Therapeutic value of thioproperazine and the importance of the associated neurological disturbances

Haloperidol's introduction in the United States: A tale of a failed trial and its consequences

Haloperidol, the first butyrophenone neuroleptic, was created in Europe by Janssen Pharmaceuticals in 1958 and was introduced swiftly throughout the continent with great enthusiasm. On September 15, 1959, at Janssen's headquarters in Belgium, teams from around Europe praised the effectiveness of haloperidol. In the United States, on the contrary, its introduction was a tremendous failure, plagued by accusations of inefficacy and patent disputes. A clinical trial in Manhattan has been blamed for this commercial failure. The results of the Manhattan trial were seen as radically different from the results obtained in continental Europe. This divide would have considerable impact not only with regard to haloperidol's path on both sides of the Atlantic, but also possibly on the practical experience and theoretical construction of psychiatry. This article tries to reconstruct the story of that trial based mainly on published papers and interviews. Exploring how societal changes and issues of gender and race shaped this process, this investigation attempts to understand and contextualize different possible reasons for this Atlantic rift.

Effects of newer antipsychotics on extrapyramidal function

Following acceptance of clozapine as a superior antipsychotic agent with low risk of adverse extrapyramidal syndromes (EPS), such as dystonia, parkinsonism, akathisia or tardive dyskinesia, several novel antipsychotic drugs have been developed with properties modelled on those of clozapine. Though generally considered 'atypical' in their relatively low risk of inducing EPS, these agents vary considerably in their pharmacology and impact on neurological functioning. Although few comparative data are available, the atypical antipsychotics can be tentatively ranked by EPS risk (excluding akathisia and neuroleptic malignant syndrome) in the following order: clozapine < quetiapine < olanzapine = ziprasidone. At higher doses, risperidone is ranked with a higher EPS risk than olanzapine and ziprasidone, but its risk of EPS is lower with lower doses. In general, this ranking is inversely related to antidopaminergic (D2 receptor) potency. The high antiserotonergic (5-HT2A receptor) potency of risperidone, clozapine, ziprasidone and olanzapine, but not quetiapine, as well as the antimuscarinic activity of olanzapine and clozapine may also limit EPS. For the treatment of psychotic reactions to dopamine agonist therapy in Parkinson's disease, clozapine is both effective and relatively well tolerated; quetiapine may be tolerated, olanzapine is not well tolerated, risperidone is poorly tolerated, and amisulpride and ziprasidone have not been well evaluated. Clozapine, perhaps because of its anticholinergic activity, can reduce parkinsonian tremor. It is useful for ongoing psychosis with tardive dyskinesia, especially for dystonic features. No atypical antipsychotic is clearly effective for motor abnormalities in Huntington's disease or Tourette's syndrome, and the effect of these drugs on other neurological disorders have been well evaluated in only small numbers of patients. In summary, with the exception of clozapine, and perhaps quetiapine, atypical antipsychotics have brought only relative avoidance of EPS, strongly encouraging continued searches for novel antipsychotic agents.

SOME PHARMACOLOGICAL PROPERTIES OF THIOPROPERAZINE AND THEIR MODIFICATION BY ANTI-PARKINSONIAN DRUGS

The pharmacological properties of a phenothiazine derivative thioproperazine have been compared with those of chlorpromazine, and the modifications by some anti-Parkinsonian drugs of its actions on the central nervous system have been studied. Thioproperazine was less potent than chlorpromazine in lowering blood pressure and antagonizing adrenaline in the cat, in depressing respiratory rate in the rabbit, in producing hypothermia and analgesia and in reducing the minimum anaesthetic dose of hexobarbitone in mice, and in protecting rats from convulsions induced by tryptamine. It was roughly equipotent to chlorpromazine in reducing locomotor activity of mice. Thioproperazine was more potent than chlorpromazine in protecting grouped mice from the acute toxicity of dexamphetamine, in preventing the acute behavioural disturbances produced by dexamphetamine in the rat, in producing a state of experimental catatonia in the rat and in preventing the emetic action of apomorphine in the dog. Hyoscine, benztropine or promethazine greatly reduced the ability of thioproperazine to prevent behavioural changes due to dexamphetamine in the rat and also abolished symptoms of experimental catatonia produced by thioproperazine. In contrast, the antiapomorphine activity of thioproperazine in the dog was not reduced to any extent by hyoscine or benztropine.

The clinical phenomenon of akathisia

The subjective and motor phenomena of neuroleptic-induced akathisia were studied in two different populations of psychiatric patients. Thirty nine (41%) of 95 patients attending community psychiatric centres and psychiatric day hospitals experienced a compulsion to move about, and 52 (55%) complained of restlessness of the body. Of 842 psychiatric in-patients 159 found to have marked hyperkinesis were divided into three groups; group 1 with motor restlessness, and a subjective desire to move about or marching on the spot (27 patients), group 2 with choreo-athetotic movements and motor restlessness (79 patients) and an indeterminate group 3 (53), bearing more similarities to group 1 than group 2. Motor disturbances associated with akathisia were repeated leg crossing, swinging of one leg, lateral knee movements, sliding of the feet and rapid walking.

