Relationship of the use of adjunctive pharmacological agents to symptoms and level of function in schizophrenia

Prescribing Trends for the Same Patients with Schizophrenia Over 20 Years

Background

Recent pharmacoepidemiology data show an increase in the proportion of patients receiving second-generation antipsychotic (SGA) monotherapy, but no studies have analyzed the same patients over a long period of time. Therefore, in this study, we retrospectively evaluated schizophrenia patients with available data for 20 years to determine whether the drug treatments in the same patients have changed in the past 20 years.

Methods

The study began in April 2021 and was conducted in 15 psychiatric hospitals in Japan. Schizophrenia patients treated in the same hospital for 20 years were retrospectively examined for all prescriptions in 2016, 2011, 2006, and 2001 (ie, every 5 years).

Results

The mean age of the 716 patients surveyed in 2021 was 61.7 years, with 49.0% being female. The rate of antipsychotic monotherapy use showed a slight increasing trend over the past 20 years; the rate of SGA use showed a marked increasing trend from 28.9% to 70.3% over the past 20 years, while the rate of SGA monotherapy use showed a gradual increasing trend over the past 20 years. The rates of concomitant use of anticholinergics, antidepressants, anxiolytics/sleep medications, and mood stabilizers showed decreasing, flat, flat, and flat trends over the past 20 years, respectively.

Conclusion

The results of this study showed a slow but steady substitution of SGAs for first-generation antipsychotics (FGAs) over time, even in the same patients.

Psychopharmacological Treatment of Schizophrenia Over Time in 30 908 Inpatients: Data From the AMSP Study

BACKGROUND

Psychotropic drugs are the cornerstone of schizophrenia treatment, often requiring lifelong treatment. Data on pharmacotherapy in inpatient settings are lacking.

METHODS

Prescription data of schizophrenic inpatients within the time period 2000-2015 were obtained from the database of the Drug Safety Program in Psychiatry (AMSP). Data were collected at 2 index dates per year; the prescription patterns and changes over time were analyzed.

RESULTS

Among 30 908 inpatients (mean age 41.6 years, 57.8% males), the drug classes administered most often were antipsychotics (94.8%), tranquilizers (32%), antidepressants (16.5%), antiparkinsonians (16%), anticonvulsants (14.1%), hypnotics (8.1%), and lithium (2.1%). The use of second-generation antipsychotics significantly increased from 62.8% in 2000 to 88.9% in 2015 (P < .001), whereas the prescription of first-generation antipsychotics decreased from 46.6% in 2000 to 24.7% in 2015 (P < .001). The administration of long-acting injectable antipsychotics decreased from 15.2% in 2000 to 11.7% in 2015 (P = .006). Clopazine was the most often used antipsychotic, having been used for 21.3% of all patients. Polypharmacy rates (≥5 drugs) increased from 19% in 2000 to 26.5% in 2015. Psychiatric polypharmacy (≥3 psychotropic drugs) was present in 44.7% of patients.

CONCLUSIONS

Combinations of antipsychotics and augmentation therapies with other drug classes are frequently prescribed for schizophrenic patients. Though treatment resistance and unsatisfactory functional outcomes reflect clinical necessity, further prospective studies are needed on real-world prescription patterns in schizophrenia to evaluate the efficacy and safety of this common practice.

Another triumph of hope over experience?

Schizophrenia continues to challenge services: recent advances in antipsychotic drug treatment and psychosocial interventions are hindered by non-adherence, disengagement and substance misuse. Furthermore, new side-effect concerns attach to atypical drugs, and psychosocial interventions may be underresourced or of unproven benefit. It is important to address all issues with which patients, families and carers need assistance, and to take a well-informed, creative approach to pharmacological treatment, using medication according to individual patient need rather than mechanistic adherence to guidelines. Psychiatrists should be realistic in their expectations of patient outcome, accepting outcomes that fall short of recovery and imply long-term supportive care, and insisting that this care be available to their patients. Psychiatrists should support early diagnosis and intervention as being possibly the only means to alleviate the burden of long-term schizophrenia for patients, families and services.

Antipsychotic prescribing and its correlates in New Zealand

OBJECTIVES

Antipsychotics are the cornerstone of schizophrenia management. There is substantial literature on their efficacy and optimal use. Doubts remain, however, regarding the translation of this knowledge into day-to-day practice. This study aimed to investigate antipsychotic prescribing in three New Zealand regions and its relationship to clinical guidelines and patient characteristics.

