Recent developments in the drug treatment of schizophrenia

Gold-catalyzed formation of aryl-fused pyrazolooxazepines via intramolecular regioselective 7-exo-dig cyclization

An efficient gold-catalyzed method was developed for the formation of aryl-fused pyrazolooxazepines from ortho-O-propargyl aryl pyrazoles via 7-exo-dig cyclization in good yields.

Intermittent drug techniques for schizophrenia

BACKGROUND

Antipsychotic medication is considered the mainstay of treatment for schizophrenia and is generally regarded as highly effective, especially in controlling positive symptoms. However, long-term antipsychotic exposure has been associated with a range of adverse effects, including extra-pyramidal symptoms (EPS), neuroleptic malignant syndrome (NMS), tardive dyskinesia and death. Intermittent drug techniques refers to the 'use of medication only during periods of incipient relapse or symptom exacerbation rather than continuously'. The aim is to reduce the risk of typical adverse effects of antipsychotics by 'reducing long-term medication exposure for patients who are receiving maintenance treatment while limiting the risk of relapse', with a further goal of improving social functioning resulting from the reduction of antipsychotic-induced side effects

OBJECTIVES

To review the effects of different intermittent drug techniques compared with maintenance treatment in people with schizophrenia or related disorders.

SEARCH METHODS

We searched The Cochrane Schizophrenia Group Trials Register (April 2012) and supplemented this by contacting relevant study authors, handsearching relevant intermittent drug treatment articles and manually searching reference lists.

SELECTION CRITERIA

All randomised controlled trials (RCTs) that compared intermittent drug techniques with standard maintenance therapy for people with schizophrenia. Primary outcomes of interest were relapse and hospitalisation.

DATA COLLECTION AND ANALYSIS

At least two review authors selected trials, assessed quality and extracted data. We calculated risk ratios (RR) and 95% confidence intervals (CI) of homogeneous dichotomous data and estimated the 95% confidence interval (CI) around this. For non-skewed continuous endpoint data extracted from valid scales, we estimated mean difference (MD) between groups with a 95% CI. Where data displayed heterogeneity, these were analysed using a random-effects model. Skewed data are presented in tables. We assessed overall quality for clinically important outcomes using the GRADE approach.

MAIN RESULTS

Of 241 records retrieved by the search, 17 trials conducted between 1961 and 2011, involving 2252 participants with follow-up from six weeks to two years, were included. Homogenous data demonstrated that instances of relapse were significantly higher in people receiving any intermittent drug treatment in the long term (n = 436, 7 RCTs, RR 2.46, 95% CI 1.70 to 3.54, moderate quality evidence). Intermittent treatment was shown to be more effective than placebo, however, and demonstrated that significantly less people receiving intermittent antipsychotics experienced full relapse by medium term (n = 290, 2 RCTs, RR 0.37, 95% CI 0.24 to 0.58, very low quality evidence). Hospitalisation rates were higher for people receiving any intermittent drug treatment by long term (n = 626, 5 RCTs, RR 1.65, 95% CI 1.33 to 2.06, moderate quality evidence). Results demonstrated little difference in instances of tardive dyskinesia in groups with any intermittent drug technique versus maintenance therapy, with equivocal results (displaying slight heterogeneity) at long term (n = 165, 4 RCTs, RR 1.15, 95% CI 0.58 to 2.30, low quality evidence).

AUTHORS' CONCLUSIONS

Results of this review support the existing evidence that intermittent antipsychotic treatment is not as effective as continuous, maintained antipsychotic therapy in preventing relapse in people with schizophrenia. More research is needed to assess any potential benefits or harm of intermittent treatment regarding adverse effects typically associated with maintained antipsychotic treatment, as well as any cost-effectiveness of this experimental treatment.

Refractory schizophrenia: Historical and currently prevailing criteria and definitions

Various historical aspects of resistant schizophrenia are described: limitations of treatment efficacy, attempts at proposing therapeutic strategies in non-responding patients, first attempts to define resistance in schizophrenia, and first attempts to distinguish resistance factors. Interest in treatment-refractory schizophrenia was stimulated by several studies in the period 1985-1990, including a pivotal study of clozapine. The need to include biological and psychosocial factors when defining resistance was emphasised by a group who defined a systematic approach to treatment resistance in schizophrenia, including degrees of resistance. The concept of a continuum from full remission to complete refractoriness was proposed by an international study group in 1990. Difficulties in identifying patients with refractory schizophrenia include: variability of schizophrenia diagnostic criteria, lack of consensus concerning good treatment practice with neuroleptic agents, and confusion between resistance, chronicity and severity. A better definition of refractoriness is needed, not only for pharmacological studies but also for a more precise characterisation of a possible subgroup of schizophrenia termed 'Kraepelinian'.

