The discontinuance of maintenance neuroleptic therapy in chronic schizophrenic patients: drug and social consequences

Risk Factors for Psychotic Relapse After Dose Reduction or Discontinuation of Antipsychotics in Patients With Chronic Schizophrenia. A Meta-Analysis of Randomized Controlled Trials

BACKGROUND AND HYPOTHESIS

Although maintenance treatment with antipsychotics protects against psychotic relapse, high doses may hamper recovery. Therefore, dose reduction or discontinuation may be considered in patients with chronic schizophrenia. Here, we identified risk factors for psychotic relapse when doses are reduced.

STUDY DESIGN

We systematically searched MEDLINE, EMBASE, and PsycINFO from January 1950 through January 2021 and reviewed randomized controlled trials (RCTs) that reported relapse rates after antipsychotic dose reduction or discontinuation in patients with chronic schizophrenia. We calculated relative risks (RRs) with 95% confidence intervals (CIs) per person-year and sought to identify potential risk factors for relapse. The study is registered with PROSPERO (CRD42017058296).

STUDY RESULTS

Forty-seven RCTs (54 patient cohorts, 1746 person-years) were included. The RR for psychotic relapse with dose reduction/discontinuation versus maintenance treatment was 2.3 per person-year (95% CI: 1.9 to 2.8). The RR was higher with antipsychotic discontinuation, dose reduction to less than 3-5 mg haloperidol equivalent (HE), or relatively rapid dose reduction (<10 weeks). The RR was lower with long-acting injectable agents versus oral antipsychotic dose reduction. Other factors that increased the risk of psychotic relapse were younger age and short follow-up time.

CONCLUSIONS

Clinicians should take several risk factors for psychotic relapse into account when considering dose reduction in patients with chronic schizophrenia. Studies of a relatively fast reduction in antipsychotic dose support a minimum dose of 3-5 mg HE. However, if the dose is tapered more gradually, relapses related to medication withdrawal might be avoided, possibly enabling lower-end doses to be achieved.

Effectiveness of Antipsychotics in Reducing Suicidal Ideation: Possible Physiologic Mechanisms

Background: The aim of this study is to evaluate whether any specific antipsychotic regimen or dosage is effective in managing suicidal ideation in schizophrenia. Four comparisons were conducted between: (1) clozapine and other antipsychotics; (2) long-acting injectable and oral antipsychotics; (3) atypical and typical antipsychotics; (4) antipsychotics augmented with antidepressants and antipsychotic treatment without antidepressant augmentation. Methods: We recruited 103 participants diagnosed with schizophrenia spectrum disorders. Participants were followed for at least six months. The Beck Scale for Suicidal Ideation (BSS) was used to assess the severity of suicidal ideation at each visit. We performed a multiple linear regression model controlling for BSS score at study entry and other confounding variables to predict the change in the BSS scores between two visits. Results: Overall, there were 28 subjects treated with clozapine (27.2%), and 21 subjects with depot antipsychotics (20.4%). In our sample, 30 subjects experienced some suicidal ideation at study entry. When considering the entire sample, there was a statistically significant decrease in suicidal ideation severity in the follow-up visit compared to the study entry visit (p = 0.043). Conclusions: To conclude, our preliminary analysis implies that antipsychotics are effective in controlling suicidal ideation in schizophrenia patients, but no difference was found among alternative antipsychotics’ classes or dosages.

Risk Factors for Psychotic Relapse After Dose Reduction or Discontinuation of Antipsychotics in Patients With Chronic Schizophrenia: A Systematic Review and Meta-analysis

High doses of antipsychotics in patients with chronic schizophrenia might lead to more severe side effects and possibly hamper recovery, but dose reduction carries the risk of psychotic relapse. It would be helpful to establish risk factors for relapse during dose reduction. We systematically searched MEDLINE, EMBASE, and PsycINFO from January 1950 through June 2019 and reviewed studies that reported on relapse rates (event rates [ERs]) after dose reduction or discontinuation of antipsychotics in cohorts of patients with chronic schizophrenia. We calculated ERs (with 95% CIs) per person-year and sought to identify potential risk factors, such as patient characteristics, dose reduction/discontinuation characteristics, and study characteristics. Of 165 publications, 40 describing dose reduction or discontinuation in 46 cohorts (1677 patients) were included. The pooled ER for psychotic relapse was 0.55 (95% CI 0.46–0.65) per person-year. The ER was significantly higher in inpatients, patients with a shorter duration of illness, patients in whom antipsychotics were discontinued or in whom the dose was reduced to less than 5 mg haloperidol equivalent, studies with a short follow-up or published before 1990, and studies in which relapse was based on clinical judgment (ie, rating scales were not used). Clinicians should consider several robust risk factors for psychotic relapse in case of dose reduction in chronic schizophrenia.

Antipsychotic reduction and/or cessation and antipsychotics as specific treatments for tardive dyskinesia

BACKGROUND

Since the 1950s antipsychotic medication has been extensively used to treat people with chronic mental illnesses such as schizophrenia. These drugs, however, have also been associated with a wide range of adverse effects, including movement disorders such as tardive dyskinesia (TD) - a problem often seen as repetitive involuntary movements around the mouth and face. Various strategies have been examined to reduce a person's cumulative exposure to antipsychotics. These strategies include dose reduction, intermittent dosing strategies such as drug holidays, and antipsychotic cessation.

OBJECTIVES

To determine whether a reduction or cessation of antipsychotic drugs is associated with a reduction in TD for people with schizophrenia (or other chronic mental illnesses) who have existing TD. Our secondary objective was to determine whether the use of specific antipsychotics for similar groups of people could be a treatment for TD that was already established.

SEARCH METHODS

We updated previous searches of Cochrane Schizophrenia's study-based Register of Trials including the registers of clinical trials (16 July 2015 and 26 April 2017). We searched references of all identified studies for further trial citations. We also contacted authors of trials for additional information.

SELECTION CRITERIA

We included reports if they assessed people with schizophrenia or other chronic mental illnesses who had established antipsychotic-induced TD, and had been randomly allocated to (a) antipsychotic maintenance versus antipsychotic cessation (placebo or no intervention), (b) antipsychotic maintenance versus antipsychotic reduction (including intermittent strategies), (c) specific antipsychotics for the treatment of TD versus placebo or no intervention, and (d) specific antipsychotics versus other antipsychotics or versus any other drugs for the treatment of TD.

DATA COLLECTION AND ANALYSIS

We independently extracted data from these trials and estimated risk ratios (RR) or mean differences (MD), with 95% confidence intervals (CI). We assumed that people who dropped out had no improvement.

MAIN RESULTS

We included 13 RCTs with 711 participants; eight of these studies were newly included in this 2017 update. One trial is ongoing.There was low-quality evidence of a clear difference on no clinically important improvement in TD favouring switch to risperidone compared with antipsychotic cessation (with placebo) (1 RCT, 42 people, RR 0.45 CI 0.23 to 0.89, low-quality evidence). Because evidence was of very low quality for antipsychotic dose reduction versus antipsychotic maintenance (2 RCTs, 17 people, RR 0.42 95% CI 0.17 to 1.04, very low-quality evidence), and for switch to a new antipsychotic versus switch to another new antipsychotic (5 comparisons, 5 RCTs, 140 people, no meta-analysis, effects for all comparisons equivocal), we are uncertain about these effects. There was low-quality evidence of a significant difference on extrapyramidal symptoms: use of antiparkinsonism medication favouring switch to quetiapine compared with switch to haloperidol (1 RCT, 45 people, RR 0.45 CI 0.21 to 0.96, low-quality evidence). There was no evidence of a difference for switch to risperidone or haloperidol compared with antipsychotic cessation (with placebo) (RR 1 RCT, 48 people, RR 2.08 95% CI 0.74 to 5.86, low-quality evidence) and switch to risperidone compared with switch to haloperidol (RR 1 RCT, 37 people, RR 0.68 95% CI 0.34 to 1.35, very low-quality evidence).Trials also reported on secondary outcomes such as other TD symptom outcomes, other adverse events outcomes, mental state, and leaving the study early, but the quality of the evidence for all these outcomes was very low due mainly to small sample sizes, very wide 95% CIs, and risk of bias. No trials reported on social confidence, social inclusion, social networks, or personalised quality of life, outcomes that we designated as being important to patients.