METHODS

We studied 451 patients discharged from inpatient units with a diagnosis of schizophrenia or a related disorder (International Classification of Disease, version 10) between July 2009 and December 2011. Available information included patient demography, legal status, prescribed medications, duration of index admission and prescriber's country of postgraduate training and years of postgraduate experience.

RESULTS

There was a high rate (33.7%) of multiple antipsychotic prescription, and lower than expected clozapine use (20%); Maori were prescribed clozapine more frequently than non-Maori (24% vs. 13%, respectively). Compulsory treatment was associated with more use of injectable medication and increased length of stay in hospital. Clinician characteristics did not significantly influence prescribing.

CONCLUSIONS

Observed prescribing practice aligned with existing guidelines except for antipsychotic polypharmacy and clozapine under-utilisation.

Augmentation with antidepressants in schizophrenia treatment: benefit or risk

We focused on the application of antidepressants in schizophrenia treatment in this review. Augmentation of antidepressants with antipsychotics is a common clinical practice to treat resistant symptoms in schizophrenia, including depressive symptoms, negative symptoms, comorbid obsessive-compulsive symptoms, and other psychotic manifestations. However, recent systematic review of the clinical effects of antidepressants is lacking. In this review, we have selected and summarized current literature on the use of antidepressants in patients with schizophrenia; the patterns of use and effectiveness, as well as risks and drug-drug interactions of this clinical practice are discussed in detail, with particular emphasis on the treatment of depressive symptoms in schizophrenia.

Drug prescription in Italian Residential Facilities

Aims — To investigate in a representative national sample (N=2,962) of patients living in Residential Facilities (RFs) patterns of polypharmacy as well as related variables, association between diagnoses and therapeutic patterns, and the rate of adverse events. Methods — Structured interviews focusing on each patient were conducted by trained research assistants with the manager and staff of each RF. Patients were rated with the HoNOS and the SOFAS, and comprehensive information about their sociodemographic and clinical status, and their pharmacological regimes were collected. Results — Conventional antipsychotics and second-generation antipsychotics were prescribed to 65% and 43% of the sample, respectively. Benzodiazepines were prescribed to two-thirds of the sample, while antidepressants were the least-used class of psychotropics. Polypharmacy was common: on average, each treated patient was taking 2.7 drugs (±1.1); antipsychotic polypharmacy was also common. Many prescriptions were loosely related to specific diagnoses. Antiparkinsonianian drugs were prescribed to approximately 1/4 of the sample. Mild or severe adverse events in the previous month were reported for 9.9% and 1.4% of the sample, respectively. About 15% of patients suffered from tardive dyskinesia. Conclusions — Psychotropic drug prescription patterns for severe patients living in RFs are only sometimes satisfactory and offer the opportunity of improvement. Specific actions are required to improve prescription patterns for severe patients in RFs.

Declaration of Interest: in the past two years GdG has received two speaker fees from Janssen-Cilag and from Eli Lilly; GS has received one speaker fee from Solvay. RM, AP, SF and RT have received no fees or other financial support from pharmaceutical companies.

Adjunctive mood stabilizer treatment for hospitalized schizophrenia patients: Asia psychotropic prescription study (2001-2008)

Recent studies indicate relatively high international rates of adjunctive psychotropic medication, including mood stabilizers, for patients with schizophrenia. Since such treatments are little studied in Asia, we examined the frequency of mood-stabilizer use and its clinical correlates among hospitalized Asian patients diagnosed with schizophrenia in 2001-2008. We evaluated usage rates of mood stabilizers with antipsychotic drugs, and associated factors, for in-patients diagnosed with DSM-IV schizophrenia in 2001, 2004 and 2008 in nine Asian regions: China, Hong Kong, India, Korea, Japan, Malaysia, Taiwan, Thailand, and Singapore. Overall, mood stabilizers were given to 20.4% (n=1377/6761) of hospitalized schizophrenia patients, with increased usage over time. Mood-stabilizer use was significantly and independently associated in multivariate logistic modeling with: aggressive behaviour, disorganized speech, year sampled (2008 vs. earlier), multiple hospitalizations, less negative symptoms, younger age, with regional variation (Japan, Hong Kong, Singapore>Taiwan or China). Co-prescription of adjunctive mood stabilizers with antipsychotics for hospitalized Asian schizophrenia patients increased over the past decade, and was associated with specific clinical characteristics. This practice parallels findings in other countries and illustrates ongoing tension between evidence-based practice vs. individualized, empirical treatment of psychotic disorders.