Clozapine for treatment-resistant schizophrenia: National Institute of Clinical Excellence (NICE) guidance in the real world

INTRODUCTION

Clozapine, a poorly tolerated antipsychotic drug, is widely recognized as the only efficacious option in treatment-resistant psychosis. The United Kingdom (U.K.) National Institute of Clinical Excellence (NICE) guidance for its consideration defined a threshold for treatment resistance substantially more liberal than that utilized in seminal studies of efficacy. This study documented adherence to NICE guidance in a patient group likely to be enriched for treatment resistance: 150 consecutive assertive outreach and former rehabilitation inpatients. Evidence of a NICE-compliant treatment trial was adduced from case notes: treatment resistance was determined through discussion with key workers about ongoing clinical problems, including treatment-resistant patients already on clozapine. Reasons for treatment-resistant patients not receiving clozapine were documented. Levels of ongoing clinical problems were compared between treatment-resistant patients on clozapine, treatment-resistant patients not on clozapine, and non-treatment-resistant patients.

RESULTS

Patients' mean age was 41, with illness duration of 16 years. Twelve percent (18 patients) had not had a NICE-compliant trial of treatment, but all 3 treatment-resistant patients in this subgroup were on clozapine already. Forty-five percent of the whole group was treatment resistant: 54% of the treatment-resistant group was treated with clozapine. Of the remaining 46% (i.e., 31 treatment-resistant patients not taking clozapine), 16 refused and 15 could not be treated for medical reasons including the failure of previous trials and neutropenia. Levels of ongoing clinical problems were generally similar between clozapine-treated patients and nontreatment-resistant patients, with significantly greater problems in treatment-resistant patients not taking clozapine. However, positive symptoms remained relatively high in the clozapine group, while substance abuse was actually lower than in the other two groups, and there were no differences between any of the groups in depression and suicide risk.

CONCLUSIONS

Tertiary referral assertive outreach and rehabilitation services include a higher proportion of treatment-resistant patients than secondary services, as appropriate. Most patients receive a NICE-compliant trial for the determination of pharmacological treatment resistance, but only just over half of the patients who need clozapine on clinical grounds are taking it. While half of these refuse, the rest encounter insuperable obstacles to treatment. In general, clozapine reduces levels of ongoing clinical problems to those of nontreatment-resistant patients. In view of the difficulties of delivering clozapine to treatment-resistant patients, the development of treatment resistance should be avoided if possible.

A systematic review of the Soteria paradigm for the treatment of people diagnosed with schizophrenia

BACKGROUND

The "Soteria paradigm" attempts to support people diagnosed with schizophrenia spectrum disorders using a minimal medication approach. Interest in this approach is growing in the United Kingdom, several European countries, North America, and Australasia.

AIMS

To summarize the findings from all controlled trials that have assessed the efficacy of the Soteria paradigm for the treatment of people diagnosed with schizophrenia spectrum disorders.

METHODS

A systematic search strategy was used to identify controlled studies (randomized, pseudorandomized, and nonrandomized) employing the Soteria paradigm to treat adults and adolescents meeting the criteria for schizophrenia spectrum disorders according to International Classification of Diseases and Diagnostic and Statistical Manual for Mental Disorders criteria.

RESULTS

We identified 3 controlled trials involving a total of 223 participants diagnosed with first- or second-episode schizophrenia spectrum disorders. There were few major significant differences between the experimental and control groups in any of the trials across a range of outcome measures at 2-year follow-up, though there were some benefits in specific areas.

CONCLUSIONS

The studies included in this review suggest that the Soteria paradigm yields equal, and in certain specific areas, better results in the treatment of people diagnosed with first- or second-episode schizophrenia spectrum disorders (achieving this with considerably lower use of medication) when compared with conventional, medication-based approaches. Further research is urgently required to evaluate this approach more rigorously because it may offer an alternative treatment for people diagnosed with schizophrenia spectrum disorders.

Molindone for schizophrenia and severe mental illness

BACKGROUND

Antipsychotic therapy is the mainstay of treatment for people with schizophrenia. In recent years new or atypical antipsychotics have been introduced. These are less likely to produce movement disorders and raise serum prolactin. Researchers have suggested that molindone should be classified as an atypical antipsychotic.

