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Jiao S, Li N, Cao T, Wang L, Chen H, Lin C, Cai H. Differential impact of intermittent versus continuous treatment with clozapine on fatty acid metabolism in the brain of an MK-801-induced mouse model of schizophrenia. Prog Neuropsychopharmacol Biol Psychiatry 2024; 133:111011. [PMID: 38642730 DOI: 10.1016/j.pnpbp.2024.111011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 03/30/2024] [Accepted: 04/14/2024] [Indexed: 04/22/2024]
Abstract
Continuous antipsychotic treatment is often recommended to prevent relapse in schizophrenia. However, the efficacy of antipsychotic treatment appears to diminish in patients with relapsed schizophrenia and the underlying mechanisms are still unknown. Moreover, though the findings are inconclusive, several recent studies suggest that intermittent versus continuous treatment may not significantly differ in recurrence risk and therapeutic efficacy but potentially reduce the drug dose and side effects. Notably, disturbances in fatty acid (FA) metabolism are linked to the onset/relapse of schizophrenia, and patients with multi-episode schizophrenia have been reported to have reduced FA biosynthesis. We thus utilized an MK-801-induced animal model of schizophrenia to evaluate whether two treatment strategies of clozapine would affect drug response and FA metabolism differently in the brain. Schizophrenia-related behaviors were assessed through open field test (OFT) and prepulse inhibition (PPI) test, and FA profiles of prefrontal cortex (PFC) and hippocampus were analyzed by gas chromatography-mass spectrometry. Additionally, we measured gene expression levels of enzymes involved in FA synthesis. Both intermittent and continuous clozapine treatment reversed hypermotion and deficits in PPI in mice. Continuous treatment decreased total polyunsaturated fatty acids (PUFAs), saturated fatty acids (SFAs) and FAs in the PFC, whereas the intermittent administration increased n-6 PUFAs, SFAs and FAs compared to continuous administration. Meanwhile, continuous treatment reduced the expression of Fads1 and Elovl2, while intermittent treatment significantly upregulated them. This study discloses the novel findings that there was no significant difference in clozapine efficacy between continuous and intermittent administration, but intermittent treatment showed certain protective effects on phospholipid metabolism in the PFC.
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Affiliation(s)
- Shimeng Jiao
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China; Institute of Clinical Pharmacy, Central South University, Changsha, China; International Research Center for Precision Medicine, Transformative Technology and Software Services, Hunan, China
| | - Nana Li
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China; Institute of Clinical Pharmacy, Central South University, Changsha, China; International Research Center for Precision Medicine, Transformative Technology and Software Services, Hunan, China
| | - Ting Cao
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China; Institute of Clinical Pharmacy, Central South University, Changsha, China; International Research Center for Precision Medicine, Transformative Technology and Software Services, Hunan, China
| | - Liwei Wang
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China; Institute of Clinical Pharmacy, Central South University, Changsha, China; International Research Center for Precision Medicine, Transformative Technology and Software Services, Hunan, China
| | - Hui Chen
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China; Institute of Clinical Pharmacy, Central South University, Changsha, China; International Research Center for Precision Medicine, Transformative Technology and Software Services, Hunan, China
| | - Chenquan Lin
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China; Institute of Clinical Pharmacy, Central South University, Changsha, China; International Research Center for Precision Medicine, Transformative Technology and Software Services, Hunan, China
| | - Hualin Cai
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China; Institute of Clinical Pharmacy, Central South University, Changsha, China; International Research Center for Precision Medicine, Transformative Technology and Software Services, Hunan, China; National Clinical Research Center on Mental Disorders, Changsha, China.