Galantamine augmentation of long-acting injectable risperidone for cognitive impairments in chronic schizophrenia

BACKGROUND

Galantamine, a reversible cholinesterase inhibitor with effects on nicotinic receptors, has shown mixed effects on cognitive impairments in patients with schizophrenia. Given these mixed results we examined whether galantamine compared to adjunctive placebo may improve cognitive functions in patients treated concomitantly with a long acting atypical antipsychotic.

METHOD

The parent study was a 52-week double-blind, randomized study of treatment with long-acting injectable risperidone 25mg or 50mg every two weeks. Adjunctive galantamine or placebo treatment was administered from Month 6 to 12. Outcome measures were neurocognitive, psychopathology, social and quality of life functions. Patients were randomized to blinded galantamine up to 24mg/day or matching placebo tablets. All patients were maintained on their randomized long-acting injectable risperidone regimen for the duration of the trial.

RESULTS

32 patients were included in the intent-to-treat analysis. No statistically significant differences were found for Attention Vigilance, Declarative Memory, Processing Speed, Reasoning/Problem Solving, Working Memory domains and the Neurocognitive Composite Score. Group specific analysis showed a statistically significant group interaction (p=0.043) with the Social Cognition domain showing in the galantamine group significantly lower scores at endpoint than placebo patients. The PANSS general psychopathology subscale showed significantly higher scores in the galantamine group at endpoint (p=0.05). ANCOVA model for within treatment group comparisons showed a significant increase of 7.3 points for the total PANSS score for the galantamine group.

CONCLUSION

Galantamine showed no ameliorative effects on cognitive measures in this 6month, double-blind study of patients with schizophrenia treated with an assured and stable antipsychotic medication delivery system. Galantamine may not be an appropriate augmentation agent for cognitive impairments in patients with schizophrenia at the dose used.

Pharmacotherapy of schizophrenic patients: preponderance of off-label drug use

Multiple drug class combinations are often prescribed for the treatment of schizophrenia, although antipsychotic monotherapy reflects FDA labeling and scientific justification for combinations is highly variable. This study was performed to gain current data regarding drug treatment of schizophrenia as practiced in the community and to assess the frequencies of off-label drug class combinations. 200 DSM IV-diagnosed schizophrenic patients recruited from community treatment sources participated in this cross-sectional study of community based schizophrenic patients. Drug class categories include First and Second Generation Antipsychotic drugs (FGA and SGA, respectively), mood stabilizers, antidepressants and anti-anxiety drugs. 25.5% of patients received antipsychotic monotherapy; 70% of patients received an antipsychotic and another drug class. A total of 42.5% of patients received more than one antipsychotic drug. The most common drug class combination was antipsychotic and a mood stabilizer. Stepwise linear discriminant function analysis identified the diagnosis of schizoaffective schizophrenia, history of having physically hurt someone and high scores on the General Portion of the PANSS rating scale predicted the combined use of an antipsychotic drug and a mood stabilizer. “Real world” pharmacotherapy of schizophrenia has developed its own established practice that is predominantly off-label and may have outstripped current data support. The economic implications for public sector payers are substantial as well as for the revenue of the pharmaceutical industry, whose promotion of off-label drug use is an increasingly problematic. These data are consistent with the recognition of the therapeutic limitations of both first and second generation antipsychotic drugs.

Differential profile of typical, atypical and third generation antipsychotics at human 5-HT7a receptors coupled to adenylyl cyclase: detection of agonist and inverse agonist properties