AUTHORS' CONCLUSIONS

Limited data from small studies using antipsychotic reduction or specific antipsychotic drugs as treatments for TD did not provide any convincing evidence of the value of these approaches. There is a need for larger trials of a longer duration to fully investigate this area.

The symptom of depression in schizophrenia and its management

Depression is a frequently occurring symptom in schizophrenia. While today it is often underrecognised and under-treated, historically such symptoms were the focus of much attention. Affective symptoms were used by Kraepelin as an important criterion with which to separate dementia praecox from manic–depressive illness. Kraepelin also recognised the importance of depression as a symptom in schizophrenia and identified several depressive subtypes of the illness. Mayer-Gross emphasised the despair that often occurs as a psychological reaction to acute psychotic episodes and Bleuler considered depression to be one of the core symptoms of schizophrenia.

Time to Discontinuation of Second-Generation Antipsychotics Versus Haloperidol and Sulpiride in People With Schizophrenia: A Naturalistic, Comparative Study

PURPOSE

A retrospective study was conducted to evaluate the time to discontinuation (TTD) of the first- (FGAs) and second-generation antipsychotics (SGAs).

METHODS

In total, 918 treatment episodes of patients with schizophrenia, initiated on one of the investigated drugs on an outpatient basis during 2004-2006, were entered into the study. The primary outcome was the duration of the investigated treatment episode. Discontinuation was defined when either patients were admitted or the investigated drug had been stopped for more than 28 days. We used the Cox proportional hazard model to compare hazards of discontinuations among 8 SGAs versus 2 FGAs (haloperidol and sulpiride). The follow-up period was up to 18 months.

RESULTS

During the follow-up period, clozapine had the highest rate of continuous treatment in the primary analysis: clozapine, 40.6%; olanzapine, 23.4%; aripiprazole, 22.9%; amisulpride, 21.9%; zotepine, 21.3%; sulpiride, 17.0%; risperidone, 12.8%; quetiapine, 12.5%; haloperidol, 10.6%; and ziprasidone, 10.4%. Compared with haloperidol, 5 SGAs had significantly longer TTD (adjusted hazard ratios and 95% confidence intervals): clozapine (0.403, 0.267-0.607), olanzapine (0.611, 0.439-0.849), aripiprazole (0.570, 0.407-0.795), amisulpride (0.680, 0.487-0.947), and zotepine (0.687, 0.497-0.948), but only clozapine had significantly longer TTD compared with sulpiride (0.519, 0.342-0.786). The sensitivity analysis showed similar results.

IMPLICATIONS/CONCLUSIONS

The current findings suggested that SGAs or FGAs are not homogeneous groups. Clozapine has the highest rate of continuous treatment among SGAs, and haloperidol is not the representative drug for all FGAs. Furthermore, antipsychotics dropout rate is high in naturalistic situation. A good service model needs to be constructed to enhance antipsychotic treatment adherence of people with schizophrenia.

Les rechutes dans la schizophrénie ; comment prévenir?

Dans le domaine de la pathologie psychotique, les rechutes représentent une problématique importante dans la trajectoire des sujets schizophrènes. À l’origine de nombreuses réhospitalisations, ces rechutes sont généralement liées à un défaut d’observance. Et lorsqu’on s’intéresse à cette dynamique, on s’aperçoit que la plupart des études qui se sont intéressées à l’observance médicamenteuse et aux comportements visant à améliorer celle-ci se sont avérées décevantes dans le domaine de la pathologie psychotique. Les progrès réalisés dans le traitement de la schizophrénie n’ont jusqu’ici pas modifié de manière radicale l’importance de l’adhésion des patients à leur médication, ni même la fréquence des rechutes. Si la rechute touche de 10 à 60 % des sujets schizophrènes selon les études, les taux de bonne observance médicamenteuse avoisinent 50 % pour l’ensemble des spécialités médicales et tombent parfois à moins de 20 % dans le domaine de la schizophrénie. Les raisons principales de cette problématique sont pour la plupart des auteurs liées à un manque d’efficacité de la molécule prescrite, à la survenue d’effets secondaires handicapants, à la présence de convictions personnelles désadaptées, voire à la pathologie elle-même. Dans un tel contexte, il semble intéressant de développer de nouvelles stratégies de prescription permettant de parvenir le plus rapidement possible à une dose minimale efficace, voire d’explorer d’autres options thérapeutiques. La revue de la littérature réalisée ici fait un point sur les études récemment publiées (2002–2008) mettant en exergue l’impact que la prescription d’un neuroleptique classique, d’un antipsychotique atypique per os ou d’un APAP peut avoir sur l’observance médicamenteuse et la fréquence des rechutes de patients souffrant de schizophrénie.

The role of long-acting injectable antipsychotics in schizophrenia: a critical appraisal

Despite their widespread use, long-acting injectable (LAI) antipsychotics (APs) are often regarded with some negativity because of the assumption of punishment, control and insufficient evolution towards psychosocial development of patients. However, LAI APs have proved effective in schizophrenia and other severe psychotic disorders because they assure stable blood levels, leading to a reduction of the risk of relapse. Therapeutic opportunities have also arisen after introduction of newer, second-generation LAI APs in recent years. Newer LAI APs are more readily dosed optimally, may be better tolerated and are better suited to integrated rehabilitation programmes. This review outlines the older and newer LAI APs available for the treatment of schizophrenia, with considerations of past and present pharmacological and therapeutic issues. Traditional, evidence-based approaches to systematic reviews and randomized clinical trials are of limited utility in this area so this paper's blending of experimental trials with observational research is particularly appropriate and effective.

The evidence for illness progression after relapse in schizophrenia

It has long been suspected that relapse in schizophrenia is associated with disease progression in so far as time to response is longer, negative and other symptoms persist, some patients become treatment refractory and neuroprogression in terms of structural brain changes may occur. This article examines the evidence for illness progression after relapse in patients with schizophrenia. It reports on indirect evidence obtained from retrospective, naturalistic and brain-imaging studies, as well as a few prospective studies examining pre- and post-relapse treatment response. Findings suggest that the treatment response after relapse is variable, with many patients responding rapidly, others exhibiting protracted impairment of response and a subgroup displaying emergent refractoriness. This subgroup comprises about 1 in 6 patients, irrespective of whether it is the first or a subsequent relapse, and even when the delay between onset of first symptoms of relapse and initiation of treatment is brief. While there is a lack of well-designed studies investigating the post-relapse treatment outcome, available evidence gives sufficient cause for concern that, in addition to the considerable psychosocial risks, an additional risk of biological harm may be associated with relapse.

Study of the efficacy and safety of switching from risperidone to paliperidone in elderly patients with schizophrenia

AIM

We investigated the clinical efficacy and safety of switching to paliperidone (PAL) in elderly schizophrenia patients receiving risperidone.

METHODS

The subjects were 27 inpatients who had been diagnosed with schizophrenia according to the DSM-IV. The patient's clinical symptoms were assessed using the Positive and Negative Syndrome Scale and the Clinical Global Impression-Severity of Illness Scale, and their safety was assessed using the Drug-induced Extrapyramidal Symptoms Scale, bodyweight, body mass index, and laboratory tests. We also investigated patient satisfaction using the Drug Attitude Inventory, a subjective outcome measure.