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Wu R, Chou S, Li M. Continuous oral olanzapine or clozapine treatment initiated in adolescence has differential short- and long-term impacts on antipsychotic sensitivity than those initiated in adulthood. Eur J Pharmacol 2024; 972:176567. [PMID: 38582275 PMCID: PMC11128075 DOI: 10.1016/j.ejphar.2024.176567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 04/03/2024] [Accepted: 04/03/2024] [Indexed: 04/08/2024]
Abstract
One of the major discoveries in recent research on antipsychotic drugs is that antipsychotic treatment in adolescence could induce robust long-term alterations in antipsychotic sensitivity that persist into adulthood. These long-term impacts are likely influenced by various factors, including the "diseased" state of animals, sex, type of drugs, mode of drug administration, and age of treatment onset. In this study we compared the short- and long-term behavioral effects of 21-day continuous oral olanzapine (7.5 mg/kg/day) or clozapine (30.0 mg/kg/day) administration in heathy or maternal immune activated adolescent (33-53 days old) or adult (80-100 days old) rats of both sexes. We used a conditioned avoidance response model to assess the drug-induced alterations in antipsychotic sensitivity. Here, we report that while under the chronic drug treatment period, olanzapine progressively increased its suppression of avoidance responding over time, especially when treatment was initiated in adulthood. Clozapine's suppression depended on the age of drug exposure, with treatment initiated in adulthood showing a suppression while that initiated in adolescent did not. After a 17-day drug-free interval, in a drug challenge test, olanzapine treatment initiated in adolescence caused a decrease in drug sensitivity, as reflected by less avoidance suppression (a tolerance effect); whereas that initiated in adulthood appeared to cause an increase (more avoidance suppression, a sensitization effect). Clozapine treatments initiated in both adolescence and adulthood caused a similar tolerance effect. Our findings indicate that the same chronic antipsychotic treatment regimen initiated in adolescence or adulthood can have differential short- and long-term impacts on drug sensitivity.
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Affiliation(s)
- Ruiyong Wu
- College of Bioscience and Biotechnology, Yangzhou University, Yangzhou, China
| | - Shinnyi Chou
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ming Li
- Department of Psychology, Nanjing University, Nanjing, China.
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Hart XM, Spangemacher M, Uchida H, Gründer G. Update Lessons from Positron Emission Tomography Imaging Part I: A Systematic Critical Review on Therapeutic Plasma Concentrations of Antipsychotics. Ther Drug Monit 2024; 46:16-32. [PMID: 38018857 DOI: 10.1097/ftd.0000000000001131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 06/06/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND Positron emission tomography (PET) and single photon emission tomography (SPECT) of molecular drug targets (neuroreceptors and transporters) provide essential information for therapeutic drug monitoring-guided antipsychotic drug therapy. The optimal therapeutic windows for D 2 antagonists and partial agonists, as well as their proposed target ranges, are discussed based on an up-to-date literature search. METHODS This part I of II presents an overview of molecular neuroimaging studies in humans and primates involving the target engagement of amisulpride, haloperidol, clozapine, aripiprazole, olanzapine, quetiapine, risperidone, cariprazine, and ziprasidone. The systemic review particularly focused on dopamine D 2 -like and 5-HT 2A receptors. Target concentration ranges were estimated based on receptor occupancy ranges that relate to clinical effects or side effects (ie, extrapyramidal side effects). In addition, findings for other relevant receptor systems were included to further enrich the discussion. RESULTS The reported reference ranges for aripiprazole and clozapine align closely with findings from PET studies. Conversely, for haloperidol, risperidone, and olanzapine, the PET studies indicate that a lowering of the previously published upper limits would be necessary to decrease the risk of extrapyramidal side effect. CONCLUSIONS Molecular neuroimaging studies serve as a strong tool for defining target ranges for antipsychotic drug treatment and directing therapeutic drug monitoring.