5-HT(7) receptors are present in thalamus and limbic structures, and a possible role of these receptors in the pathology of schizophrenia has been evoked. In this study, we examined binding affinity and agonist/antagonist/inverse agonist properties at these receptors of a large series of antipsychotics, i.e., typical, atypical, and third generation compounds preferentially targeting D(2) and 5-HT(1A) sites. Adenylyl cyclase (AC) activity was measured in HEK293 cells stably expressing the human (h) 5-HT(7a) receptor isoform. 5-HT and 5-CT increased cyclic adenosine monophosphate level by about 20-fold whereas (+)-8-OH-DPAT, the antidyskinetic agent sarizotan, and the novel antipsychotic compound bifeprunox exhibited partial agonist properties at h5-HT(7a) receptors stimulating AC. Other compounds antagonized 5-HT-induced AC activity with pK (B) values which correlated with their pK (i) as determined by competition binding vs [(3)H]5-CT. The selective 5-HT(7) receptor ligand, SB269970, was the most potent antagonist. For antipsychotic compounds, the following rank order of antagonism potency (pK (B)) was ziprasidone > tiospirone > SSR181507 > or = clozapine > or = olanzapine > SLV-314 > SLV-313 > or = aripiprazole > or = chlorpromazine > nemonapride > haloperidol. Interestingly, pretreatment of HEK293-h5-HT(7a) cells with forskolin enhanced basal AC activity and revealed inverse agonist properties for both typical and atypical antipsychotics as well as for aripiprazole. In contrast, other novel antipsychotics exhibited diverse 5-HT(7a) properties; SLV-313 and SLV-314 behaved as quasi-neutral antagonists, SSR181507 acted as an inverse agonist, and bifeprunox as a partial agonist, as mentioned above. In conclusion, the differential properties of third generation antipsychotics at 5-HT(7) receptors may influence their antipsychotic profile.

F15063, a compound with D2/D3 antagonist, 5-HT 1A agonist and D4 partial agonist properties. II. Activity in models of positive symptoms of schizophrenia

BACKGROUND AND PURPOSE

F15063 is a high affinity D(2)/D(3) antagonist, D(4) partial agonist, and high efficacy 5-HT(1A) agonist, with little affinity (40-fold lower than for D(2) receptors) at other central targets. Here, the profile of F15063 was evaluated in models of positive symptoms of schizophrenia and motor side-effects.

EXPERIMENTAL APPROACH

Rodent behavioural tests were based on reversal of hyperactivity induced by psychostimulants and on measures of induction of catalepsy and 'serotonin syndrome'.

KEY RESULTS

F15063 potently (ED(50)s: 0.23 to 1.10 mg kg(-1) i.p.) reversed methylphenidate-induced stereotyped behaviors, blocked d-amphetamine and ketamine hyperlocomotion, attenuated apomorphine-induced prepulse inhibition (PPI) deficits, and was active in the conditioned avoidance test. In mice, it reversed apomorphine-induced climbing (ED(50)=0.30 mg kg(-1) i.p.). F15063, owing to its 5-HT(1A) agonism, did not produce (ED(50)>40 mg kg(-1) i.p.) catalepsy in rats and mice, a behavior predictive of occurrence of extra-pyramidal syndrome (EPS) in man. This absence of cataleptogenic activity was maintained upon sub-chronic treatment of rats for 5 days at 40 mg kg(-1) p.o. Furthermore, F15063 did not induce the 'serotonin syndrome' in rats (flat body posture and forepaw treading: ED(50) >32 mg kg(-1) i.p.).

CONCLUSIONS AND IMPLICATIONS

F15063 conformed to the profile of an atypical antipsychotic, with potent actions in models of hyperdopaminergic activity but without inducing catalepsy. These data suggest that F15063 may display potent antipsychotic actions with low EPS liability. This profile is complemented by a favourable profile in rodent models of negative symptoms and cognitive deficits of schizophrenia (companion paper).

Pharmacological profiles in rats of novel antipsychotics with combined dopamine D2/serotonin 5-HT1A activity: comparison with typical and atypical conventional antipsychotics

Combining antagonist/partial agonist activity at dopamine D2 and agonist activity at serotonin 5-HT1A receptors is one of the approaches that has recently been chosen to develop new generation antipsychotics, including bifeprunox, SSR181507 and SLV313. There have been, however, few comparative data on their pharmacological profiles. Here, we have directly compared a wide array of these novel dopamine D2/5-HT1A and conventional antipsychotics in rat models predictive of antipsychotic activity. Potency of antipsychotics to antagonize conditioned avoidance, methylphenidate-induced behaviour and D-amphetamine-induced hyperlocomotion correlated with their affinity at dopamine D2 receptors. Potency against ketamine-induced hyperlocomotion was independent of affinity at dopamine D2 or 5-HT1A receptors. Propensity to induce catalepsy, predictive of occurrence of extrapyramidal side effects, was inversely related to affinity at 5-HT1A receptors. As a result, preferential D2/5-HT1A antipsychotics displayed a large separation between doses producing 'antipsychotic-like' vs. cataleptogenic actions. These data support the contention that 5-HT1A receptor activation greatly reduces or prevents the cataleptogenic potential of novel antipsychotics. They also emphasize that interactions at 5-HT1A and D2 receptors, and the nature of effects (antagonism or partial agonism) at the latter has a profound influence on pharmacological activities, and is likely to affect therapeutic profiles.