OBJECTIVES

To determine the effects of molindone compared with placebo, typical and other atypical antipsychotic drugs for schizophrenia and related psychoses.

SEARCH STRATEGY

For the original search we searched the following databases: Biological Abstracts (1980-1999), The Cochrane Library CENTRAL (Issue 1, 1999), The Cochrane Schizophrenia Group's Register (January 1999), CINAHL (1982-1999), EMBASE (1980-1999), MEDLINE (1966-1999), LILACS (1982-1999), PSYNDEX (1977-1999), and PsycLIT (1974-1999). We also searched pharmaceutical databases on the Dialog Corporation Datastar and Dialog and the references of all identified studies for further trials. Finally, we contacted the manufacturer of molindone and the authors of any relevant trials. For the update of this review, we searched The Cochrane Schizophrenia Group's Trials Register (August 2005).

SELECTION CRITERIA

We included all randomised controlled trials that compared molindone to other treatments for schizophrenia and schizophrenia-like psychoses.

DATA COLLECTION AND ANALYSIS

We extracted data independently and analysed on an intention to treat basis calculating, for binary data, the fixed effect relative risk (RR), their 95% confidence intervals (CI), and the number needed to treat or harm (NNT or NNH). We excluded data if loss to follow up was greater than 50%.

MAIN RESULTS

We included fourteen studies. Duration ranged from very short (10 days) studies of the intramuscular preparation, to trials lasting over three months. For measures of global assessment, available data do not justify any conclusions on the comparative efficacy of molindone and placebo. When compared to other typical antipsychotics we found no evidence of a difference in effectiveness (doctors' 4 RCTs n=150, RR 1.13, CI 0.69 to 1.86; nurses 4RCTs n=146, RR 1.23, CI 0.82 to 1.86). Molindone is no more or less likely than typical drugs to cause movement disorders, but it does cause significantly more weight loss (2RCTs n=60 RR 2.78, CI 1.10 to 6.99, NNH 5 CI 2 to 77).

AUTHORS' CONCLUSIONS

The strength of the evidence relating to this compound is limited, owing to small sample size, poor study design, limited outcomes and incomplete reporting. Molindone may be an effective antipsychotic but its adverse effect profile does not differ significantly from that of typical antipsychotics (apart from the event of weight loss). Data from this review suggest, at present, there is no evidence to suggest that it may have an atypical profile.

Molindone for schizophrenia and severe mental illness

BACKGROUND

Typical antipsychotic drugs are widely used as the first line treatment for people with schizophrenia. However, the atypical class of antipsychotic drugs is making important inroads into this approach. 'Atypical' is a term widely used to describe some antipsychotics which have a low propensity to produce movement disorders, sedation and raised serum prolactin. There is some suggestion that the different adverse effect profiles of the atypical antipsychotic group make them more acceptable to people with schizophrenia. Molindone has a similar profile to quetiapine (a novel atypical antipsychotic), with very low binding to all receptors. Some authors have suggested that molindone is safer than other 'typical' antipsychotics in that extrapyramidal adverse effects are not usually seen at clinically effective antipsychotic doses and that it should therefore be classed as an atypical antipsychotic.

OBJECTIVES

To determine the effects of molindone compared with placebo, typical and other atypical antipsychotic drugs for schizophrenia and related psychoses.

SEARCH STRATEGY

Electronic searches of Biological Abstracts (1980-1999), The Cochrane Library CENTRAL (Issue 1, 1999), The Cochrane Schizophrenia Group's Register (January 1999), CINAHL (1982-1999), EMBASE (1980-1999), MEDLINE (1966-1999), LILACS (1982-1999), PSYNDEX (1977-1999), and PsycLIT (1974-1999) were undertaken. In addition, pharmaceutical databases on the Dialog Corporation Datastar and Dialog services were searched. References of all identified studies were searched for further trials. The manufacturer of molindone and authors of trials were contacted.

SELECTION CRITERIA

All randomised controlled trials that compared molindone to other treatments for schizophrenia and schizophrenia-like psychoses were included by independent assessment.

DATA COLLECTION AND ANALYSIS

Citations and, where possible, abstracts were independently inspected by reviewers, papers ordered, re-inspected and quality assessed. Data were independently extracted. Data were excluded if loss to follow up was greater than 50%. For homogeneous dichotomous data the risk ratio (RR), 95% confidence interval (CI) and, where appropriate, the number needed to treat (NNT) were calculated on an intention-to-treat basis. For continuous data, weighted mean differences (WMD) were calculated. All data were inspected for heterogeneity.