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Affiliation(s)
- Xenia M Hart
- Central Institute of Mental Health, Department of Molecular Neuroimaging, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Moritz Spangemacher
- Central Institute of Mental Health, Department of Molecular Neuroimaging, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
- Central Institute of Mental Health, Department of Psychiatry, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany; and
| | - Hiroyuki Uchida
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Gerhard Gründer
- Central Institute of Mental Health, Department of Molecular Neuroimaging, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
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Davidson M, Carpenter WT. Targeted Treatment of Schizophrenia Symptoms as They Manifest, or Continuous Treatment to Reduce the Risk of Psychosis Recurrence. Schizophr Bull 2024; 50:14-21. [PMID: 37929893 PMCID: PMC10754173 DOI: 10.1093/schbul/sbad145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Abstract
Current pharmacological treatment of schizophrenia employs drugs that interfere with dopamine neurotransmission, aiming to suppress acute exacerbation of psychosis and maintenance treatment to reduce the risk of psychosis recurrence. According to this treatment scheme, available psychotropic drugs intended to treat negative symptoms, cognitive impairment, or anxiety are administered as add-ons to treatment with antipsychotics. However, an alternative treatment scheme proposes a targeted or intermittent treatment approach, by which antipsychotic drugs are administered upon psychosis exacerbation and discontinued upon remission or stabilization, while negative symptoms, cognitive impairment, or anxiety are treated with specific psychotropics as monotherapy. Along these lines, antipsychotics are renewed only in the event of recurrence of psychotic symptoms. This 50-year-old debate between targeted and continuous treatment schemes arises from disagreements about interpreting scientific evidence and discordant views regarding benefit/risk assessment. Among the debate's questions are: (1) what is the percentage of individuals who can maintain stability without antipsychotic maintenance treatment, and what is the percentage of those who exacerbate despite antipsychotic treatment? (2) how to interpret results of placebo-controlled 9- to 18-month-long maintenance trials in a life-long chronic disorder, and how to interpret results of the targeted trials, some of which are open label or not randomized; (3) how to weigh the decreased risk for psychotic recurrence vs the almost certainty of adverse effects on patient's quality of life. Patients' profiles, preferences, and circumstances of the care provision should be considered as the targeted vs continuous treatment options are considered.
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Affiliation(s)
- Michael Davidson
- Department of Basic and Clinical Sciences, Psychiatry, University of Nicosia Medical School, 2414, Nicosia, Cyprus and Minerva Neurosciences, 1500 District Avenue, Burlington, MA 01803, USA
| | - William T Carpenter
- University of Maryland School of Medicine, Department of Psychiatry, Maryland Psychiatric Research Center, Baltimore, MD, USA
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Panov G, Panova P. Neurobiochemical Disturbances in Psychosis and their Implications for Therapeutic Intervention. Curr Top Med Chem 2024; 24:1784-1798. [PMID: 38265370 DOI: 10.2174/0115680266282773240116073618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 12/17/2023] [Accepted: 12/19/2023] [Indexed: 01/25/2024]
Abstract
Psychosis, marked by the emergence of psychotic symptoms, delves into the intricate dance of neurotransmitter dynamics, prominently featuring dopamine as a key orchestrator. In individuals living with psychotic conditions, the finely tuned balance of dopamine becomes disrupted, setting off a cascade of perceptual distortions and the manifestation of psychotic symptoms. A lot of factors can impact dopamine metabolism, further complicating its effects. From genetic predispositions to environmental stressors and inflammation, the delicate equilibrium is susceptible to various influences. The sensorium, the origin of incoming information, loses its intrinsic valence in this complex interplay. The concept of the "signal-to-noise ratio" encapsulates dopamine's role as a molecular switch in neural networks, influencing the flow of information serving the basic biological functions. This nuanced modulation acts as a cognitive prism, shaping how the world is perceived. However, in psychosis, this balance is disrupted, steering individuals away from a shared reality. Understanding dopamine's centrality requires acknowledging its unique status among neurotransmitters. Unlike strictly excitatory or inhibitory counterparts, dopamine's versatility allows it to toggle between roles and act as a cognitive director in the neural orchestra. Disruptions in dopamine synthesis, exchange, and receptor representation set off a chain reaction, impacting the delivery of biologically crucial information. The essence of psychosis is intricately woven into the delicate biochemical ballet choreographed by dopamine. The disruption of this neurotransmitter not only distorts reality but fundamentally reshapes the cognitive and behavioral field of our experience. Recognizing dopamine's role as a cognitive prism provides vital insights into the multifaceted nature of psychotic conditions, offering avenues for targeted therapeutic interventions aimed at restoring this delicate neurotransmitter balance.
