (OR 1.2 CI 0.3-4) and tardive dyskinesia (OR 1.60 CI 0.4-6). Two trials comparing high doses of flupenthixol decanoate to the standard approximately 40mg per injection reported no significant difference for the outcome of relapse (OR 0.32 CI 0.09-1.2). One small (n=59) trial comparing a very low dose of flupenthixol decanoate ( approximately 6 mg/IM) to a very low dose approximately 9 mg per injection also reported no difference in relapse rates (OR 0.3 CI 0.1-1.1).

REVIEWER'S CONCLUSIONS

From the data reported in clinical trials, it would be understandable if those suffering from schizophrenia, who are willing to take flupenthixol decanoate, would request the standard dose rather than the high dose. In the current state of evidence, there is nothing to choose between flupenthixol decanoate and other depot antipsychotics. The choice of which depot to use must therefore be based on clinical judgement and the preferences of people with schizophrenia and their carers. Managers and policy makers should expect better data than the research community has provided thus far. This review highlighted the need for large, well-designed and reported randomised clinical trials to address the effects of flupenthixol decanoate, in particular when compared to oral antipsychotics. Future studies should also consider hospital and service outcomes, satisfaction with care and record economic data.

Flupenthixol treatment for cocaine abusers with schizophrenia: a pilot study

Cocaine use is common among individuals with schizophrenia and schizoaffective illness, with a prevalence ranging from 15-60% of patient samples. It is hypothesized that some schizophrenic cocaine abusers may use cocaine as an attempt to improve anhedonic symptoms or combat neuroleptic side-effects. Flupenthixol (FLX) has the distinct advantage of being both a neuroleptic medication and a potential treatment for cocaine abuse. We evaluated the efficacy of FLX in this dually diagnosed population in an open pilot study consisting of a 4-week inpatient phase and a 6-week outpatient phase. Eight individuals were initially cross-tapered off their neuroleptic medication and were given FLX in a dose of 40 mg of the decanoate every 2 weeks. Psychiatric symptomatology was assessed weekly, using the Positive and Negative Symptom Scale (PANSS) and the Beck Depression Inventory (BDI). Medication side-effects were monitored weekly, using the Simpson Neurological Rating Scale and the Abnormal Involuntary Movement Scale (AIMS). Substantial improvement in psychiatric symptomatology was noted when preadmission scores were compared to scores obtained during the last week of study enrollment. On the PANSS, positive symptom scores and negative symptom scores decreased by 31% and 29%, respectively. Similarly, BDI scores decreased by 57%. Comparing preadmission urine results to those for the last 6 weeks of enrollment in the study showed that cocaine-positive urines decreased by 28%, although most of the patients had a reduction of >75%. Missed clinic visits decreased by 26%. Thus, FLX was well-tolerated by schizophrenic cocaine abusers, suggesting that FLX may be useful for the treatment of this dually diagnosed population.

The psychopharmacological era: notes toward a history

Cultural and economic influences on the psychopharmacological era are reviewed, in an attempt to bring into focus what has been happening in psychopharmacology for the past thirty years. It is argued that the belief that clinical advances are made through the heroic achievements of disinterested scientists is a simplistic view that may militate against future significant discoveries. Such discoveries, it is argued, still come about for the most part serendipitously, despite a widespread belief that psychopharmacology has become a rational science.

Fluphenazine decanoate dose and severity of depression in patients with post-psychotic depression

The authors examined the fluphenazine decanoate dose and the fluphenazine plasma levels in comparison with measures of severity of depression in schizophrenic and schizoaffective patients. All patients were selected for study on the basis of having stable, syndromally defined, antiparkinsonian non-responsive syndromes of post-psychotic depression. No meaningful relationships were found. The implications of this observation with regard to the notion that depressive symptomatology in such patients is neuroleptic-induced is discussed.