Relationship between estrogen and schizophrenia

There is a wealth of historical and circumstantial evidence to suggest that female patients with schizophrenia may suffer from a deficit in estrogenic function. The prolactin-inducing properties of most antipsychotic drugs, and subsequent negative feedback on estrogen levels, is in keeping with this. The functions of estrogen, its complex receptor organization and its numerous actions are the focus of ongoing research activity. Of particular interest are its neuroprotective properties, particularly with regard to cognitive impairment, and its involvement with neurotransmitter systems, which are the substrate for psychotropic drugs. Estrogen has now been used as an adjunct to standard antipsychotic medication in quite a few studies of female schizophrenia patients. However, most of these are not double-blind, randomized, controlled trials. Only two relatively small double-blind, randomized clinical trials returned positive results: one long-term study that selected for hypoestrogenism reported negative findings. Furthermore, recent evidence of the risks of long-term hormone replacement therapy is of concern. The advent of specific estrogen receptor modulators, which may avoid excess risks of cancer and cardiovascular events, will have little to add to schizophrenia treatment if estrogen is, essentially, devoid of any specific antipsychotic or adjuvant mechanism of action relevant to the pathophysiology of this disorder.

Galantamine improves cognition in schizophrenic patients stabilized on risperidone

BACKGROUND

Cognition in schizophrenia is impaired in a variety of cognitive domains. Galantamine, a cholinesterase inhibitor with putative nicotinic agonist-like effects, improves cognition in Alzheimer's patients.

METHODS

Sixteen schizophrenic or schizoaffective patients stabilized on risperidone were administered galantamine (n=8) or placebo (n=8) in a randomized, double-blind trial. The Repeatable Battery for Assessment of Neuropsychological Status (RBANS) assessed changes in cognitive performance over an eight-week treatment interval.

RESULTS

Clinical symptoms improved in both groups during the trial with no evidence that galantamine exacerbated extrapyramidal symptoms. Patients treated with galantamine experienced an overall improvement in cognitive performance (RBANS Total scale score; galantamine = 12.1 +/- 12.8 SD, placebo = .5 +/- 13.5, t = 2.32, p < .04). Confidence intervals suggest that RBANS Attention and Delayed Memory subscale performance was robustly improved in galantamine patients by approximately one standard deviation, effectively normalizing cognitive performance in these domains.

CONCLUSIONS

Adjunctive treatment with galantamine improves memory and attention in patients with schizophrenia who are stabilized on risperidone, providing the opportunity to improve functional outcome in these patients.

Antipsychotic-like vs cataleptogenic actions in mice of novel antipsychotics having D2 antagonist and 5-HT1A agonist properties

A new generation of proven or potential antipsychotics, including aripiprazole, bifeprunox, SSR181507 and SLV313, exhibit agonist actions at serotonin 5-HT1A receptors, but little comparative data are available on their pharmacological profiles. Here, we compared in mice the in vivo antipsychotic-like vs cataleptogenic activities of these compounds with those of drugs that exhibit little interaction at 5-HT1A receptors, such as haloperidol, olanzapine and risperidone. All the drugs dose-dependently reduced apomorphine-induced climbing or sniffing and, with the exception of ziprasidone, produced complete suppression of these responses. In the bar catalepsy test, when administered alone, haloperidol, olanzapine and risperidone produced marked catalepsy, whereas, at doses up to 40 mg/kg, aripiprazole, SLV313, SSR181507, and sarizotan produced little or no catalepsy. The latter compounds, therefore, displayed a large separation between doses with 'antipsychotic-like' and those with cataleptogenic actions. When 5-HT1A receptors were blocked by pretreatment with WAY100635 (2.5 mg/kg, s.c.), cataleptogenic properties of SSR181507 and sarizotan were unmasked, and the catalepsy induced by bifeprunox was enhanced. In the case of aripiprazole and SLV313, although WAY100635 produced upward shifts in their dose-response, the magnitude of catalepsy appeared to reach an asymptotic plateau, suggesting that other mechanisms may be involved in their low cataleptogenic liability. The present data confirm that 5-HT1A receptor activation reduces or even completely prevents the cataleptogenic potential of novel antipsychotic agents. Further, they indicate that the balance of affinity and/or efficacy between D2 and 5-HT1A receptors profoundly influences their pharmacological activities, and will likely impact their therapeutic profiles.