MAIN RESULTS

Thirteen studies were included in the review. Data for this compound range from very short (10 day) studies of the intramuscular preparation to trials lasting over three months. For measures of global state available data do not justify any conclusions on the comparative efficacy of molindone and placebo. When compared to other typical antipsychotics no difference in effectiveness was evidenced (doctors' RR 1.13, CI 0.69 to 1.86; nurses' RR 1.23, CI 0.82 to 1.86). It is no more or less likely than typical drugs to cause movement disorders, but causes significantly more weight loss (RR 2.78, CI 1.10 to 6.99).

REVIEWER'S CONCLUSIONS

The strength of the evidence relating to this compound is limited, owing to small sample size, poor study design, limited outcomes and incomplete reporting. Molindone may be an effective antipsychotic; however, its adverse effect profile does not differ significantly from that of typical antipsychotics, apart from the event of weight loss. At present there is no evidence to suggest that it may have an atypical profile.

A study of enhanced management in patients with treatment-resistant schizophrenia

The clinical efficacy of two intensive treatment packages (one including the new antipsychotic risperidone and the other not doing so) was compared with that of standard management in 43 patients with long-standing treatment-resistant schizophrenia. Significant differences between the groups in terms of total positive or total negative symptoms were not demonstrated, but the pattern of change between the treatment groups differed, so that benefit in positive symptomatology was seen in both intensive treatment groups and in negative symptomatology in the intensive treatment/risperidone group and the standard group. Changes in general psychopathology were most marked in the risperidone group and were compatible with a relatively non-sedative profile. Using the Disability Assessment Schedule, substantial significant advantages for the intensive treatment groups were found.

Lack of relationship of neuroleptic dose and blood serum levels to neuropsychological performance on the LNNB in chronic schizophrenia

The relationship of neuroleptic dose and blood serum levels to performance on the Luria Nebraska Neuropsychological Battery in chronic schizophrenics was assessed. Thirty chronic schizophrenics were individually administered the LNNB and a small sample of blood was obtained. No significant correlation between neuroleptic serum levels and test performance in these subjects was found although different conversion formulas related differentially to the blood serum levels.

L-dopa helps positive but not negative features of neuroleptic-insensitive chronic schizophrenia

L-dopa (Sinemet-110 in a final dose equivalent to - 4 g per day) added to maintenance chlorpromazine, produced a small antipsychotic effect in a group of eight severely impaired male chronic schizophrenic in-patients. Negative symptoms were unaffected by L-dopa, although the improvement in psychotic behaviour and positive symptoms was restricted to the four patients with the most severe negative symptoms measured during the control treatment period. These L-dopa responders also tended to improve slightly when the dose of chlorpromazine was halved, an indication of their poor, or even counter-therapeutic response to conventional neuroleptic medication given in relatively high dosage. Signs of increased dopaminergic activity (raised eye blink rate and reduced plasma prolactin) were not observed in subjects showing an antipsychotic response to L-dopa. This raises the possibility that L-dopa may exert an antipsychotic effect in neuroleptic-insensitive subjects by altering noradrenergic activity in the brain.

Lithium carbonate in chronic schizophrenia--a brief trial of lithium carbonate added to neuroleptics for treatment of resistant schizophrenic patients

The value of lithium carbonate as an adjunctive treatment of resistant schizophrenia was tested in a 4-week clinical trial using a single-blind, randomized, consent design. Treatment and control groups were drawn from a population of detained patients in an English special (maximum security) hospital. The 2 groups were comparable in terms of age, sex, severity of symptoms, length of hospitalization and concurrent neuroleptic dosage. The addition of lithium carbonate to the treatment regimen did not result in symptomatic improvement in patients completing the treatment protocol. The ethical and practical difficulties raised by the trial are discussed.

A case of resistant schizophrenia

In an era when it is generally believed that the acute symptoms of schizophrenia can be controlled pharmacologically, the case of a young man who has remained almost continuously floridly psychotic for 13 years, despite treatment, is disquieting. Conventional psychiatric treatment appears to be rendered impotent. It is in this context that it may be of interest to report a summary of the proceedings of a Special Problems Conference held at the Institute of Psychiatry on 18 February 1985 to discuss such a case.