Therapeutic efficacy of flupenthixol decanoate in schizoaffective disorder: a clinical evaluation

The present open study was undertaken to evaluate the therapeutic efficacy and side-effects of flupenthixol, a thioxanthene derivative in the treatment of schizoaffective psychosis. A total of twenty in-patients, selected according to specific research criteria were treated with flupenthixol (20 mg to 60 mg i.m. q.2.weeks) for a period of 6 months. During the course of the study, a detailed battery of psychiatric rating scales was completed prior to the commencement of the treatment and at regular intervals thereafter. Additionally, detailed physical examinations and laboratory tests were also carried out at regular intervals. Results show that fifteen patients improved significantly, two patients remained unchanged while three patients deteriorated and were discontinued. Adverse effects were minimal and limited to tremor and akathisia. The present study highlights the usefulness of flupenthixol as a monotherapy in the management of schizoaffective psychosis.

Comparative double-blind study of flupenthixol decanoate and fluphenazine decanoate in the treatment of patients relapsing in a schizophrenic symptomatology

Thirty-two chronic schizophrenics who had relapsed entered a double-blind randomised study and were followed-up for 2 years with the intention of measuring any difference in therapeutic effect and side effects between flupenthixol decanoate and fluphenazine decanoate. No differences could be seen as regards the global effect or the effect on the schizophrenic symptomatology during the first 6 months. After 1 year of treatment flupenthixol decanoate showed a trend towards a better effect on schizophrenic symptomatology. A corresponding result was seen for the depressive symptoms. There were no differences in the appearance of side effects. The need for additional neuroleptics in the initial phase seemed to be identical for both drugs. A possible slow antipsychotic effect with flupenthixol decanoate is probably due to the administered dose being somewhat low (in the present study approximately 31 mg flupenthixol corresponding to 27 mg fluphenazine). This suggests that flupenthixol should have been given in a somewhat higher dose (25 mg fluphenazine decanoate corresponding to 40 mg flupenthixol decanoate).

Major tranquillisers used as antidepressants. A review

The use of major tranquillisers as antidepressants is reviewed and 34 double-blind trials evaluating this were found. Results suggest that some neuroleptics have antidepressant properties, although most studies have been conducted on mixed anxiety-depressive states. Advantages over the tricyclic antidepressants are the early onset of action and relative lack of side-effects. Post psychotic depression following major tranquilliser therapy is considered, and it is concluded that it is likely to be part of the underlying illness and not a drug-induced effect. It is suggested that further work with major tranquillisers in depression may be of value in exploring the mechanism of action of antidepressant drugs.

Depressions in schizophrenia: some observations on prevalence, etiology, and treatment

The results suggest that not only is depression a common symptom or syndrome in all stages of schizophrenia, but it is common even in the absence of treatment. However, there are a number of reasons for thinking that a proportion of patients on drugs may well suffer from drug related depressions, possibly 7.5-12.5 per cent. A difference in the effect upon mood, in the acute schizophrenic state, between flupenthixol and fluphenazine, has already been suggested (Johnson & Malik (1975)). Current research (Johnson (1976, 1979)) suggests that regular neuroleptic maintenance therapy is necessary for many years, certainly for more than four years following the most recent relapse. It is therefore of particular importance to concern ourselves with all potential side-effects such as extrapyramidal symptoms, weight gain (Johnson & Breen (1979)) an tardive dyskinesia (Gibson (1978)), and to keep the patients on personalised dose regimes which can frequently be reduced with time, particularly over the first two years of treatment (Johnson (1975, 1977)). WE must equally be on our guard against unnecessary polypharmacy which ultimately increases the risks for an already greatly disadvantaged patient.

Depressive and extrapyramidal symptoms and clinical effects: a trial of fluphenazine versus flupenthixol in maintenance of schizophrenic out-patients

Fifty-seven patients with a diagnosis of schizophrenia were started on either fluphenazine decanoate or flupenthixol decanoate injections in a double-blind trial just prior to discharge into the community. During the six month follow-up 30 per cent dropped out of the treatment. Of those observed for six months, 7 per cent relapsed, 54 per cent experienced depressive symptoms and 88 per cent extrapyramidial side-effects. Analysis of both clinical data and the ratings failed to discriminate between the two drugs.

