Clinical Trials with Melleril (TP21) in the Treatment of Schizophrenia

The World Federation of Societies of Biological Psychiatry (WFSBP) 2020 guidelines for the pharmacological treatment of paraphilic disorders

Objectives: The primary aim of these guidelines is to evaluate the role of pharmacological agents in the treatment and management of patients with paraphilic disorders, with a focus on the treatment of adult males. Because such treatments are not delivered in isolation, the role of specific psychotherapeutic interventions is also briefly covered. These guidelines are intended for use in clinical practice by clinicians who diagnose and treat patients, including sexual offenders, with paraphilic disorders. The aim of these guidelines is to bring together different views on the appropriate treatment of paraphilic disorders from experts representing different countries in order to aid physicians in clinical decisions and to improve the quality of care.Methods: An extensive literature search was conducted using the English-language-literature indexed on MEDLINE/PubMed (1990-2018 for SSRIs) (1969-2018 for hormonal treatments), supplemented by other sources, including published reviews.Results: Each treatment recommendation was evaluated and discussed with respect to the strength of evidence for its efficacy, safety, tolerability, and feasibility. The type of medication used depends on the severity of the paraphilic disorder and the respective risk of behaviour endangering others. GnRH analogue treatment constitutes the most relevant treatment for patients with severe paraphilic disorders.Conclusions: An algorithm is proposed with different levels of treatment for different categories of paraphilic disorders accompanied by different risk levels.

Experience with Thioridazine (“Melleril”) Therapy

“A doctor must know not only the virtue of a drug, but also its drawbacks”—

Carling (1960).

Thioridazine is one of the newer phenothiazine derivatives used in psychiatry. Previous workers have reported few serious side-effects with it. The following pilot trial was carried out on male patients suffering from chronic schizophrenia who required nursing in a closed ward.

A Controlled Study of the Use of Thioridazine in the Treatment of Hyperactive and Aggressive Children in a Children's Psychiatric Hospital

Studies on the use of thioridazine in adults and children were reviewed and the paucity of the controlled objective investigated, observed.

Thioridazine in doses of 25 mg. t.i.d. was administered to nine children with persistent marked aggressivity and hyper-activity. A double-blind study revealed a considerable reduction in aggressive, destructive and hyperactive behaviour. Status epilepticus occurred in an epileptic boy, necessitating an increase in anticonvulsant medication. No other side effects were observed.

It is concluded that thioridazine is a safe and useful drug in the treatment of hyperactive, aggressive, destructive patterns of behaviour in children.

The World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the biological treatment of paraphilias

OBJECTIVES

The primary aim of these guidelines was to evaluate the role of pharmacological agents in the treatment and management of paraphilia, with a focus on the treatment of adults males. Because such treatments are not delivered in isolation, the role of specific psychosocial and psychotherapeutic interventions was also briefly covered. These guidelines are intended for use in clinical practice by clinicians who diagnose and treat patients with paraphilia. The aim of these guidelines is to improve the quality of care and to aid physicians in clinical decisions.

METHODS

The aim of these guidelines was to bring together different views on the appropriate treatment of paraphilias from experts representing different continents. To achieve this aim, an extensive literature search was conducted using the English language literature indexed on MEDLINE/PubMed (1990-2009 for SSRIs) (1969-2009 for antiandrogen treatments), supplemented by other sources, including published reviews.

RESULTS

Each treatment recommendation was evaluated and discussed with respect to the strength of evidence for its efficacy, safety, tolerability and feasibility.

CONCLUSIONS

An algorithm was proposed with six levels of treatment for different categories of paraphilias.