RESULTS

No significant differences in clinical symptom improvement efficacy were seen between the PAL-switching group and the control group. The mean changes from baseline on the Drug-induced Extrapyramidal Symptoms Scale total score, Drug Attitude Inventory score, and prolactin level were significantly greater in the PAL-switching group than in the control group. Furthermore, patients with PAL needed less biperiden, even though they had similar risperidone-equivalent daily dosages to the control group.

CONCLUSIONS

The results of this study suggest that switching elderly patients from risperidone to PAL may result in superior safety and patient satisfaction, and may also make it possible to reduce the dosage of biperiden.

[Recommendations for the prevention and management of suicidal behaviour]

INTRODUCTION

Suicidal behaviour is a major public health issue. Suicidal behaviour is one of the main causes of years of life lost and it is the third leading cause of death among young adults. This project was initiated by the Spanish Society of Psychiatry and the Spanish Society of Biological Psychiatry with the aim of providing a document containing the main recommendations on the prevention and management of suicidal behaviour; these recommendations should be based on the best available evidence and the experts' opinion.

MATERIAL AND METHODS

In this article we summarize the review of the available evidence on the epidemiology and impact of suicidal behaviour, risk and protective factors, evaluation tools for the assessment of suicide risk, international and local preventive protocols, educational interventions for health professionals, and potential interventions for at risk populations.

RESULTS

Based on this review, a panel of psychiatrists summarized and agreed a set of recommendations about the impact, prevention and management of suicidal behaviour.

CONCLUSION

The recommendations on the prevention and management of suicidal behaviour were summarized in the ten conclusions reported in this article.

A naturalistic controlled study of relapsing schizophrenic patients with tardive dyskinesia and supersensitivity psychosis

Despite advances in treatments, relapses in schizophrenia still occur. The causes of relapse are not always apparent, especially for patients that are compliant with medication. One possibility is that the brain adapts to long-term antipsychotic drug treatment, leading to tolerance and withdrawal symptoms. This has been described as supersensitivity psychosis. Tardive dyskinesia is also thought to occur as a consequence of dopamine supersensitivity caused by chronic treatment with antipsychotics. Another associated feature is sensitivity to life stress. This study investigated the relationship between abnormal movements, life events and drug treatment in patients relapsing on antipsychotics with high potency at the dopamine D2 receptor. Twenty-two patients from a cohort of 128 patients experiencing a psychotic relapse were assessed; of these, seven (32%) met criteria for the presence of abnormal involuntary movements. These subjects were found to be clinically distinct from the subjects without abnormal movements. They tended to be older with a greater duration of illness and higher dosage of antipsychotics but more symptoms of psychosis compared with the other subjects. Relapse was also associated with minor life events. The association between abnormal involuntary movements and high levels of psychotic symptoms suggests that dopamine sensitization/supersensitivity may underlie both phenomena. These results suggest that clinicians may have to consider alternative dosing strategies, novel agents or switching to one of the antipsychotics that have a lower affinity for the D2 receptor.

Managing suicide risk in patients with schizophrenia

The management of suicide risk in patients with schizophrenia poses many challenges for clinicians. Compared with the general population, these patients have an 8.5-fold greater risk of suicide. This article reviews the literature dealing with the treatment of at-risk patients with schizophrenia. An integrated psychosocial and pharmacological approach to managing this population of patients is recommended. Although there is at least modest evidence suggesting that antipsychotic medications protect against suicidal risk, the evidence appears to be most favourable for second-generation antipsychotics, particularly clozapine, which is the only medication approved by the US FDA for preventing suicide in patients with schizophrenia. In addition, treating depressive symptoms in patients with schizophrenia is an important component of suicide risk reduction. While selective serotonin receptor inhibitors (SSRIs) ameliorate depressive symptoms in patients with schizophrenia, they also appear to attenuate suicidal thoughts. Further research is needed to more effectively personalize the treatment of suicidal thoughts and behaviours and the prevention of suicide in patients with schizophrenia.

Long-acting injectable antipsychotics in the treatment of schizophrenia: their role in relapse prevention

IMPORTANCE OF THE FIELD

Antipsychotic medications are the cornerstone of treatment in schizophrenia, and a large body of data confirms the value of ongoing and continuous antipsychotic pharmacotherapy in controlling symptoms and preventing relapse. However, nonadherence with antipsychotic treatment is a significant issue, with estimates as high as 90%.

AREAS COVERED IN THIS REVIEW

This review focuses on long-acting injectable (LAI) antipsychotics and their role in the treatment of schizophrenia. The existing literature, with an emphasis on clinical evidence, is assessed. This includes both reviews and specific trials that examine LAIs and compare them with oral agents, with measures ranging from relapse and rehospitalization to adherence. Both advantages and limitations (e.g., challenges in terms of dose titration and time to steady state) are examined.

WHAT THE READER WILL GAIN

This overview serves as an update for clinicians wishing to understand LAIs better, including the newer second-generation antipsychotics (SGAs) with this formulation available, and their potential role in the long-term treatment of individuals with schizophrenia.

TAKE HOME MESSAGE

Despite identified advantages, LAIs are not used as widely as might be expected. It would seem that clinicians are at least partly responsible for this, influenced by our own misperceptions (e.g., that LAIs are not acceptable to patients) and, perhaps, misinformation (e.g., increased side effect risk). As clinicians, we may well be shortchanging LAIs if we position them as a treatment of last resort for the multi-episode, nonadherent, 'revolving door' patient, especially given recent evidence underscoring their potential benefits in first-episode patients. The search for new and more effective antipsychotics will continue, but we are reminded that suboptimal outcomes may have as much to do with nonadherence as inadequate treatments. Evidence has established that LAI antipsychotics demonstrate distinct benefits in this regard, and we would be remiss if we did not exploit this already available strategy. As well as additional research, we need to rethink how we position these agents in our treatment algorithms if we are to maximize their potential.

Suicide attempts in a prospective cohort of patients with schizophrenia treated with sertindole or risperidone

The incidence of suicide attempts (fatal and non-fatal) was analysed in a prospective cohort of patients with schizophrenia randomly assigned to sertindole (4905 patients) or risperidone (4904 patients) in a parallel-group open-label study with blinded classification of outcomes (the sertindole cohort prospective study--SCoP). The total exposure was 6978 and 7975 patient-years in the sertindole and risperidone groups, respectively. Suicide mortality in the study was low (0.21 and 0.28 per 100 patients per year with sertindole and risperidone, respectively). The majority (84%) of suicide attempts occurred within the first year of treatment. Cox's proportional hazards model analysis of the time to the first suicide attempt, reported by treating psychiatrists and blindly reviewed by an independent expert group according to the Columbia Classification Algorithm of Suicide Assessment (both defining suicide attempts by association of suicidal act and intent to die), showed a lower risk of suicide attempt for sertindole-treated patients than for risperidone-treated patients. The effect was statistically significant with both evaluation methods during the first year of randomized treatment (hazard ratios [95% CI]: 0.5 [0.31-0.82], p=0.006; and 0.57 [0.35-0.92], p=0.02, respectively). With classification by an independent safety committee using a broader definition including all incidences of intentional self-harm, also those without clear suicidal intent, the results were not significant. A history of previous suicide attempts was significantly associated with attempted suicides in both treatment groups.