The prescription of psychotropic drugs in psychiatric residential facilities: a national survey in Italy

OBJECTIVE

This paper reports the prescriptions of psychotropic drugs made to 2962 patients living in 265 residential facilities (RFs) in Italy.

METHOD

Structured interviews were administered to RF managers and staff to obtain data on patients' sociodemographic and clinical characteristics; information about current drug prescriptions were obtained from clinical records.

RESULTS

Polypharmacy was common: on average, each treated patient was taking 2.7 drugs (+/-1.1). The association of one atypical antipsychotic with one benzodiazepine represented the most common prescription profile. The variable most consistently associated with a higher likelihood of receiving polypharmacy was a history of admission to an acute general hospital psychiatric ward in the previous 12 months. Many prescriptions were loosely related to specific diagnoses.

CONCLUSION

Psychotropic drug prescription patterns for severe patients living in RFs are characterized by substantial rates of polypharmacy. Specific guidelines may be helpful for long-stay patients living in RFs, who exhibit complex care needs.

Psychotropic combination in schizophrenia

OBJECTIVE

To study adjunctive medications used with antipsychotic agents in schizophrenia via comparisons of antidepressant, anxiolytic and antiparkinsonian co-prescribing.

METHOD

In the context of a national naturalistic prospective observational study, a database containing all the prescriptions from 100 French psychiatrists during the year 2002 was analysed. The inclusion criteria were a diagnosis of schizophrenia or schizoaffective disorder and age over 18. A log-linear model and generalised linear mixed models were used.

RESULTS

In all 5,257 prescriptions for 922 patients were analysed. The proportion of patients who were prescribed an antiparkinsonian drug was 32.9%. Amisulpride, haloperidol, phenothiazines with a sedative action and depot typical antipsychotics proved more likely to be prescribed with antiparkinsonians. The frequency of antidepressant and anxiolytic prescriptions was 51.2% and 52.3%, respectively. Associations between atypical antipsychotics (except clozapine) and antidepressants were positive while associations between typical antipsychotics and antidepressants were not. There were no differences among antipsychotics for the prescription of anxiolytics.

CONCLUSIONS

Atypical antipsychotics can be expected to be less likely associated with antiparkinsonians. This result is indeed found for olanzapine, clozapine and to a limited extent for risperidone. Furthermore, a trend towards a positive association between atypical antipsychotics and antidepressants appears. In view of the antidepressive action of certain atypical antipsychotics, this result is surprising. The increase in the prescriptions of anxiolytics concerns all types of antipsychotics. In view of the increase in associated medications in schizophrenia and the difficulty of estimating it in randomised trials, this study underlines the contribution of naturalistic studies on this score.

Análisis de la correlación entre la calidad de la prescripción de antipsicóticos y el estado clínico en pacientes con esquizofrenia

OBJECTIVE

The aim of this study is to describe the psychopharmacological aspects of psychiatric practice in a group of schizophrenic patients and to evaluate whether or not practice agrees with treatment guidelines. The study also intends to objectively measure the psychopathological state of patients in order to establish correlation between different pharmacological aspects of treatment and their clinical outcomes.

METHOD

We have elaborated six recommendations concerning the pharmacological treatment of schizophrenia, taken from several guides, which are based on evidence. The psychopathological state of patients has been evaluated with the Brief Psychiatric Rating Scale (BPRS) and real prescription practice has been analysed. BPRS rates are compared depending on compliance with guidelines.

RESULTS

More than 60% of patients do not comply with at least 4 of 6 evidence-based recommendations; compliance with recommendations being associated with a minor BPRS punctuation. Differences in BPRS punctuation between compliant and not compliant groups for 3 recommendations (maintenance antipsychotic dosage, antipsychotic association and drugs with a negative effect on cognitive functions), are statistically significant(p < 0,05; bilateral).

DISCUSSION

Medical practice which closely follows treatment guidelines results in satisfactory clinical outcomes.