Sexual dysfunction in Japanese patients with schizophrenia treated with antipsychotics

Various studies have revealed that sexual dysfunction is prevalent in schizophrenia patients treated with either first- or second-generation antipsychotics. Although sexual dysfunction may have a negative impact on adherence to treatment, no reports have studied sexual dysfunction in schizophrenia patients compared with healthy controls in Asian populations. We employed a cross-sectional, case-control survey design to collect data from 352 schizophrenic Japanese outpatients treated with antipsychotics and 367 healthy subjects. Sexual dysfunction was evaluated using the Udvalg for Kliniske Undersøgelser (UKU) Side Effect Rating Scale. The prevalence of sexual dysfunction in schizophrenic patients was 59.3% for males and 49.1% for females, while that in healthy controls was 38.0% for males and 38.4% for females. High rates of low sexual interest (37.3%), erectile dysfunction (37.3%), and problems related to ejaculation (35.6%) were found in male patients, while amenorrhea (38.7%) and low sexual interest (25.7%) were found in female patients. Significant differences were observed between cases and controls concerning the prevalence of total sexual dysfunction in males under 30 years of age (p<0.01) and in their 40s (p<0.01), as well as in females in their 30s (p<0.05) and over 50 years of age (p<0.01). When patients were divided into four monotherapy groups (risperidone, olanzapine, aripiprazole, and haloperidol), there were still no differences in any form of sexual dysfunction. The present study demonstrated a higher prevalence of sexual dysfunction in schizophrenia patients than in healthy controls. Clinicians should keep these problems in mind and discuss potential solutions with their patients in Asian populations.

Thioridazine for schizophrenia

BACKGROUND

Thioridazine is an antipsychotic that can still be used for schizophrenia although it is associated with the cardiac arrhythmia, torsades de pointe.

OBJECTIVES

To review the effects of thioridazine for people with schizophrenia.

SEARCH STRATEGY

For this 2006 update, we searched the Cochrane Schizophrenia Group's Register (June 2006).

SELECTION CRITERIA

We included all randomised clinical trials comparing thioridazine with other treatments for people with schizophrenia or other psychoses.

DATA COLLECTION AND ANALYSIS

We reliably selected, quality rated and extracted data from relevant studies. For dichotomous data, we estimated relative risks (RR), with the 95% confidence intervals (CI). Where possible, we calculated the number needed to treat/harm statistic (NNT/H) on an intention-to-treat basis.

MAIN RESULTS

This review currently includes 42 RCTs with 3498 participants. When thioridazine was compared with placebo (total n=668, 14 RCTs) we found global state outcomes favoured thioridazine (n=105, 3 RCTs, RR 'no change or worse' by 6 months 0.33 CI 0.2 to 0.5, NNT of 2 CI 2 to 3). Thioridazine is sedating (n=324, 3 RCTs, RR 5.37 CI 3.2 to 9.1, NNH 4 CI 2 to 74). Generally, thioridazine did not cause more movement disorders than placebo.Twenty-seven studies (total n=2598) compared thioridazine with typical antipsychotics. We found no significant difference in global state (n=743, 11 RCTs, RR no short-term change or worse 0.98 CI 0.8 to 1.2) and medium-term assessments (n=142, 3 RCTs, RR 0.99, CI 0.6 to 1.6). We found no significant differences in the number of people leaving the study early 'for any reason' (short-term, n=1587, 19 RCTs, RR 1.07 CI 0.9 to 1.3). Extrapyramidal adverse events lower for those allocated to thioridazine (n=1082, 7 RCTs, RR use of antiparkinsonian drugs 0.45 CI 0.4 to 0.6). Thioridazine did seem associated with cardiac adverse effects (n=74, 1 RCT, RR 'any cardiovascular adverse event' 3.17 CI 1.4 to 7.0, NNH 3 CI 2 to 5). Electrocardiogram changes were significantly more frequent in the thioridazine group (n=254, 2 RCTs, RR 2.38, CI 1.6 to 3.6, NNH 4 CI 3 to 10). Six RCTs (total n=344) randomised thioridazine against atypical antipsychotics. Global state rating did not reveal any short-term difference between thioridazine and remoxipride and sulpiride (n=203, RR not improved or worse 1.00 CI 0.8 to 1.3). Limited data did not highlight differences in adverse event profiles.

AUTHORS' CONCLUSIONS

Although there are shortcomings, there appears to be enough consistency over different outcomes and periods to confirm that thioridazine is an antipsychotic of similar efficacy to other commonly used antipsychotics for people with schizophrenia. Its adverse events profile is similar to that of other drugs, but it may have a lower level of extrapyramidal problems and higher level of ECG changes. We would advocate the use of alternative drugs, but if its use in unavoidable, cardiac monitoring is justified.