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Affiliation(s)
- Georgi Panov
- Psychiatric Clinic, University Hospital for Active Treatment "Prof. Dr. Stoyan Kirkovich," Trakia University, Stara Zagora, 6000, Bulgaria
- Department "Neurology, Psychiatry, Psychology," Medical Faculty of University "Prof. Dr. Asen Zlatarov," Burgas, 8000, Bulgaria
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Amarasekera R, Wood E. Worsening stimulant use disorder outcomes coinciding with off-label antipsychotic prescribing: a commonly unrecognised side effect? BMJ Case Rep 2023; 16:e255129. [PMID: 37907321 PMCID: PMC10618975 DOI: 10.1136/bcr-2023-255129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2023] [Indexed: 11/02/2023] Open
Abstract
Antipsychotic medications exert their effects via dopamine antagonism and are widely used off-label among persons with substance use disorders (SUD). While dopamine antagonists are recognised to stimulate food craving and weight gain, outside of possibly increasing nicotine craving and use, their impact on other SUD outcomes is poorly recognised. In this context, research has demonstrated that antipsychotic therapy can produce 'supersensitivity' to dopamine, enhancing the motivational effects of addictive drugs. Worsened drug craving and higher rates of substance use have also been observed in double-blind placebo-controlled trials. Nevertheless, widespread off-label antipsychotic prescribing among persons with SUD implies that the risks of worsening SUD outcomes are overall poorly recognised in both primary care and among specialists. We present a typical case of worsening stimulant use disorder in a patient prescribed antipsychotic medication for low mood and insomnia, highlighting that this is likely a widely under-recognised adverse effect of off-label antipsychotic therapy.
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Affiliation(s)
- Ruvini Amarasekera
- BC Centre on Substance Use, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Evan Wood
- BC Centre on Substance Use, The University of British Columbia, Vancouver, British Columbia, Canada
- Medicine, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
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Abuelazm H, Elsayed OH, El-Mallakh RS. Evaluating lumateperone for its use in treating depressive episodes associated with bipolar I or II disorder in adults. Expert Rev Neurother 2023; 23:751-756. [PMID: 37458003 DOI: 10.1080/14737175.2023.2236795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 07/11/2023] [Indexed: 07/18/2023]
Abstract
INTRODUCTION Lumateperone is a novel antipsychotic medication that has recently received approval by the United States Food and Drug Administration for treatment of major depressive episodes of type I and II bipolar disorder. It is approved for use as monotherapy or as an adjunctive treatment to lithium or valproic acid. AREAS COVERED Clinical trials performed with lumateperone for bipolar disorder were reviewed. Additionally, pharmacodynamic actions of lumateperone are reviewed. Lumateperone is superior to placebo whether used alone or in combination with a mood stabilizer in patients with type I or type II bipolar disorder. It achieves this effect with minimal dopamine blockade-related side effects due to less than 50% dopamine D2 receptor occupancy. While the pharmacodynamic profile of lumateperone is unique, the mechanism of action in bipolar depression remains obscure. EXPERT OPINION Lumateperone is an antipsychotic with full antagonist effects at the post-synaptic D2, and partial agonist effects at the presynaptic D2. This unique profile allows for both antipsychotic and antidepressant effects at the same dose, which does not produce dopamine-related side effects. Consequently, lumateperone is exceptionally well tolerated compared to other antidepressant-acting antipsychotic agents. It is now the only agent approved as an adjunct to the mood stabilizer for bipolar II depression.
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Affiliation(s)
- Hagar Abuelazm
- Mood Disorders Research Program, Depression Center, Department of Psychiatry and Behavioral Sciences, University of Louisville School of Medicine, Louisville, KY, USA
| | - Omar H Elsayed
- Mood Disorders Research Program, Depression Center, Department of Psychiatry and Behavioral Sciences, University of Louisville School of Medicine, Louisville, KY, USA
| | - Rif S El-Mallakh
- Mood Disorders Research Program, Depression Center, Department of Psychiatry and Behavioral Sciences, University of Louisville School of Medicine, Louisville, KY, USA
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Seok JW, Soltis-Vaughan B, Lew BJ, Ahmad A, Blair RJR, Hwang S. Psychopharmacological treatment of disruptive behavior in youths: systematic review and network meta-analysis. Sci Rep 2023; 13:6921. [PMID: 37117632 PMCID: PMC10147946 DOI: 10.1038/s41598-023-33979-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 04/21/2023] [Indexed: 04/30/2023] Open
Abstract
To conduct a systematic review of the comparative efficacy of various psychotropic medications for the treatment of disruptive behavior (DBs) in youths. To this aim, we systematically reviewed randomized clinical trials (RCTs) of various psychotropic medications targeting symptoms of DBs and applied network meta-analysis to investigate their relative efficacy. Fifty-five RCTs meeting the inclusion criteria were selected. To predict and interpret relative treatment efficacy, we compared the efficacy of various psychotropic medications prescribed for DB symptoms based on their mechanism of action. Network meta-analysis revealed that for reducing DBs, second-generation antipsychotics, stimulants, and non-stimulant ADHD medications were more efficacious than placebo, and second-generation antipsychotics were the most efficacious. The dopaminergic modulation of top-down inhibitory process by these medications is discussed in this review. This study offers information on the relative efficacy of various psychotropic medications for the treatment of DB, and insight into a potential neurobiological underpinning for those symptoms. It also illustrates the potential utility of these neurobiological mechanisms as a target for future treatment studies.