Paliperidone palmitate, a potential long-acting treatment for patients with schizophrenia. Results of a randomized, double-blind, placebo-controlled efficacy and safety study

We evaluated the efficacy and safety of the investigational long-acting injectable antipsychotic agent paliperidone palmitate (PP) in the treatment of schizophrenia. Patients were randomized to receive gluteal injections of placebo or PP (50 or 100 mg eq., fixed doses), without oral supplementation, on days 1, 8, and 36 (9-wk, double-blind phase) in this phase 2b study. Patients (n=197, intent-to-treat analysis set) were 62% men, mean (s.d.) age 39 (10) yr, with a baseline mean (s.d.) Positive and Negative Syndrome Scale (PANSS) total score of 87.0 (12.5). Mean (s.d.) PANSS total scores showed significant improvement at endpoint (primary measure) for both the PP 50 mg eq. [-5.2 (21.5)] and PP 100 mg eq. [-7.8 (19.4)] groups, vs. placebo [6.2 (18.3)] (p0.001, each dose vs. placebo). This improvement was detected by day 8 and maintained to endpoint (p0.011) for both doses. In the safety analysis set (n=247), fewer PP-treated patients (2%) discontinued for treatment-emergent adverse events vs. placebo-treated (10%). Rates of treatment-emergent extrapyramidal syndrome-related adverse events were comparable between active treatment and placebo, with the exception of parkinsonism-related disorders (50 mg eq. 5%, 100 mg eq. 8%, placebo 1%). Results of other safety measures suggest PP to be generally well-tolerated. Throughout the study, investigators rated injection-site pain as absent (56-71%), mild (24-39%), moderate (2-12%), or severe (0-2%). PP (50 and 100 mg eq. doses) administered as a gluteal intramuscular injection was efficacious and generally tolerated in these patients with acute symptomatic schizophrenia.

[A randomized controlled study on the impact of pharmacoeducation on a French patient population with schizophrenic and schizoaffective disorders]

OBJECTIVE

To evaluate the impact of a pharmacoeducation module both on hospital stay and on clinical and functional state in a French patient population with schizophrenic and schizoaffective disorders.

METHODS

After inclusion, 82 patients were randomly distributed in 2 groups, one group receiving the pharmacoeducation module and the other to be a control group. Data on the number of hospital stays and emergency visits, and the type of medication received, were compiled. Patients were evaluated with the Positive and Negative Syndrome Scale, Clinical Global Impression Scale, Barnes Akathisia Scale, Simpson-Angus Scale, Quality of Life Scale, and Global Assessment of Functioning; data were gathered at baseline, then each year for 2 years.

RESULTS

Among the 72 analyzed patients, those receiving pharmacoeducation had significantly lower total hospital stays, forced hospital stays, and emergency visits, compared with the control group patients. They also had more improvement in their symptomatology, autonomy, and quality of life. They presented less akathisia and less medication intake.

CONCLUSIONS

Pharmacoeducation can reduce the hospital stays of patients with schizophrenia and schizoaffective disorders, as well as improve their clinical and functional state, likely through better compliance.

Do antipsychotics limit disability in schizophrenia? A naturalistic comparative study in the community

BACKGROUND

Though antipsychotics are effective against symptoms of schizophrenia and prevent relapses, their effect on disability has not been studied in a comparative design.

AIM

To compare disability of schizophrenia patients receiving continuous antipsychotic treatment with that of those not receiving or receiving irregular treatment in a rural community setting using a naturalistic comparative study design.

PATIENTS AND METHODS

Disability was assessed in 182 schizophrenia patients living in Thirthahalli Taluk of Shimoga District, Karnataka, using Indian Disability Evaluation and Assessment Scale (IDEAS). Fifty patients (27.5%) were receiving regular treatment in the previous 2 years and their disability was assessed for the period when they were on antipsychotics. The remaining 132 patients (72.5%) had off-antipsychotics periods in the previous 2 years and their disability was assessed for the period when they were off-antipsychotics.

RESULTS

Patients on antipsychotics had significantly less disability across all domains of disability and in total IDEAS scores. Multivariate regression analysis showed that treatment status predicted disability scores after controlling for the effects of the confounding factors. Different levels of exposure to antipsychotic treatment were associated with different levels of disability.

CONCLUSIONS

Treatment with antipsychotics is associated with significantly less disability. There is an urgent need to bring schizophrenia patients under the umbrella of treatment.

A comparative study of antipsychotic medication taking in people with schizophrenia

Medication adherence is problematic in all chronic illnesses, none more so than in individuals with schizophrenia. The purpose of this exploratory study was to examine the factors that impacted upon antipsychotic medication taking in people with schizophrenia living in regional-rural and metropolitan Victoria, Australia, and to assess if differences existed between these two groups of participants in the factors that affected medication taking. The Factors Influencing Neuroleptic Medication Taking Scale was used with a non-probability survey sample of 81 people with schizophrenia. Ethics approval was given by university and hospital ethics committees. The results showed, overall, that there were no significant differences between the sets of participants in several demographic characteristics, insight, stigma, substance abuse, types of antipsychotic medications, significant others' support, and access to case managers and general practitioners. There were statistically significant differences between the two groups concerning living circumstances, involvement in religious/spiritual activities, perceived impact of medication side-effects, and access to psychiatrists. However, there were no statistically significant relationships between these factors and medication omission. The implications of the findings for consumers, mental health nurse case managers, families, mental health service provision, and further research, are considered.

Advances in psychotropic formulations

BACKGROUND

Successful pharmacotherapy is dependent on several factors. While efficacy is obviously important, other factors that are often overlooked include the availability of optimal dosage forms, treatment compliance and reduction in side effects. A number of innovative delivery systems have been developed to address suboptimal therapy outcomes by enhancing drug delivery, assuring efficacy of treatment, reducing side effects, and improving compliance.

OBJECTIVE

The purpose of this review is to discuss the advances in formulations for various psychotropic agents that have been developed for the treatment of psychiatric illnesses such as depression, attention deficit hyperactivity disorder, schizophrenia and other psychotic disorders.

METHODS

Information was identified via a MEDLINE and EMBASE search of data published between 2002 and 2005 with keywords 'psychotropic', 'atypical antipsychotic', 'antidepressant' or 'anxiolytic' in combination with 'new/novel/advanced formulation/delivery/technology', or 'controlled release/extended release', or 'fast-acting/fast-dissolving/orodispensible', or 'intramuscular/inject'.

RESULTS

In antidepressant therapy, formulations that allow extended release for once-daily and even once-weekly administration, orally disintegrating tablets, and transdermal systems have all been introduced. Long-acting central nervous system stimulants for the treatment of attention deficit hyperactivity disorder eliminate the need for multiple dosing. A number of new formulations of atypical antipsychotic agents have become available, offering important alternatives in certain patient groups. These include rapid-acting intramuscular injections, liquid formulations, and fast-dissolving tablets, all of which are useful options in the acute treatment setting as well as for geriatric and/or pediatric populations. Furthermore, formulations that deliver sustained levels of medications, including a long-acting antipsychotic and a new extended-release oral formulation, are important new developments that may improve compliance and offer efficacy and safety benefits in long-term management.

CONCLUSIONS

New formulations of psychotropics can offer advantages over older formulations in terms of convenience, side-effect profiles, efficacy, and/or a fast onset of action. Treatment-related factors can help to enhance patient's satisfaction with treatment and compliance, thereby improving patient prognosis and outcomes in both acute and outpatient management.

Medication-free research in early episode schizophrenia: evidence of long-term harm?