A systematic review on clinical management of antipsychotic-induced sexual dysfunction in schizophrenia

INTRODUCTION

Sexual dysfunction frequently occurs in patients with schizophrenia under antipsychotic therapy, and the presence of sexual side effects may affect compliance. The aim of this study was to review and describe clinical findings relating to the appropriate management of such dysfunctions.

MATERIAL AND METHODS

The research was carried out through Medline (from 1966 to March 2005), PsycInfo (from 1974 to March 2005), and Cochrane Library (from 1965 to March 2005) and included any kind of study, from case reports to randomized trials.

RESULTS

The most common sexual dysfunctions found in the literature were libido decrease, difficulties in achieving and maintaining erection, ejaculatory dysfunction, orgasmic dysfunction, and menstrual irregularities. Thirteen papers were found: eight of them were open-label studies, four were descriptions of cases, and only one was a randomized clinical trial. All of them were short-term and had small sample sizes. The agents used were: bromocriptine, cabergoline, cyproheptadine, amantadine, shakuyaku-kanzo-to, sildenafil and selegiline.

DISCUSSION

There was no evidence that those agents had proper efficacy in treating the antipsychotic-induced sexual dysfunction. An algorithm for managing sexual dysfunction induced by antipsychotics is suggested as a support for clinical decisions. Since the outcome from schizophrenia treatment is strongly related to compliance with the antipsychotics, prevention of sexual dysfunction is better than its treatment, since there is a scarcity of data available regarding the efficacy of intervention to deal with these problems.

Economic consequences of the adverse reactions related with antipsychotics: an economic model comparing tolerability of ziprasidone, olanzapine, risperidone, and haloperidol in Spain

Frequency of adverse reactions (ARs) related with antipsychotics usage is high. Along with clinical implications, economic impact might be important. The purpose of this study was to model the economic consequences of ARs related with ziprasidone, olanzapine, risperidone, and haloperidol in Spain, by means of a cost-effectiveness model developed using a Markov modeling approach. The model simulated treatment of a cohort of 1000 schizophrenics for 12 months, initiating treatment with one of four antipsychotic drugs; haloperidol, risperidone, olanzapine and ziprasidone. Conditional probabilities of developing any of four adverse events were calculated. Treatment was modified (decrease dose, switch medication) according to incidence of ARs and physician judgments, obtained from a local cross-sectional study and clinical trials previously published. The analysis was conducted in year 2002 from a third party payer perspective. Results are shown as annual cost per month with psychotic symptoms controlled and included univariate sensitivity analysis. The therapeutic strategy starting with ziprasidone showed the lower costs and the greater number of months with symptoms controlled in most scenarios evaluated versus the other options considered, although the differences were weak: 9.6, 9.3, 9.5 and 9.5 controlled months per patient in base scenario, with annual cost per patient per month with symptoms controlled of 1035 Euros, 1084 Euros, 1087 Euros and 1090 Euros for ziprasidone, haloperidol, risperidone and olanzapine, respectively. Results were robust to one-way sensitivity analysis. Despite the unlike drug prices of antipsychotics, a considerable economic impact due to adverse reactions was seen in our setting. These results should be taken into account by health decision makers and clinicians in the management of patients with schizophrenia.

Hyperprolactinemia and bone mineral density: the potential impact of antipsychotic agents

The prevalence of schizophrenia is about 1% worldwide. Individuals with schizophrenia are at increased risk for osteoporosis and fractures for several reasons, including poor diet, lack of exercise, cigarette smoking, and polydipsia. Some antipsychotic medications may further increase the risk of fractures by causing dizziness, orthostatic hypotension, and falls. Studies in women with hyperprolactinemia resulting from pituitary tumors have demonstrated high rates of osteoporosis believed to result from hypoestrogenism. Similarly, hyperprolactinemia in men results in hypogonadism and bone loss. Preliminary surveys have indicated that schizophrenia patients also may have elevated rates of osteoporosis and pathological fractures, possibly resulting in part from the long-term administration of antipsychotic agents that produce hyperprolactinemia and secondarily lower estrogen and testosterone levels. This potential complication of treatment with certain antipsychotic agents requires careful study and could represent a serious public health problem.