A double-blind comparison of flupenthixol decanoate and fluphenazine decanoate in the treatment of chronic schizophrenia

Sixty-four chronic stabilised schizophrenics were studied for 18 months in order to assess the possible difference in therapeutic effects and side effects between flupenthixol decanoate and fluphenazine decanoate. Although certain differences in the BPRS sub-scores in favour of flupenthixol were present at various stages in the study, there was no significant difference between the two drugs in the overall antipsychotic scores at the end of the assessment period; however, more patients on fluphenating required additional therpay for depression or anxiety during the trial period.

A comparative trial of the decanoates of flupenthixol and fluphenazine

A double-blind trial was carried out comparing the effects of decanoates of flupenthixol and fluphenazine on the symptoms, ward behaviour and functional capacity in occupational therapy in 51 chronic schizophrenic patients. The patients were carefully selected on the basis of rigid criteria for diagnoses. To exclude nonresponders to neuroleptics the patients were first taken off neuroleptic drugs and only those who appeared to show deterioration were included in the trial. The dosage of drugs was varied according to clinical indications. The length of the trial was initially 4 months and 31 patients were followed for an additional 4 months. To ensure reliability multiple assessments were made at the start and the end of the trial. Most of the statistical tests showed no differences between the treatments, but some of those relating to affective symptoms showed an advantage for flupenthixol as compared with fluphenazine. There were no differences in the incidence of extra-pyramidal side-effects which required treatment in only 32% of the patients on each drug.

A double-blind comparison of flupenthixol, nortriptyline and diazepam in neurotic depression

A double-blind trial of flupenthixol, nortriptyline and diazepam in neurotic depression using flexible dose schedules suggested that each drug is an efficient treatment for this category of depression although the patterns of response and prevalence of side-effects varied. No differences reaching a level of significance could be shown on rating scales of depression or anxiety, but trends favoured flupenthixol. However, clinical evaluation suggested flupenthixol to be more effective than diazepam on mental state examination (P less than 0.05) and to have a greater overall therapeutic effect than nortriptyline (P less than 0.05). It also had fewer side-effects than nortriptyline (P less than 0.05).

Comparison of antipsychotic depot injections in the maintenance treatment of schizophrenia

122 Schizophrenic patients treated with injections of fluphenazine ethanate, 97 with fluphenazine decanoate and 199 with flupenthixol decanoate were followed up for mean times of 41, 33 and 21 months respectively. Their progress was compared by examining reasons for discontinuing injections and outcome in three separate groups defined according to first preparation given; relating the events causing patients to discontinue injections or be readmitted to patient-months spent on each drug; and analysing reasons for inter-drug transfers 43 per cent, 24 per cent and 23 per cent respectively of these three groups of patients discontinued the injections. Severe extrapyramidal effects were most frequent with fluphenazine ethanate, intermediate with fluphenazine decanote, and least frequent frequent with flupenthixol. Lack of cooperation was rather more frequent with flupenthixol than with the other drugs. Severe depression occurred with all three. More patients on fluphenazine injections were transferred for any reason to flupenthixol than vice-versa. A case of 'irreversible' movement disorder was seen with each preparation. It is suggested that current maintenance doses of flupenthixol decanoate are too low.

The expectation of outcome from maintenance therapy in chronic schizophrenic patients

The results from a prospective follow-up study of a group of schizophrenic patients suggest that a significant proportion (41 per cent) are likely to relapse during a two-year period despite the prescription of long-acting injectable neuroleptic drugs. Some will relapse because of a failure of the regime, but others (32-37 per cent) because the pharmacological protection of these drugs would appear to be less effective in certain patients. Even with the major advantages of the long-acting injectable neuroleptics over oral medication, the schizophrenic patient population remains a group with a high incidence of psychiatric and social morbidity which continues to require the full resources of both the hospital and community services.