Neuroendocrine effects of clonidine in chronic schizophrenic patients under long-term neuroleptic therapy and after drug withdrawal: relations to psychopathology

The sensitivity of the alpha-adrenergic hypothalamic pituitary system, as indicated by growth hormone (GH) release after clonidine (0.15 mg i.v.), was studied in nine chronic schizophrenic in-patients (study 1) under long-term neuroleptic (NL) therapy and after 5 days' drug withdrawal and in 17 chronic schizophrenic in-patients (study 2) under long-term NL therapy and after 12 days' drug withdrawal. GH response after 5- and 12-day drug-free periods did not differ significantly from that under NL treatment; however, it was significantly lower after 12 days' drug withdrawal (AUC: 319.9 +/- 445.5 ng/ml X min) compared to age- and sex-matched normal controls (579 +/- 611 ng/ml X min). The basal norepinephrine (NE) plasma levels under long-term NL therapy were significantly elevated in both studies (study 1:894 +/- 553 pg/ml; study 2:432 +/- 268 pg/ml) compared to controls (study 1:253 +/- 55 pg/ml, study 2:234 +/- 126 pg/ml), and were decreased significantly after 5 days' drug withdrawal compared to NL treatment. There was no significant correlation between age, duration of NL therapy, last daily dosage, psychopathology, and NE plasma levels and GH response. The data presented suggest hyposensitivity of alpha-adrenergic receptor function in the hypothalamic-pituitary axis after 12 days' drug withdrawal in chronic schizophrenics. The significantly elevated NE plasma levels under NL therapy indicate that there is no adaption mechanism, even after long-term treatment.

Long-term depot maintenance of chronic schizophrenic out-patients: the seven year follow-up of the Medical Research Council fluphenazine/placebo trial. III. Relapse postponement or relapse prevention? The implications for long-term outcome

The relapse and admission histories revealed a positive correlation between number of schizophrenic episodes and time on maintenance medication, probably reflecting severity of illness. Relapse rates after drug discontinuation rose to 45% within 13 months. There were no differences of predictive value between those relapsing on or off medication. The relationship between relapse rates, drug treatment, and social outcome is complex; antipsychotic drugs may postpone relapse, and frequent relapses might inhibit improvement in social performance long after florid symptoms have been controlled by medication.

Haloperidol plasma levels and clinical response in paranoid schizophrenics

The relationship between haloperidol plasma levels, plasma prolactin, and therapeutic efficacy was evaluated in 20 paranoïd schizophrenics in a fixed-dose study for 6 weeks. We found a significant intrapatient cross-correlation of therapeutic efficacy, as measured by decrease in MSS and BPRS rating scales and time-dependent haloperidol and prolactin changes, which were tested at weekly intervals. However, no significant curvilinear relationship was present between steady-state haloperidol plasma levels and MSS and BPRS improvement scores. Our data do not furnish clear-cut evidence in favor of the existence of a therapeutic window for haloperidol plasma levels in paranoïd schizophrenia.

The treatment-resistant patient and the need to stay crazy

This paper reviews treatment-resistant patients with emphasis on two case studies and the possible dynamic issues which may have contributed to a psychological need to remain psychotic. Possible treatment approaches are considered, as are issues of organicity, staff reactions, family dynamics, and the social question of where these patients will receive treatment.

Clonidine treatment of schizophrenia. Double-blind comparison to placebo and neuroleptic drugs

Antipsychotic effects of clonidine were evaluated in one schizoaffective and seven schizophrenic patients, using a double-blind, cross-over design to compare placebo, clonidine, and standard neuroleptic drugs. Mean improvement on clonidine and neuroleptics was equal, and improvement scores on the two treatments were closely correlated for individual patients. Clonidine was selected because it blocks noradrenergic but not dopaminergic neurotransmission. Patients were selected because of co-existing psychosis and tardive dyskinesia, a movement disorder thought to be caused by the antidopaminergic properties of the neuroleptics. For all patients, dyskinesia improved when neuroleptics were discontinued during clonidine and placebo periods of the study. The data provide preliminary evidence that clonidine may be an effective alternative to neuroleptics, particularly for patients for whom the dopaminergic blocking action of the neuroleptics is undesirable. The study also prompts re-evaluation of theories of a unique role for dopamine in schizophrenia.

Medical treatment of mental illness

Psychotherapeutic drugs have dramatically improved the prognosis for patients with severe mental illness. The drug treatments are not a panacea. The medications sometimes cause irreversible side effects, and they are not helpful for all patients. They allow large numbers of individuals to leave the hospital, but to return to communities that are often poorly prepared to provide continuing care. Despite their limitations, psychotherapeutic drugs relieve a great deal of human suffering. They also involve psychiatry in modern biological science. This has led to the continuing search for more effective medications based on the study of possible biochemical substrates of psychiatric disorders.