This study investigates the question of whether short periods of medication-free research in early episode schizophrenia result in demonstrable long-term harm to human subjects. A meta-analysis of published quasi-experimental and random assignment studies that had a majority of first- or second-episode schizophrenia spectrum subjects, at least 1 initially unmedicated group, and a minimum of 1-year results was conducted. Only 6 studies, with 623 subjects, met inclusion criteria. The initially unmedicated groups showed a small, statistically nonsignificant long-term advantage (r = -0.09). Incorporating only random assignment studies into a composite effect size produced a similar near-zero result (r = 0.01). Good-quality evidence is inadequate to support a conclusion of long-term harm resulting from short-term postponement of medication in early episode schizophrenia research. A categorical prohibition against such research should be reconsidered.

Neuroleptic reduction and/or cessation and neuroleptics as specific treatments for tardive dyskinesia

BACKGROUND

Since the 1950s neuroleptic medication has been extensively used to treat people with chronic mental illnesses such as schizophrenia. These drugs, however, have been also associated with a wide range of adverse effects, including movement disorders such as tardive dyskinesia (TD). Various strategies have been examined to reduce a person's cumulative exposure to neuroleptics. These studies include dose reduction, intermittent dosing strategies such as drug holidays, and neuroleptic cessation.

OBJECTIVES

To determine whether a reduction or cessation of neuroleptic drugs is associated with a reduction in TD, for people with schizophrenia (or other chronic mental illnesses) who have existing TD. Our secondary objective was to determine whether the use of specific neuroleptics for similar groups of people could be a treatment for TD that was already established.

SEARCH STRATEGY

We updated previous searches of the Cochrane Schizophrenia Groups Register (1997), Biological Abstracts (1982-1997), EMBASE (1980-1997), LILACS (1982-1996), MEDLINE (1966-1997), PsycLIT (1974-1997), and SCISEARCH (1997) by searching the Cochrane Schizophrenia Groups Register (July 2003). We searched references of all identified studies for further trial citations. We also contacted the principal authors of trials for further unpublished trials.

SELECTION CRITERIA

We included reports if they assessed people with schizophrenia or other chronic mental illnesses who had established neuroleptic-induced TD, and had been randomly allocated to (a) neuroleptic maintenance versus neuroleptic cessation (placebo or no intervention), (b) neuroleptic maintenance versus neuroleptic reduction (including intermittent strategies), and (c) specific neuroleptics for the treatment of TD versus, placebo or intervention. A post hoc decision was made to broaden comparison (c) to include specific neuroleptics versus other neuroleptics for the treatment of TD.

DATA COLLECTION AND ANALYSIS

We (KSW, JR) independently inspected citations and, where possible, abstracts, ordered papers, and re-inspected and quality assessed these and extracted data. We analysed dichotomous data using random effects relative risk (RR) and estimated the 95% confidence interval (CI). Where possible we calculated the number needed to treat (NNT) or number needed to harm statistic (NNH). We excluded continuous data if more than 50% of people were lost to follow up, but, where possible, we calculated the weighted mean difference (WMD). It was assumed that those leaving the study early showed no improvement.

MAIN RESULTS

We included five trials and excluded 102. One small two week study (n=18), reported on the 'masking' effects of molindone and haloperidol on TD, which favoured haloperidol (RR 3.44 CI 1.1 to 5.8). Two (total n=17) studies found no reduction in TD associated with neuroleptic reduction (RR 0.38 CI 0.1 to 1.0). One study (n=20) found no significant differences in oral dyskinesia (RR 2.45 CI 0.3 to 19.7) when neuroleptics were compared as a specific treatment for TD. Dyskinesia was found to be not significantly different (n=32, RR 0.62 CI 0.3 to 1.26) between quetiapine and haloperidol when these neuroleptics were used as specific treatments for TD, although the need for additional neuroleptics was significantly lower in the quetiapine group (n=47, RR 0.49 CI 0.2 to 1.0) than in those given haloperidol.

AUTHORS' CONCLUSIONS

Limited data from small studies using neuroleptic reduction or specific neuroleptic drugs as treatments for TD did not provide any convincing evidence of the value of these approaches. There is a need for larger trials of a longer duration in order to fully investigate this area.

Long-acting risperidone compared with oral olanzapine and haloperidol depot in schizophrenia: a Belgian cost-effectiveness analysis

Patients with schizophrenia suffer numerous relapses and rehospitalizations that are associated with high direct and indirect medical expense. Suboptimal therapeutic efficacy and, in particular, problems with compliance are major factors leading to relapse. Atypical antipsychotic agents offer improved efficacy and a lower rate of extrapyramidal adverse effects compared with conventional antipsychotic drugs. Long-acting intramuscular risperidone combines these benefits with improvements in compliance associated with depot injections. To assist decision making regarding the place of long-acting risperidone in therapy, a cost-effectiveness analysis of strategies involving first-line treatment with long-acting risperidone, oral olanzapine or depot haloperidol was performed from the perspective of the Belgian healthcare system. A decision tree model was created to compare the cost effectiveness of three first-line treatment strategies in a sample of young schizophrenic patients who had been treated for 1 year and whose disease had not been diagnosed for longer than 5 years. The model used a time horizon of 2 years, with health state transition probabilities, resource use and cost estimates derived from clinical trials, expert opinion and published prices. The four health states in the model were derived from an analysis of the literature. The principal efficacy measure was the proportion of patients successfully treated, defined as those who responded to initial treatment and who had none to two episodes of clinical deterioration without needing a change of treatment over the 2-year period. Comprehensive sensitivity analysis was carried out to test the robustness of the model. A greater proportion of patients were successfully treated with long-acting risperidone (82.7%) for 2 years, compared with those treated with olanzapine (74.8%) or haloperidol (57.3%). Total mean costs per patient over 2 years were 16,406 Euro with long-acting risperidone, 17,074 Euro with olanzapine and 21,779 Euro with haloperidol (year of costing 2003). The mean cost-effectiveness ratios were 19,839 Euro, 22,826 Euro and 38,008 Euro per successfully treated patient for long-acting risperidone, olanzapine and haloperidol, respectively. Results of the sensitivity analysis confirmed that the results were robust to a wide variation of different input variables (effectiveness, dosing distribution, patient status according to healthcare system). Long-acting risperidone was the dominant strategy, being both more effective and less costly than either oral olanzapine or depot haloperidol. Long-acting risperidone appears to represent a favourable first-line strategy for patients with schizophrenia requiring long-term maintenance treatment.

A review of pharmacologic strategies for switching to atypical antipsychotics

BACKGROUND

In daily clinical practice, frequent switching of antipsychotic medications is widespread. There are various reasons for switching, including a partial or complete lack of efficacy, adverse side effects, and partial or noncompliance with medication. Patients switched from conventional drugs to oral atypical antipsychotic drugs have been shown to benefit from significant improvements in clinical response and tolerability. This review examines the strategies for switching patients from conventional antipsychotic drugs to both oral and long-acting formulations of atypical antipsychotic drugs that are the recommended treatment in the majority of patients with schizophrenia.

DATA SOURCES AND STUDY SELECTION

An electronic literature search of relevant studies using MEDLINE (January 1994-June 2004) was performed using the search terms antipsychotic, atypical, conventional, schizophrenia, and switching. English-language articles, references from bibliographies of reviews, original research articles, and other articles of interest were reviewed.

DATA EXTRACTION AND SYNTHESIS

Data quality was determined by publication in the peer-reviewed literature and the most important information identified. Data from clinical trials suggest that switching to an atypical antipsychotic drug is beneficial for the patient with schizophrenia.

CONCLUSIONS

If initiated appropriately, switching to atypical antipsychotic medications should not compromise patient functioning; indeed, individualized strategies have been shown to provide continuous treatment efficacy. Switching to atypical antipsychotic therapy should, therefore, be employed as a pharmacologic strategy to maximize patient outcomes.