The motor disorders of severe psychiatric illness: a conflict of paradigms

The motor disorder of 100 patients with severe psychiatric illness is described and the contribution of previous treatment, hospitalization and possible neurological disorder is considered. The conflict of paradigms between the concept that this motor disorder has two distinct aetiologies, psychiatric and neurological, and the concept that both motor and mental disorder are an expression of underlying cerebral disorder is discussed. An attempt is made to resolve this conflict by description of motor disorder without reference to neurological or psychiatric diagnosis.

Pharmacological characterization of tardive dyskinesia

Tardive dyskinesia (TD) may be a clinical manifestation of a relative imbalance between the inversely related dopaminergic (DA) and acetylcholinergic (ACh) influences in the central nervous system (CNS). Six patients were evaluated with single challenge doses of a DA agonist, levodopa, and antagonist, droperidol, as well as with an ACh agonist, physostigmine, an antagonist, benztropine, and a placebo. A single blind trial with deanol and placebo followed. Responses, measured by an electrophysiological technique, formed two subgroups. The patients who improved with a DA antagonist or an ACh agonist improved while taking deanol. Another group of patients were made worse with a DA antagonist or ACh agonist and were worsened or had no response while taking deanol. While the results add support to the concept of counterbalancing DA-ACh influences in TD, further investigation of TD subtypes and predictors of drug response is warranted.

Long-acting phenothiazines in the prevention of relapse of schizophrenic patients

The development of the depot fluphenazine preparations has been a major advance in the drug treatment of schizophrenia, ensuring continuous medication and stimulating the development of adequate community care services, resulting in significant reduction of relapse and readmission.

This report compares the incidence of readmissions and the duration of hospital stay in a group of chronic schizophrenic patients who had first received oral medication and then long-acting injectable fluphenazine enanthate and decanoate over identical periods of time. A percentage of 93.3 of the subjects were maintained on continuous treatment for twelve to forty months. The readmission rate was reduced from 191 to 50, and the time spent in hospital from 8,713 to 1,335 days.

"DISCONTINUOUS" THIOPROPERAZINE: A CONTROLLED TRIAL IN CHRONIC SCHIZOPHRENIA

It became apparent soon after the introduction of chlorpromazine and reserpine that these drugs were capable both of influencing psychoses and of producing neurological disturbances closely resembling those seen in post-encephalitic Parkinsonism. In classifying drugs with these effects as “neuroleptics” Delay et al. (2) indicated that they considered the two actions to be inseparable thus implying that both resulted from common or closely related neurophysiological changes. On this basis it seemed likely that drugs which more readily produced these neurological disturbances would prove more effective in psychotic illness. It also seemed possible that there might be therapeutic value in the deliberate provocation of such disturbances, as was first advocated by Fleugel (6). The theoretical issues involved were referred to in a previous paper (MacLeod and Moffat (8)).

THIOPROPERAZINE IN CHRONIC SCHIZOPHRENIA

Despite the advent of the stimulant phenothiazines—effective, sometimes, when older dimethyl compounds fail—a proportion of chronic schizophrenics continue to resist treatment with both types of drug, and also fail to respond to intensive nursing regimes designed to combat the effects of institutionalization. These patients constitute a major therapeutic problem.

The effect of thioproperazine administered by a continuous method on long-term schizophrenic patients

Thioproperazine is a phenothiazine compound with a piperazine nucleus in the side chain. The pharmacological investigations of Courvoisier et al. (1958) indicate that it is much less sedative than other phenothiazines and that it has weak anti-adrenaline, anti-histamine and anti-serotonin activity. Clinical reports by Delay et al. (1958), Perrin et al. (1958), Denber et al. (1959), Levy and Maarek (1960) and Perret et al. (1961) indicate improvement in schizophrenic patients, but their papers described trials of this drug in which both recent and long-term cases or other diagnostic groups were included. Denham and Carrick (1961) reported the total remission of symptoms in 32 of 58 chronic schizophrenics treated by the discontinuous method with significant improvement in a further 25. Their acceptance of the view that improvement was correlated with the occurrence of hypertonic syndromes and that failure of treatment was likely if anti-parkinsonism drugs were used to suppress the hypertonicity, excludes the possibility of the type of continuous treatment employed with other phenothiazines. Denber et al., however, advocated the suppression of these drug effects and Perret et al. reported 47% improvement using the continuous method in another mixed group of chronic patients.