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Affiliation(s)
- Ji-Woo Seok
- Department of Psychiatry, University of Nebraska Medical Center, 985578 Nebraska Medical Center, Omaha, NE, 68198-5578, USA
- Digital Health Research Division, Korea Institute of Oriental Medicine, Daejeon, South Korea
| | - Brigette Soltis-Vaughan
- Department of Psychiatry, University of Nebraska Medical Center, 985578 Nebraska Medical Center, Omaha, NE, 68198-5578, USA
| | - Brandon J Lew
- Department of Psychiatry, University of Nebraska Medical Center, 985578 Nebraska Medical Center, Omaha, NE, 68198-5578, USA
| | - Aatiya Ahmad
- Department of Psychiatry, University of Nebraska Medical Center, 985578 Nebraska Medical Center, Omaha, NE, 68198-5578, USA
| | - R J R Blair
- Child and Adolescent Mental Health Centre, Mental Health Services, Capital Region of Denmark, Copenhagen, Denmark
| | - Soonjo Hwang
- Department of Psychiatry, University of Nebraska Medical Center, 985578 Nebraska Medical Center, Omaha, NE, 68198-5578, USA.
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Valle-León M, Casajuana-Martin N, Del Torrent CL, Argerich J, Gómez-Acero L, Sahlholm K, Ferré S, Pardo L, Ciruela F. Unique effect of clozapine on adenosine A 2A-dopamine D 2 receptor heteromerization. Biomed Pharmacother 2023; 160:114327. [PMID: 36736280 DOI: 10.1016/j.biopha.2023.114327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 01/21/2023] [Accepted: 01/26/2023] [Indexed: 02/04/2023] Open
Abstract
The striatal dopamine D2 receptor (D2R) is generally accepted to be involved in positive symptoms of schizophrenia and is a main target for clinically used antipsychotics. D2R are highly expressed in the striatum, where they form heteromers with the adenosine A2A receptor (A2AR). Changes in the density of A2AR-D2R heteromers have been reported in postmortem tissue from patients with schizophrenia, but the degree to which A2R are involved in schizophrenia and the effect of antipsychotic drugs is unknown. Here, we examine the effect of exposure to three prototypical antipsychotic drugs on A2AR-D2R heteromerization in mammalian cells using a NanoBiT assay. After 16 h of exposure, a significant increase in the density of A2AR-D2R heteromers was found with haloperidol and aripiprazole, but not with clozapine. On the other hand, clozapine, but not haloperidol or aripiprazole, was associated with a significant decrease in A2AR-D2R heteromerization after 2 h of treatment. Computational binding models of these compounds revealed distinctive molecular signatures that explain their different influence on heteromerization. The bulky tricyclic moiety of clozapine displaces TM 5 of D2R, inducing a clash with A2AR, while the extended binding mode of haloperidol and aripiprazole stabilizes a specific conformation of the second extracellular loop of D2R that enhances the interaction with A2AR. It is proposed that an increase in A2AR-D2R heteromerization is involved in the extrapyramidal side effects (EPS) of antipsychotics and that the specific clozapine-mediated destabilization of A2AR-D2R heteromerization can explain its low EPS liability.