Sustained drug delivery optimizes long-term treatment of patients with schizophrenia

Chronic disorders such as schizophrenia require long-term treatment programs in order to maintain patients at the lowest level of symptomatology, reduce the likelihood of psychotic relapse, and support achievement of remission and recovery. Evidence suggests that treatment with long-acting injectable antipsychotics reduces the impact of partial compliance and provides predictable release of medication, assuring continuous therapeutic coverage. Until recently, only conventional antipsychotic agents were available in long-acting formulations, thereby foregoing the advantages of the atypical class. Atypical agents which are given orally have been shown to provide long-term efficacy and tolerability benefits compared with conventional agents, but are limited by the need for daily administration. The most recent pharmacological strategy to achieve optimal maintenance treatment has been to combine the benefits of an atypical antipsychotic with delivery in a water-based long-acting formulation. The first antipsychotic to achieve this combination - long-acting risperidone - may thus represent an important advance in the optimization of long-term treatment outcomes in patients with schizophrenia.

Disease Models of Mental Illness and Aftercare Patient Education: Critical Observations from Meta-Analyses, Cross-Cultural Practice and Anthropological Study

This paper examines critically the idea of educating mental health service users in the frame of neurobiological psychiatry as a way of understanding their experience. This idea is compared with the findings in five broad areas of the literature on schizophrenia: psychopharmacological research, psychosocial rehabilitation, first person accounts, international epidemiology and familial expressed emotion research. This literature, which includes reports of five meta-analyses, is used to highlight ethnographic findings from the author's original research. The implications of the argument made about aftercare education for the practice of occupational therapists in hospital and community psychiatry conclude the article.

Antisuicide properties of psychotropic drugs: a critical review

The authors consider the extent to which psychotropic medications demonstrate benefits in the prevention of suicidal behavior in psychiatric patients. Results of a MedLine search are critically reviewed for lithium, divalproex and other anticonvulsants, conventional and atypical antipsychotics, and antidepressants. The existing literature is almost entirely limited to noncontrolled, often retrospective studies that do not control for potential biases in treatment selection, the use of multiple medications, the impact of medication nonadherence, and nonrandomized treatment discontinuations. Nevertheless, an extensive literature has arisen regarding observed reductions in suicidal behavior with lithium for mood disorders and, to a lesser extent, with clozapine for schizophrenia. A substantially smaller literature suggests more negative than positive data with divalproex or carbamazepine in bipolar disorder, while minimal information exists regarding suicidality with atypical antipsychotics other than clozapine. Studies of antidepressants have mostly been short-term and have focused more on whether they induce (rather than ameliorate) suicidal thoughts or behaviors. The sum of existing studies is generally inconclusive about whether antidepressants appreciably reduce risk for suicide completions. Relatively little is known about pharmacotherapy effects on suicidal ideation as distinct from behaviors. Possible mechanistic considerations for understanding antisuicide properties include a therapeutic impact on depression, impulsivity, or aggression, potentially mediated through serotonergic or other neuromodulatory systems. Recommendations are provided to guide future research as well as clinical practice.

Transdermal drug delivery system of haloperidol to overcome self-induced extrapyramidal syndrome

Haloperidol (HAL), an antipsychotic, is associated with side effects of drug-induced extrapyramidal syndrome (EPS) in conventional monotherapy. Controlled released transdermal dosage form (TDDS) of the drug was designed for maintenance therapy. Matrix-diffusion type transdermal film of HAL was designed with Eudragit NE 30D copolymer without permeation enhancer in different combinations. For the feasibility studies, all standard evaluations were performed, and their results pointed toward the suitability of TDDS. The drug release and permeation studies in Franz diffusion cell in 20% PEG-normal saline followed the Higuchi equation with optimum correlation coefficient. The neuroleptic efficacy was confirmed by maximum graded response in a rotarod apparatus. The neuroleptic-induced catatonia (EPS) in albino rats was minimum with a score of zero over a 72-hr study. The pharmacokinetic parameters in rabbit model showed a very significant prolongation of action up to 72 hr with steady-state plasma concentration (cp(ss)) of 11.58 ng/mL. Thus, the HAL-loaded TDDS improved the therapeutic profile by preventing the neuroleptic-induced EPS and might be a better alternative during its long period of psychiatric treatment over conventional dosage form.

The therapeutic misconception, beneficence, and respect

In order to provide benefits to society, human medical trials must place subjects at risk of harm. This activity is thought to be justified in part by the consent of the subjects involved. But, studies have shown that most such consents are based on a therapeutic misconception (TM); the false belief of subjects that their researchers will act as their personal physicians (seeking their benefit and protecting them from harm), rather than placing them at risk of harm for the good of others. Toleration by researchers of the TM in their subjects is a form of "informational manipulation" that renders consent procedures disrespectful to subject autonomy. Consent obtained from subjects who labor under a TM is neither voluntary nor informed; as long as they have not been disabused of the TM, the action they take in enrolling in a trial is not the one they intend nor is it autonomously chosen. Changes in consent procedures should be adopted to ensure that all subjects are aware inter alia that (a) the health interests of future patients (as well as the researchers' and their sponsors' financial interests) may be more important to researchers than the interest of a subject in his or her health, and (b) normal subjects neither understand nor believe this when told. Close attention to the response of prospective subjects to this information should allow for the exclusion of all but the truly altruistic. However, the result of conscientious implementation of such policies would likely be that human medical research could no longer be conducted on more than a minimal level.

Neuroleptic reduction and/or cessation and neuroleptics as specific treatments for tardive dyskinesia

BACKGROUND

Since the 1950s neuroleptic medication has been extensively used to treat people with chronic mental illnesses, such as schizophrenia. These drugs, however, have been also associated with a wide range of adverse effects, including movement disorders such as tardive dyskinesia (TD). Various strategies have been examined to reduce a person's cumulative exposure to neuroleptics. These studies include dose reduction, intermittent dosing strategies, such as drug holidays, and neuroleptic cessation.

OBJECTIVES

To determine whether, for those people with both schizophrenia (or other chronic mental illnesses) and tardive dyskinesia (TD), a reduction or cessation of neuroleptic drugs was associated with reduction in TD symptoms. A secondary objective was to determine whether the use of specific neuroleptics for similar groups of people could be a treatment for already established TD.

SEARCH STRATEGY

Electronic searches of Biological Abstracts (1982-1997), Cochrane Schizophrenia Group's Register of trials (1997), EMBASE (1980-1997), LILACS (1982-1996), MEDLINE (1966-1997), PsycLIT (1974-1997), and SCISEARCH (1997) were undertaken. References of all identified studies were searched for further trial citations. Principal authors of trials were contacted.

SELECTION CRITERIA

Reports were included if they assessed the treatment of neuroleptic-induced tardive dyskinesia in people with schizophrenia or other chronic mental illnesses and already established TD, who had been randomly allocated to (a) neuroleptic cessation (placebo or no intervention) versus neuroleptic maintenance; b. neuroleptic reduction (including intermittent strategies) versus neuroleptic maintenance; or c. specific neuroleptics for the treatment of TD versus placebo or no intervention.

DATA COLLECTION AND ANALYSIS

The reviewers extracted the data independently and the Odds Ratio (95% CI) or the average difference (95% CI) were estimated. The reviewers assumed that people who dropped out had no improvement.

MAIN RESULTS

Two trials were able to be included in this review. Sixty two were excluded and 16 are awaiting assessment. Seven trials are still pending classification. No randomised controlled trial-derived data were available to clarify the role of neuroleptics as treatments for TD. This includes the atypical antipsychotics including clozapine. Despite neuroleptic cessation being a frequently first-line recommendation, there were no RCT-derived data to support this. Two studies ( approximately approximately Cookson 1987 approximately approximately , approximately approximately Kane 1983 approximately approximately ) found a reduction in TD associated with neuroleptic reduction.