SSR181507, a putative atypical antipsychotic with dopamine D2 antagonist and 5-HT1A agonist activities: improvement of social interaction deficits induced by phencyclidine in rats

Social behaviour is frequently impaired in schizophrenic patients, and current antipsychotics appear poorly effective in alleviating this deficit. SSR181507 is a selective dopamine D2 receptor antagonist and 5-HT1A receptor agonist [Neuropsychopharmacology 28 (2003) 2064] with an atypical antipsychotic profile and additional antidepressant/anxiolytic activities [Neuropsychopharmacology 28 (2003) 1889]. Here, we sought to assess the efficacy of SSR181507, and of reference antipsychotics and antidepressant/anxiolytics, to counteract phencyclidine (PCP)-induced social interaction deficit in rats. Pairs of unfamiliar rats were placed for 10 min each day into a dimly lit arena, during four consecutive days. On the test day (5th day), each pair was placed into the arena 30 min after i.p. treatment with PCP (or vehicle) and a challenge compound or vehicle (same for both rats, i.p. or s.c.). The time spent in social interaction was scored during 10 min. PCP (1 mg/kg) decreased social interaction time by about 35%. This effect was fully antagonized by pre-treatment with SSR181507 (1 mg/kg). In contrast, neither haloperidol (0.05 and 0.1 mg/kg) nor clozapine (0.3 and 1 mg/kg) antagonized this PCP-induced deficit. The selective 5-HT1A receptor agonist 8-OH-DPAT (0.025 and 0.05 mg/kg s.c.), but not the anxiolytic diazepam (0.75 and 1.5 mg/kg), also improved social interaction impairment in PCP-treated rats: this would indicate that the 5-HT1A receptor agonist properties of SSR181507 are responsible for the reversal of PCP-induced social deficit. These data suggest that, in addition to its atypical antipsychotic profile and antidepressant/anxiolytic activities, SSR181507 has a potential therapeutic activity in another key feature of schizophrenia poorly controlled by current antipsychotics, namely deterioration in social functioning.

Results of a naturalistic study of treatment options: Switching atypical antipsychotic drugs or augmenting with valproate

BACKGROUND

Combination therapy with atypical antipsychotic agents has not been well studied. Duration of persistence with a prescribed treatment regimen can be used to estimate overall treatment success.

OBJECTIVE

The aim of this study was to determine whether valproate augmentation improved treatment efficacy (ie, persistence with the prescribed regimen) and efficacy (ie, reduction of antipsychotic dose) with atypical antipsychotic drugs for older and younger patients, using a retrospective database analysis.

METHODS

Prescription refill data for atypical antipsychotics during calendar-year 2001 from a national pharmacy chain was used for longitudinal analyses. The database was used to identify patients aged 15 to 64 years and > or =65 years taking risperidone, quetiapine, or olanzapine (but not valproate). Patients who switched to another atypical antipsychotic (group A) or added valproate (group B) were followed after the index prescription to determine the duration of persistence with the treatment regimen and dose changes.

RESULTS

We identified 10,262 patients who were prescribed an atypical antipsychotic, of whom 1022 patients switched to an alternative atypical and 1651 added valproate to the index atypical. The addition of valproate provided significantly longer duration of treatment regimen (mean, 155-159 days) than switching from any atypical antipsychotic drug (mean, 127-130 days) for patients aged 15 to 64 years or > or =65 years (all P<0.001). Atypical antipsychotic doses did not change significantly from baseline to final prescription in groups A or B. The final mean (SD) dose of valproate added to risperidone (389.1 [130.7] mg/d) was significantly lower than valproate added to quetiapine (424.6 [117.1] mg/d; P=0.002) or olanzapine (411.6 [122.8] mg/d; P=0.007).

CONCLUSIONS

In this naturalistic study, the addition of valproate to an atypical antipsychotic increased the duration of treatment compared with switching among atypical antipsychotics. Valproate augmentation may be a good treatment strategy for patients whose atypical antipsychotic monotherapy is inadequate.

Antipsychotic drug use pattern for patients with schizophrenia in an outpatient clinic in Turkey: A retrospective study

INTRODUCTION

Pharmacotherapy for schizophrenia is a dynamic process that can change over time. The goal of this study was to examine the pattern of antipsychotic drug (APD) use for patients with schizophrenia in an outpatient clinic.

METHOD

We evaluated the medication use pattern in patients with schizophrenia treated with antipsychotic drugs in an outpatient clinic in a period of 4 years. Patients who used any antipsychotic medication stably for at least 6 months were included in the study in this period. Patients who had been noncompliant to the treatment or did not come to the clinic again were excluded. Patients' records were reviewed in respect to the use of APD as an initial treatment, the duration of a single or combined APD use, the changing of APD regimen, and adding of a new APD or other adjuvant drugs to APDs.

