Drugs of the psychopharmacological revolution in clinical psychiatry

On the so-called psychopharmacological revolution: the discovery of chlorpromazine and the management of madness

This article analyzes the shortcomings and problems of the thesis that a true revolution took place in the field of biological psychiatry between 1952 and 1954 thanks to the discovery of chlorpromazine. To do so, it analyzes the discourses and strategies that led to the discovery of this drug, which became a model for the production of new psychopharmaceuticals. It seeks to understand, also, what is meant by "therapeutic efficacy" with regard to this drug.

Amisulpride, aripiprazole, and olanzapine in patients with schizophrenia-spectrum disorders (BeSt InTro): a pragmatic, rater-blind, semi-randomised trial

BACKGROUND

Amisulpride, aripiprazole, and olanzapine are first-line atypical antipsychotics that have not previously been compared head-to-head in a pragmatic trial. We aimed to compare the efficacy and safety of these agents in a controlled trial.

METHODS

This pragmatic, rater-blind, randomised controlled trial was done in three academic centres of psychiatry in Norway, and one in Austria. Eligible patients were aged 18 years or older, met ICD-10 criteria for schizophrenia-spectrum disorders (F20-29), and had symptoms of active psychosis. Eligible patients were randomly assigned to receive oral amisulpride, aripiprazole, or olanzapine. Treatment allocation was open to patients and staff, and starting dose, treatment changes, and adjustments were left to the discretion of the treating physician. Computer-generated randomisation lists for each study centre were prepared by independent statisticians. Patients were followed up for 52 weeks after random assignment, during which assessments were done 8 times by researchers masked to treatment. The primary outcome was reduction of the Positive And Negative Syndrome Scale (PANSS) total score at 52 weeks, and primary analyses were done in the intention-to-treat population. This trial is registered with ClinicalTrials.gov, number NCT01446328.

FINDINGS

Between Oct 20, 2011, and Dec 30, 2016, we assessed 359 patients for eligibility. 215 patients were excluded (107 did not meet inclusion criteria, 82 declined to participate, 26 other reasons). 144 patients (mean baseline PANSS total estimated score 78·4 [SD 1·4]) were randomly assigned 1:1:1 to receive amisulpride (44 patients), aripiprazole (48 patients) or olanzapine (52 patients). After 52 weeks, the patients allocated to amisulpride had a PANSS total score reduction of 32·7 points (SD 3·1) compared with 21·9 points reduction with aripiprazole (SD 3·9, p=0·027) and 23·3 points with olanzapine (2·9, p=0·025). We observed weight gain and increases of serum lipids and prolactin in all groups. 26 serious adverse events (SAEs) among 20 patients were registered (four [9%] of 44 patients allocated to amisulpride, ten [21%] of 48 patients allocated to aripiprazole, and six [12%] of 52 patients allocated to olanzapine), with no statistically significant differences between the study drugs. 17 (65%) of the 26 SAEs occurred during the use of the study drug, with readmission or protracted hospital admission accounting for 13 SAEs. One death by suicide, one unspecified death, and one life-threatening accident occurred during follow-up, after cessation of treatment.

INTERPRETATION

Amisulpride was more efficacious than aripiprazole or olanzapine for reducing the PANSS total scores in adults with schizophrenia-spectrum disorders. Side-effect differences among the groups were generally small. This study supports the notion that clinically relevant efficacy differences exist between antipsychotic drugs. Future research should aim to compare first-line antipsychotics directly in pragmatic clinical trials that reflect everyday clinical practice.

FUNDING

The Research Council of Norway, the Western Norway Regional Health Trust, and participating hospitals and universities.

Receptor visualization and the atomic bomb. A historical account of the development of the chemical neuroanatomy of receptors for neurotransmitters and drugs during the Cold War

This is a historical account of how receptors for neurotransmitters and drugs got to be seen at the regional, cellular, and subcellular levels in brain, in the years going from the end of the World War II until the collapse of the Soviet Union, the Cold War (1945-1991). The realization in the US of the problem of mental health care, as a consequence of the results of medical evaluation for military service during the war, let the US Government to act creating among other things the National Institute for Mental Health (NIMH). Coincident with that, new drug treatments for these disorders were introduced. War science also created an important number of tools and instruments, such as the radioisotopes, that played a significant role in the development of our story. The scientific context was marked by the development of Biochemistry, Molecular Biology and the introduction in the early 80's of the DNA recombinant technologies. The concepts of chemical neurotransmission in the brain and of receptors for drugs and transmitters, although proposed before the war, where not generally accepted. Neurotransmitters were identified and the mechanisms of biosynthesis, storage, release and termination of action by mechanisms such as reuptake, elucidated. Furthermore, the synapse was seen with the electron microscope and more important for our account, neurons and their processes visualized in the brain first by fluorescence histochemistry, then using radioisotopes and autoradiography, and later by immunohistochemistry (IHC), originating the Chemical Neuroanatomy. The concept of chemical neurotransmission evolved from the amines, expanded to excitatory and inhibitory amino acids, then to neuropeptides and finally to gases and other "atypical" neurotransmitters. In addition, coexpression of more than one transmitter in a neuron, changed the initial ideas of neurotransmission. The concept of receptors for these and other messengers underwent a significant evolution from an abstract chemical concept to their physical reality as gene products. Important steps were the introduction in the 70's of radioligand binding techniques and the cloning of receptor genes in the 80's. Receptors were first visualized using radioligands and autoradiography, and analyzed with the newly developed computer-assisted image analysis systems. Using Positron Emission Tomography transmitters and receptors were visualized in living human brain. The cloning of receptor genes allowed the use of in situ hybridization histochemistry and immunohistochemistry to visualize with the light and electron microscopes the receptor mRNAs and proteins. The results showed the wide heterogeneity of receptors and the diversity of mode of signal transmission, synaptic and extra-synaptic, again radically modifying the early views of neurotransmission. During the entire period the interplay between basic science and Psychopharmacology and Psychiatry generated different transmitter or receptor-based theories of brain drug action. These concepts and technologies also changed the way new drugs were discovered and developed. At the end of the period, a number of declines in these theories, the use of certain tools and the ability to generate new diagnostics and treatments, the end of an era and the beginning of a new one in the research of how the brain functions.