Antipsychotic medication, prolactin elevation, and ovarian function in women with schizophrenia and schizoaffective disorder

Some, but not all, antipsychotics elevate serum prolactin. Antipsychotic-induced hyperprolactinemia is thought to account for high rates of menstrual dysfunction and diminished estrogen levels in women with schizophrenia. However, few studies have directly assessed the relationships between prolactin, menstrual function, and ovarian hormone levels in this population. Sixteen premenopausal women with schizophrenia and schizoaffective disorder, eight treated with an antipsychotic with prolactin-elevating potential (five with typical antipsychotics and three with risperidone) and eight treated with an antipsychotic with prolactin-sparing potential (seven with olanzapine and one with clozapine), were studied for eight weeks. Data were collected on menstrual functioning and on serum prolactin, estradiol, and progesterone levels, and were compared between subjects who received an antipsychotic with prolactin-elevating potential and an antipsychotic with prolactin-sparing potential, and between subjects with hyperprolactinemia (N=6) and normoprolactinemia (N=10). Additionally, peak ovarian hormone levels were compared to normal values. While mean prolactin levels of subjects who received an antipsychotic with prolactin-elevating potential were significantly greater than those of subjects who received an antipsychotic with prolactin-sparing potential, there were no differences in rates of menstrual dysfunction or in ovarian hormone values between the two groups. Additionally, similar rates of menstrual dysfunction and ovarian hormone values were observed between the hyperprolactinemic and normoprolactinemic subjects. Moreover, irrespective of medication type or prolactin status, most subjects had peak estradiol levels below normal reference values for the periovulatory phase of the menstrual cycle. While our sample size is small, warranting the need for further investigation, the findings of this preliminary study suggest that antipsychotic-induced hyperprolactinemia, alone, may not adequately explain the observed ovarian dysfunction in women with schizophrenia.

Relationship of gender and menstrual status to symptoms and medication side effects in patients with schizophrenia

Schizophrenic outpatients (62 females, 59 males) were evaluated to examine the relationships between menstrual status, gender, clinical measures of psychopathology and drug side effects. Menstrual status was determined for 55 female patients. Blood from 44 female subjects, drawn before the AM dose of neuroleptic, was assayed for prolactin concentrations. In 27 premenopausal women (age < 45 years), six (22%) reported irregular menses and one (4%) reported amenorrhea. Women with irregular menses did not differ in their prolactin levels or neuroleptic dose, from women with regular menses. Amenorrheic women (n = 22) were significantly older than men (n = 59) and menstruating women (n = 33). After controlling for age, menstruating women did not differ in clinical measures of psychopathology, drug side effects, or neuroleptic dose compared to amenorrheic women or men. Comparison of 15 age-matched pairs of menstruating females and amenorrheic females revealed significantly lower levels of akathisia and depression in the menstruating group and a trend towards lower serum prolactin concentrations (P = 0.08). In female subjects, prolactin levels correlated significantly with neuroleptic dose (r = 0.36, P < 0.005). Our results only partially support hypothesized relationships between menstrual status, prolactin levels and neuroleptic effects and serve to emphasize the importance of controlling for age when comparing these clinical variables.

Drug-induced infertility

Primary infertility may result from the use of various drugs. This phenomenon may be the result of an effect on the hypothalamic-pituitary-gonadal axis or a direct toxic effect on the gonads. Some of the drugs considered in this article demonstrate sex-related differences in their ability to cause infertility; there also may be age-related differences. The drugs described in this review, in regard to their association with the development of infertility, include various individual antineoplastic agents (cyclophosphamide, chlorambucil, busulphan, and methotrexate) and combinations of these chemotherapeutic drugs, glucocorticosteroids, hormonal steroids (diethylstilbestrol, medroxyprogesterone acetate, estrogen, and the constituents of oral contraceptives), antibiotics (sulfasalazine and co-trimoxazole), thyroid supplements, spironolactone, cimetidine, colchicine, marihuana, opiates, and neuroleptic agents.