RESULTS

A total of 152 patients diagnosed with schizophrenia were treated during the study period, of whom 60 (39.5%) maintained the treatment with compliance for at least 6 months. Mean duration of the treatment was 15.8 (+10.7) months (range 6-48). The most commonly used antipsychotic drugs were atypical agents (in 68.3% of patients), and depot neuroleptics were used in the 46.7% of patients more often than any other antipsychotic drug at any time of the treatment. Two or more antipsychotic drugs were used at some time during this period in 24 patients (40.0%). Of all patients, 45.0% had their drug regimen changed: medication regimen was changed once in 28.3% patients and two to four times in 16.7% patients. The longer the duration of treatment, the more patients had their medication changed. Most added drugs were typical ones (16.7%). Of all patients, 48 (80.0%) had used adjuvant drugs at any time during the treatment. There were no differences between the use of combined drug, medication changing and demographic variables of the patients.

CONCLUSION

The results of this study support previous reports of the frequent use of atypical antipsychotic drugs, combination antipsychotic therapy, and adjuvant drugs in clinical practice. Medication switching is more common in the treatment of patients with schizophrenia. Prospective controlled trials are needed to determine whether combination antipsychotic therapy or switching medication regimen is clinically beneficial and to provide guidelines on when and for whom that should be considered. (Int J Psych Clin Pract 2004; 8: 41-45).

SSR181507, a dopamine D2 receptor antagonist and 5-HT1A receptor agonist. II: Behavioral profile predictive of an atypical antipsychotic activity

SSR181507 ((3-exo)-8-benzoyl-N-(((2S)7-chloro-2,3-dihydro-1,4-benzodioxin-1-yl)methyl)-8-azabicyclo(3.2.1)octane-3-methanamine monohydrochloride) is a novel tropanemethanamine benzodioxane that displays antagonist activity at dopamine D(2) receptors and agonist activity at 5-HT(1A) receptors. SSR181507 antagonized apomorphine-induced climbing in mice and stereotypies in rats (ED(50) of 2 and 3.4 mg/kg i.p., respectively) and blocked D-amphetamine-induced hyperlocomotion in rats at lower doses (0.3-1 mg/kg i.p.). At 1-10 mg/kg, it was found to disrupt active avoidance in mice. SSR181507 did not induce catalepsy in rats (MED>60 mg/kg i.p.) and antagonized (3-10 mg/kg i.p.) haloperidol-induced catalepsy. SSR181507 was also active in two models sensitive to antidepressant/anxiolytic drugs: in a guinea-pig pup/mother separation test, it decreased (1-3 mg/kg i.p.) the time spent vocalizing during the separation episode, and in a lithium-induced taste aversion procedure in rats, it partially reversed (3 mg/kg i.p.) the decrease of intake of a saccharin solution. Furthermore, SSR181507 increased (3 mg/kg i.p.) the latency time to paradoxical sleep in rats, an effect commonly observed with antidepressants. Coadministration of the selective 5-HT(1A) blocker SL88.0338 produced catalepsy and antagonized the effects of SSR181507 in the depression/anxiety tests, confirming the view that activation of 5-HT(1A) receptors confers an atypical profile on SSR181507, and is responsible for its antidepressant/anxiolytic properties. Finally, SSR181507 (1-3 mg/kg) did not affect memory performance in a Morris water maze task in rats. The pharmacological profile of SSR181507 suggests that it should control the symptoms of schizophrenia, in the absence of extrapyramidal signs and cognitive deficits, with the additional benefit of antidepressant/anxiolytic activities.

Antipsychotic treatment in schizophrenia: atypical options and NICE guidance

Following the reintroduction of clozapine, several atypical antipsychotics have become available for the treatment of schizophrenia. These drugs are at least as effective as conventional treatment. Although each has an individual pattern of affinities, new work suggests that the hallmark of atypicality is fast dissociation at the dopamine-2 receptor. Numerous novel drugs are in development, but it is not clear how these conform to this theory of therapeutic effect. Atypical antipsychotics cause less extrapyramidal side effects than conventional treatment, but other effects such as hyperprolactinaemia, weight gain, glucose dysregulation and prolonged QTc interval remain problematic for some. Current antipsychotic prescribing practice is far from ideal: the NICE guidance stresses that atypical treatments should be considered unless symptoms are well controlled and side effects are acceptable, or depot formulation is indicated. There is a welcome emphasis on drug treatment as part of an integrated package of care negotiated with patients and their carers.