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Affiliation(s)
- Marta Valle-León
- Pharmacology Unit, Department of Pathology and Experimental Therapeutics, School of Medicine and Health Sciences, Institute of Neurosciences, University of Barcelona, 08907 L'Hospitalet de Llobregat, Spain; Neuropharmacology and Pain Group, Neuroscience Program, Institut d'Investigació Biomèdica de Bellvitge, IDIBELL, 08907 L'Hospitalet de Llobregat, Spain
| | - Nil Casajuana-Martin
- Laboratory of Computational Medicine, Biostatistics Unit, Faculty of Medicine, Universitat Autònoma Barcelona, Bellaterra, 08193 Barcelona, Spain
| | - Claudia Llinas Del Torrent
- Laboratory of Computational Medicine, Biostatistics Unit, Faculty of Medicine, Universitat Autònoma Barcelona, Bellaterra, 08193 Barcelona, Spain
| | - Josep Argerich
- Pharmacology Unit, Department of Pathology and Experimental Therapeutics, School of Medicine and Health Sciences, Institute of Neurosciences, University of Barcelona, 08907 L'Hospitalet de Llobregat, Spain; Neuropharmacology and Pain Group, Neuroscience Program, Institut d'Investigació Biomèdica de Bellvitge, IDIBELL, 08907 L'Hospitalet de Llobregat, Spain
| | - Laura Gómez-Acero
- Pharmacology Unit, Department of Pathology and Experimental Therapeutics, School of Medicine and Health Sciences, Institute of Neurosciences, University of Barcelona, 08907 L'Hospitalet de Llobregat, Spain; Neuropharmacology and Pain Group, Neuroscience Program, Institut d'Investigació Biomèdica de Bellvitge, IDIBELL, 08907 L'Hospitalet de Llobregat, Spain
| | - Kristoffer Sahlholm
- Pharmacology Unit, Department of Pathology and Experimental Therapeutics, School of Medicine and Health Sciences, Institute of Neurosciences, University of Barcelona, 08907 L'Hospitalet de Llobregat, Spain; Neuropharmacology and Pain Group, Neuroscience Program, Institut d'Investigació Biomèdica de Bellvitge, IDIBELL, 08907 L'Hospitalet de Llobregat, Spain; Department of Integrative Medical Biology, Wallenberg Centre for Molecular Medicine, Umeå University, 907 87 Umeå, Sweden; Department of Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Sergi Ferré
- Integrative Neurobiology Section, National Institute on Drug Abuse, Intramural Research Program, National Institutes of Health, Baltimore, MD, USA.
| | - Leonardo Pardo
- Laboratory of Computational Medicine, Biostatistics Unit, Faculty of Medicine, Universitat Autònoma Barcelona, Bellaterra, 08193 Barcelona, Spain.
| | - Francisco Ciruela
- Pharmacology Unit, Department of Pathology and Experimental Therapeutics, School of Medicine and Health Sciences, Institute of Neurosciences, University of Barcelona, 08907 L'Hospitalet de Llobregat, Spain; Neuropharmacology and Pain Group, Neuroscience Program, Institut d'Investigació Biomèdica de Bellvitge, IDIBELL, 08907 L'Hospitalet de Llobregat, Spain.
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Dopamine Dynamics and Neurobiology of Non-Response to Antipsychotics, Relevance for Treatment Resistant Schizophrenia: A Systematic Review and Critical Appraisal. Biomedicines 2023; 11:biomedicines11030895. [PMID: 36979877 PMCID: PMC10046109 DOI: 10.3390/biomedicines11030895] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 03/08/2023] [Accepted: 03/12/2023] [Indexed: 03/17/2023] Open
Abstract
Treatment resistant schizophrenia (TRS) is characterized by a lack of, or suboptimal response to, antipsychotic agents. The biological underpinnings of this clinical condition are still scarcely understood. Since all antipsychotics block dopamine D2 receptors (D2R), dopamine-related mechanisms should be considered the main candidates in the neurobiology of antipsychotic non-response, although other neurotransmitter systems play a role. The aims of this review are: (i) to recapitulate and critically appraise the relevant literature on dopamine-related mechanisms of TRS; (ii) to discuss the methodological limitations of the studies so far conducted and delineate a theoretical framework on dopamine mechanisms of TRS; and (iii) to highlight future perspectives of research and unmet needs. Dopamine-related neurobiological mechanisms of TRS may be multiple and putatively subdivided into three biological points: (1) D2R-related, including increased D2R levels; increased density of D2Rs in the high-affinity state; aberrant D2R dimer or heteromer formation; imbalance between D2R short and long variants; extrastriatal D2Rs; (2) presynaptic dopamine, including low or normal dopamine synthesis and/or release compared to responder patients; and (3) exaggerated postsynaptic D2R-mediated neurotransmission. Future points to be addressed are: (i) a more neurobiologically-oriented phenotypic categorization of TRS; (ii) implementation of neurobiological studies by directly comparing treatment resistant vs. treatment responder patients; (iii) development of a reliable animal model of non-response to antipsychotics.