A factual study of male potency disorders

The literature on “psychogenic” potency disorders in the male is vast, and opinions abound on every aspect of these disorders. However, despite this abundance there is a dearth of factual data. The present author has been able to find only two major studies which have set out to study systematically and objectively facets of these conditions. El-Senoussi et al. (1959) undertook a statistical study to delineate psychological factors related causally to impotence; whilst Johnson (1965b) retrospectively studied male potency disorders to define their natural history.

[The use of thioridazine in an emergency and home care psychiatric service]

This paper describes the activities of a home treatment program for psychiatric patients. In 1962 the Canadian Mental Health Association, Quebec Division, awarded a grant to the Notre-Dame Hospital for the establishment of a Home-Care Program and Emergency Psychiatric Service. To demonstrate the type of patient admitted to this newly established service and the results obtained, special records were compiled for 69 patients for the purpose of a study. All patients were admitted at random to the investigation and all received thioridazine, the drug employed by the service because of its reported margin of safety. Diagnostically, the patient population can be grouped into four separate categories:

a) Schizophrenic reaction 38 patients

b) Depressive reaction 20 patients

c) Anxiety reaction 6 patients

d) Character disorder 5 patients

Total 69 patients

The dosage range of thioridazine varied from 10 mg. t.i.d. to 200 mg. t.i.d. depending upon the severity of the symptoms with a mean average of 25 to 50 mg. A beneficial effect was noted in 74% of the patients.

The data presented describing the cooperation of the patients and their environment towards treatment of the psychiatric disorder, clearly demonstrate that the treatment prescribed had to overcome many difficulties. Most patients were unco-operative and there was also strong resistance towards the treatment of the patient by his family.

In conclusion, the therapeutic results are gratifying. This is especially so in view of the majority of the patients who were not co-operative or severely ill who would never have obtained a psychiatric consultation were it not for the Home-Care Psychiatric Service. The lack of serious side effects and therapeutic effectiveness of thioridazine observed during this trial contributed to the improvement of the patient population.

Many questions should be raised concerning home treatment or house call by psychiatrists. The experience of the service can be termed a research experiment by only the broadest interpretation. The most important appear evident in our concluding observations:

1) Home treatment could reach a large segment of people who otherwise would not receive treatment and are in need of it.

2) The co-operation and motivation of the patient is not necessarily a pre-requisite for treatment as it was previously believed.

3) The use of auxiliary services, social agencies and drug therapy facilitate the treatment.

4) A better understanding of the institution—the family, will be required in the near future. The meaning of the coined words ‘family crisis’ is still esoteric and should be defined according to scientific measurable standards. The psychiatrist, in order to proceed with the treatment depends on the family and must allow the family to depend on him, with the implication that he must do certain things according to the way of the family. An acute situation resulting either in a psychotic breakdown and/or emergency call must be understood as a communication between the patient and the ‘milieu’. The crisis provoked is a message of the distress of the patient, which means despite the negativistic facade that the patient wished to be helped.

It has also been our experience that the family resorts to the service with the concealed desire to have a witness to their situation. The psychiatrist then becomes the ‘pacifier’ by only his presence, whether he takes a direct active role or not. Repeated crises have appeared to us as a means to solve difficult problems in front of a passive outsider — thus the family dynamics were operative towards seeking a solution and integrative measures. In other words, if an individual demands attention the same can be said for a family, which explains many additional visits required in certain cases. 5) The role and change in the therapist as a result of the home visit will ensue. It is quite clear that the fact of the role reversal, that the patient is the host and the psychiatrist the visitor, unlike the situation in the office, places the onus and burden on the psychiatrist.

The use of manipulation which then becomes a social prescription can be attained if only communication is established between the family and the psychiatrist. In many instances various members of the team are better suited for the initial visit at the onset of treatment be it a nurse, a social worker, or a doctor. The establishment of a therapeutic alliance should be the major objective but additional knowledge must be gained before principles are clearly outlined in this area.

A trial of thioridazine in mental deficiency

The majority of subnormal and severely subnormal patients do not present behaviour problems provided planned daily occupation of mind and body is achieved. In a large mental deficiency hospital, however, there is usually a group of grossly disturbed patients whose behaviour is frequently or continually disturbed, and who fail to respond adequately to drug therapy. These patients present a serious nursing problem since they occupy a disproportionate amount of the nurse's time.