REVIEWER'S CONCLUSIONS

The lack of evidence to support the efficacy of neuroleptic cessation as a treatment for TD, combined with the accumulating evidence of an increased risk of relapse should antipsychotic drugs be reduced, makes this intervention a hazardous treatment for TD. Dose reduction may offer some benefit as a treatment for TD compared to standard levels of neuroleptic use. There is a need to evaluate the utility of clozapine and the 'atypical' antipsychotics as treatments for established TD.

The long-term effects of placebo in patients with chronic schizophrenia

BACKGROUND

It has been hypothesized that placebo periods may increase long-term morbidity for patients with schizophrenia. In this study, the long-term effect of a placebo period was evaluated in a group of relatively treatment-refractory patients with chronic schizophrenia.

METHODS

This retrospective study examined behavioral rating scores for 127 patients with chronic schizophrenia who were placed in a double-blind placebo study on the inpatient units of the National Institute of Mental Health Neuropsychiatric Research Hospital. Patients were rated daily with the Psychiatric Symptom Assessment Scale (PSAS), an extended and anchored version of the Brief Psychiatric Rating Scale (BPRS). At the end of the placebo phase, most patients were placed on haloperidol. Pre-placebo baseline PSAS ratings were compared with, first, discharge ratings and second, post-placebo ratings. To determine expected variability in the course of illness, patients in the placebo group were compared with patients hospitalized during the same time period, but who did not enter the placebo study.

RESULTS

By discharge, ratings for placebo patients had returned to baseline. Post-placebo ratings were quite variable. Although many of the placebo patients had returned to baseline by day 3 of the post-placebo phase, others had not returned to baseline by post-placebo day 42. PSAS Total Scores for patients who left the study early were no different at baseline, placebo, or through post-placebo day 35 compared with patients who completed the study.

CONCLUSIONS

The results indicate that given a sufficiently lengthy recovery period, patients with chronic schizophrenia who go through a placebo phase return to baseline, but that the speed with which they attain that recovery is highly variable.

The effects of early and sustained intervention on the long-term morbidity of schizophrenia

By examining the literature concerning early intervention with antipsychotic medications, and how it affects long-term morbidity, this article will review the concept that early intervention with antipsychotic medications improves the long-term course of schizophrenia. It also looks at the potential long-term effects of discontinuing antipsychotic medications early in the course of schizophrenia. It appears that early intervention with antipsychotic medications decreases some of the long-term morbidity associated with schizophrenia. Some of the implications of this finding are discussed in the context of both clinical practice and clinical research.

The limitations of antipsychotic medication on schizophrenia relapse and adjustment and the contributions of psychosocial treatment

Whether psychosocial treatment adds substantially to the prophylactic efficacy of maintenance antipsychotic monotherapy requires a more accurate estimate of relapse risks than those contained in recent reviews. A reappraisal of the literature suggests a 1-year, post-hospital, relapse rate of 40% on medication, and a substantially higher rate among patients who live in stressful environments, rather than earlier estimates of 16%. Relapse rates of 65% at 1 year and over 80% by 2 years among drug discontinued or placebo substituted outpatients are also more accurate than the 53% relapse rate previously estimated. When psychosocial treatment is added to maintenance chemotherapy, there is compelling evidence that relapse rates are reduced by as much as 50% compared with relapse associated with medication and standard care. However, psychosocial treatment without medication is as ineffective as placebo. The additive effects appear greater for recent, theoretically based psychosocial approaches than earlier atheoretical, altruistic forms of caring. However, effects vary according to the patient's clinical state, the nature and timing of the intervention, and the presence of environmental stressors. Regarding adjustment, very little definitive information regarding psychosocial treatment effects has existed until recently. A novel, disorder-relevant approach has now been shown to have broad and significant effects on social adjustment compared with medication and support. However, the magnitude of effects is not fully realized until a third year of treatment: a distinct challenge in the era of managed care. Atypical antipsychotics and more definitive psychosocial strategies that target social cognitive deficits hold promise for enhanced outcomes in the next generation of studies.

Is rehospitalization a measure of the efficacy of neuroleptics in the treatment of schizophrenia?

This study was undertaken to evaluate the efficacy of standard neuroleptic treatment versus depot neuroleptic treatment. The major criterion for evaluation was the number of patients hospitalized. Patients were chosen on the basis of their rating by the ICD-10 classification for schizophrenic disorders. The first study period was defined as the time when patients were treated with standard neuroleptics; the second was when patients were treated with depot neuroleptics. There were 231 hospitalizations during the first period, which involved 48 patients, i.e. 4.8 hospitalizations per patient. The mean total duration of these hospitalizations was 5.2 years, i.e. it was on average 5 years before the patient was treated with a depot neuroleptic, with 0.93 hospitalizations per year. The duration of the second period was the same as the first. Only 44 patients remained in the study during this period; their mean number of hospitalizations was 7.2 per patient. The mean number of hospitalizations per year per patient was 1.25. The results suggest that the number of hospitalizations is only a partially satisfactory way of evaluating the efficacy of neuroleptic treatments, and questions the relative efficacy of depot neuroleptics compared with standard neuroleptic treatment.

Factors influencing relapse in the long-term course of schizophrenia

Highly effective neuroleptic drugs have been available for the past 40 years, but 50% of schizophrenic patients, under normal treatment conditions, relapse within 1 year after their latest episode, frequently spending 15-20% of their time in psychiatric institutions. The term relapse usually refers to a deterioration or recurrence of positive rather than negative features, and relapses appear to impair the course of the disease. Impairment is often longer than expected for those patients who discontinue antipsychotic medication and then relapse to their prediscontinuation clinical state of function. Drug therapy is an important defense against relapse. Marked differences in relapse rate between patients receiving placebo and neuroleptic drugs have been observed (approximately 69% after 1 year for the placebo group versus 26% for the neuroleptic group). First-year relapse rates can be reduced from 75% to 15% with prophylactic treatment with neuroleptics. Follow-up studies suggest that noncompliance with medication, pharmacological factors, psychosocial factors and alcohol and drug abuse contribute to setting off new psychotic episodes. The most important of these is noncompliance with medication. The overwhelming majority of schizophrenic patients who suffered a clinical exacerbation and required hospitalization (73%) did not comply with the treatment prescribed. The effect of new antipsychotic agents should be examined in patients who relapse despite maintenance treatment with conventional neuroleptics. We have found that the rate of current drug abuse among patients with schizophrenic relapse (44%) was significantly higher than that in schizophrenic patients who regularly attended outpatient clinics. Also, the rate of alcohol and substance abuse is higher in males (79%) than in females (21%). Psychiatric units should integrate addiction treatments with psychotic-relapse management.