Antipsychotic occupancy of dopamine receptors in schizophrenia

Antipsychotic drugs were introduced in the early 50s on the basis of clinical observations in patients with schizophrenia. Experimental studies later revealed that antagonism at the D(2) dopamine receptor is a common characteristic of all antipsychotic drugs. In the 80s, the advent of brain imaging technologies such as positron emission tomography (PET) allowed for direct noninvasive studies of drug binding in treated patients. The concept receptor occupancy is defined as the fraction (%) of a receptor population that is occupied during treatment with an unlabelled drug. With regard to antipsychotic drugs, the radioligand [(11) C]-raclopride has been the most widely used for binding to the D(2) /D(3) -dopamine receptors. The present review discusses the contribution from molecular imaging to the current understanding of mechanism of action (MoA) of antipsychotic drugs. Consistent initial PET-findings of high D2-receptor occupancy in the striatum of patients responding to different antipsychotic drug treatments provided clinical support for the dopamine hypothesis of antipsychotic drug action. It has subsequently been demonstrated that patients with extrapyramidal syndromes (EPS) have higher occupancy (above 80%) than patients with good response but no EPS (65-80%). The PET-defined interval for optimal antipsychotic drug treatment has been implemented in the evolvement of dose recommendations for classical as well as more recently developed drugs. Another consistent finding is lower D(2) -occupancy during treatment with the prototype atypical antipsychotic clozapine. The MoA of clozapine remains to be fully understood and may include nondopaminergic mechanisms. A general limitation is that currently available PET-radioligands are not selective for any of the five dopamine receptor subtypes. Current attempts at developing such ligands may provide the tools required to refine further the MoA of antipsychotic drugs.

Patterns of clinical use of antipsychotics in hospitalized psychiatric patients

The ways of using antipsychotic drugs have greatly changed over the last 10 years. The aim of this study was to evaluate such changes in psychiatric patients admitted to the Psychiatric Department of Milan's Ospedale Maggiore in 1989 (n=350), 1999 (n=718) and 2002 (n=628). The medical records of the hospitalized patients were evaluated by analyzing the anamnestic and clinical data with particular reference to age, gender, diagnosis and medication use. In 2002, atypical antipsychotics were more frequently prescribed as monotherapy upon discharge than typical antipsychotics (32.64% vs. 30.10%). Combinations of two or more antipsychotic drugs were prescribed upon discharge for 20.63% of the patients in 1989, 31.24% in 1999 and 23.09% in 2002. The combinations of one typical and one atypical drug increased from 4.04% in 1999 to 13.06% in 2002. The mean (+/-S.D.) daily antipsychotic drug dose (expressed in chlorpromazine equivalents) was significantly higher in 2002 than in 1999 and 1989. The results of this study confirm the trend to use combinations of one typical and one atypical antipsychotic, and higher doses.

Assessment of independent effect of olanzapine and risperidone on risk of diabetes among patients with schizophrenia: population based nested case-control study

OBJECTIVE

To quantify the association between olanzapine and diabetes.

DESIGN

Population based nested case-control study.

SETTING

United Kingdom based General Practice Research Database comprising 3.5 million patients followed between 1987 and 2000.

PARTICIPANTS

19 637 patients who had been diagnosed as having and treated for schizophrenia. 451 incident cases of diabetes were matched with 2696 controls.

MAIN OUTCOME MEASURES

Diagnosis and treatment of diabetes.

RESULTS

Patients taking olanzapine had a significantly increased risk of developing diabetes than non-users of antipsychotics (odds ratio 5.8, 95% confidence interval 2.0 to 16.7) and those taking conventional antipsychotics (4.2, 1.5 to 12.2). Patients taking risperidone had a non-significant increased risk of developing diabetes than non-users of antipsychotics (2.2, 0.9 to 5.2) and those taking conventional antipsychotics (1.6, 0.7 to 3.8).

CONCLUSION

Olanzapine is associated with a clinically important and significant increased risk of diabetes.