New strategies for old problems: tardive dyskinesia (TD). Review and report on severe TD cases treated with clozapine, with 12, 8 and 5 years of video follow-up

Tardive dyskinesia (TD) is the most feared and troublesome extrapyramidal side-effect of prolonged neuroleptic (NL) treatment. We present a review of TD. Its pathophysiology remains elusive, although extrapyramidal symptoms (EPS) increase the liability for TD. Nowadays, therefore, avoidance of all EPS remains the best preventive strategy, as it is not possible to predict which liable patients will develop TD, or of what type or severity. TD frequently includes dystonic features, and is more disabling when these dystonias are present. Clozapine (CLZ) has been reported to be effective in suppressing nearly 60% of TD syndromes, specially those with dystonic features. Based on the few reports in the literature on CLZ and TD by the early 1980s, we started to videotape the first severe TD patient treated with CLZ in 1984. We present the first three case reports of severe TD, with prominent disabling dystonic features, treated with CLZ and videotaped since pretreatment and then periodically for 12, 8 and 5 years of follow-up, respectively. The patients' current diagnosis, gender and age are: Case 1, DSM-IV Schizophrenia Residual Type, male, 39 years; Case 2, DSM-IV Polysubstance Related Disorder, Borderline Personality Disorder, female, 28 years; Case 3, DSM-IV Schizoaffective Disorder, male, 40 years. Two of them presented with a recurrence of TD because of CLZ interruption within the first 2 months of treatment, with no further breakthrough to date. The first two cases have complete remission of TD; the third case is still improving after 5 years of CLZ treatment, with only minor dystonic features persisting that constitute no impairment for work or daily routines at present. All patients, independent of their psychiatric primary diagnosis, have shown significant and progressive improvement in both motor and psychosocial aspects. None of them has been rehospitalized. Long-term treatment and follow-up is required to avoid TD recurrence and to assure full assessment of treatment effectiveness. Ideally, periodic video recording with standardized examination is advisable for long-term follow-up and outcome assessment. At present, CLZ could be regarded as the drug of choice for patients with TD, specially for those with disabling and or dystonic features and who require ongoing NL therapy. The use of novel antipsychotic agents for TD treatment and prevention, with their low EPS liability, is promising, but has yet to be tested.

Tardive dyskinesia: who is at risk?

Tardive dyskinesia (TD) has been associated with female gender, affective symptoms and good outcome, but also with negative symptoms, cognitive deterioration and deteriorating illness course. Furthermore, antipsychotic medication is thought to be an important risk factor, yet abnormal movements also occur in patients who have never received such medication. We followed 166 subjects with recent onset of psychotic illness and brief previous exposure to antipsychotic medication. Information on 17 previously reported risk factors was available for 125 patients at baseline and, for factors that vary over time, again at follow-up 4 years later (median, 50 months; interquartile range, 29-70). Movement disorder was assessed at follow-up using the Abnormal Involuntary Movement Scale (AIMS). Six noninteracting variables were independently associated with the 4-year risk of TD: male sex (OR, 2.5; 95% CI, 1.1-5.0), age (OR over quartiles at baseline, 1.6; 95% CI, 1.1-2.2), lack of insight at baseline (OR over four categories, 2.0; 95% CI, 1.2-3.2), time on antipsychotics during the follow-up period (OR over quartiles, 2.3; 95% CI, 1.5-3.4), an increase in negative symptoms during the follow-up period (OR over quartiles, 1.7; 95% CI, 1.2-2.5), and alcohol/drug misuse at follow-up (OR, 3.0; 95% CI, 1.3-7.4). The presence of individual risk factors was found to be of little use as a screening test for subsequent clinically relevant TD. Given the absence of a risk factor, however, the probability that an individual would not develop TD was high. These results suggest that two discrete effects may operate to increase the risk of TD, namely an exogenous factor (medication, drugs), and an illness-related factor, the highest risk being conferred by deteriorating illness course in male patients.

Medication compliance among the seriously mentally ill in a public mental health system

Medication non-compliance, a pervasive problem among persons with serious, chronic mental illness, has been linked to increased inpatient resources use in public mental health systems. The objective of this analysis was to determine which factors are associated with medication compliance in this population so that more appropriate screening and intervention programs can be designed. Using knowledge gained from clinical research on compliance in schizophrenia and research testing the Health Belief Model as a conceptual framework in studying compliance behavior, we conducted a secondary analysis of data collected in the Mississippi public mental health system in 1988. The study subjects were schizophrenic patients (n = 202), the majority of whom were low-income, African-American males. Data sources included structured interviews with patients and family members, as well as state hospital and community mental health clinic administrative records. Receipt of consistent outpatient mental health treatment and belief that one had a mental illness were significantly associated with higher levels of medication compliance in this population of seriously mentally ill patients. Our results suggest that screening programs to identify those at highest risk for non-compliance in this population might be more productive if they included a review of inpatient and outpatient mental health service utilization patterns, in addition to formal assessment of patients' attitudes and beliefs about their illness. This study illustrates an approach to examining predictors of a policy-relevant health behavior in a minority population within a public mental health system.

Proper psychosocial rehabilitation for stabilised patients with schizophrenia: the role of new therapies

Schizophrenia impairs the development of social skills needed for useful, independent living. Psychotherapeutic approaches increase the value of antipsychotic drugs by helping patients cope with the social pressures to which they are particularly vulnerable. Antipsychotic drugs reduce psychosis, protect against stressors and, taken lifelong, provide considerable relapse protection. Low-dose or intermittent medication regimens reduce the incidence of side effects but give less protection against relapse than continuous full-dose therapy. For the move towards community- rather than hospital-based care to succeed, comprehensive, multidisciplinary, integrated services are essential. Individually tailored psychosocial rehabilitation enables patients to make the best use of their capabilities. In addition, family therapy increases the effectiveness of drugs and reduces relapse rates. New antipsychotic drugs are likely to be more effective than conventional neuroleptics because they offer broader spectra of activity, induce fewer side effects and are more likely to be taken as directed.

Long-term depot antipsychotics. A risk-benefit assessment

The main advantage of depot antipsychotic medication is that it overcomes the problem of covert noncompliance. Patients receiving depot treatment who refuse their injection or fail to receive it for any other reason can be immediately identified and appropriate action taken. In the context of a carefully monitored management programme, depot treatment can have a major impact on compliance and, consequently, the risk of relapse and hospitalisation can be reduced. Another major advantage is that the considerable individual variation in bioavailability and metabolism with oral antipsychotic drugs is markedly reduced with depot treatment. A better correlation between the dose administered and the concentration of medication found in blood or plasma is achieved with depot treatment, and thus, the clinician has greater control over the amount of drug being delivered to the site of activity. A further benefit of depot treatment is the achievement of stable plasma concentrations over long periods, allowing injections to be given every few weeks. However, this also represents a potential disadvantage in that there is a lack of flexibility of administration. Should adverse effects develop, the drug cannot be rapidly withdrawn. Furthermore, adjustment to the optimal dose becomes a long term strategy. The controlled studies of low dose maintenance therapy with depot treatment suggest that it can take months or years for the consequences of dose reduction, in terms of increased risk of relapse, to become manifest. When weighing up the risks and benefits of long term antipsychotic treatment for the individual patient with schizophrenia, the clinician must take into account the nature, severity and frequency of past relapses, and the degree of distress and disability related to any adverse effects. However, the clinical decision to prescribe either a depot or an oral antipsychotic for maintenance treatment will probably rest largely on an assessment of the risk of poor compliance in the particular patient. There is no convincing evidence that the range, nature or severity of adverse effects reported with depot treatment is significantly different from that seen with oral treatment, and depot treatment has been shown to be as good or better than oral medication in preventing or postponing relapse. Furthermore, when adjusting the dose or frequency of depot injection, to improve control of psychotic symptoms or reduce adverse effects, the clinician can be confident that the dose prescribed is the dose being received by the patient.

Factors affecting rehospitalisation rates of chronic schizophrenic patients living in the community

Eighty-eight [corrected] patients selected from a depot neuroleptic clinic in the hospital outpatients department were assessed clinically on various demographic and clinical variables with a view to determining the factors that may contribute to high rates of rehospitalisation amongst schizophrenics in remission. It was found that rehospitalisation rates during the preceding 5 years correlated with an early age of onset of illness, severity of positive and affective symptoms, current neuroleptic dose and total AIMS score, all reflecting the severity of underlying psychotic disorder and the neuroleptic treatment required to treat the psychosis. Poor compliance with neuroleptic prophylaxis was not found to be of importance in contributing to high relapse rates in this sample. It was concluded that patients who repeatedly relapse may do so because of the clinical characteristics of their illness.