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11
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Funding research to understand mechanisms of commercialized antipsychotic drugs could transform the future of mental health therapeutics. Behav Brain Res 2023; 438:114214. [PMID: 36372241 DOI: 10.1016/j.bbr.2022.114214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Affiliation(s)
- Martin Harrow
- Department of Psychiatry, University of Illinois at Chicago, Chicago, IL, USA
| | - Thomas H Jobe
- Department of Psychiatry, University of Illinois at Chicago, Chicago, IL, USA
| | - Liping Tong
- Advocate Aurora Health, Downers Grove, IL, USA
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Nagaoka K, Asaoka N, Nagayasu K, Shirakawa H, Kaneko S. Enhancement of adenosine A 2A signaling improves dopamine D 2 receptor antagonist-induced dyskinesia via β-arrestin signaling. Front Neurosci 2023; 16:1082375. [PMID: 36760795 PMCID: PMC9902764 DOI: 10.3389/fnins.2022.1082375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 12/28/2022] [Indexed: 01/26/2023] Open
Abstract
Repeated administration of dopamine D2 receptor (D2R) antagonists, which is the treatment for psychosis, often causes tardive dyskinesia (TD). Despite notable clinical demand, effective treatment for TD has not been established yet. The neural mechanism involving the hyperinhibition of indirect pathway medium spiny neurons (iMSNs) in the striatum is considered one of the main causes of TD. In this study, we focused on adenosine A2A receptors (A2ARs) expressed in iMSNs and investigated whether pharmacological activation of A2ARs improves dyskinetic symptoms in a TD mouse model. A 21-day treatment with haloperidol increased the number of vacuous chewing movements (VCMs) and decreased the number of c-Fos+/ppENK+ iMSNs in the dorsal striatum. Haloperidol-induced VCMs were reduced by acute intraperitoneal administration of an A2AR agonist, CGS 21680A. Consistently, haloperidol-induced VCMs and decrease in the number of c-Fos+/ppENK+ iMSNs were also mitigated by intrastriatal injection of CGS 21680A. The effects of intrastriatal CGS 21680A were not observed when it was concomitantly administered with a β-arrestin inhibitor, barbadin. Finally, intrastriatal injection of an arrestin-biased D2R agonist, UNC9994, also inhibited haloperidol-induced VCMs. These results suggest that A2AR agonists mitigate TD symptoms by activating striatal iMSNs via β-arrestin signaling.
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Affiliation(s)
- Koki Nagaoka
- Department of Molecular Pharmacology, Graduate School of Pharmaceutical Sciences, Kyoto University, Kyoto, Japan
| | - Nozomi Asaoka
- Department of Molecular Pharmacology, Graduate School of Pharmaceutical Sciences, Kyoto University, Kyoto, Japan,Department of Pharmacology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kazuki Nagayasu
- Department of Molecular Pharmacology, Graduate School of Pharmaceutical Sciences, Kyoto University, Kyoto, Japan
| | - Hisashi Shirakawa
- Department of Molecular Pharmacology, Graduate School of Pharmaceutical Sciences, Kyoto University, Kyoto, Japan
| | - Shuji Kaneko
- Department of Molecular Pharmacology, Graduate School of Pharmaceutical Sciences, Kyoto University, Kyoto, Japan,*Correspondence: Shuji Kaneko,
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14
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Abstract
BACKGROUND Studies that examine course and outcome in psychosis have reported considerable heterogeneity in terms of recovery, remission, employment, symptom presentation, social outcomes, and antipsychotic medication effects. Even with demonstrated heterogeneity in course and outcome, prophylactic antipsychotic maintenance therapy remains the prominent practice, particularly in participants with schizophrenia. Lack of efficacy in maintenance antipsychotic treatment and concerns over health detriments gives cause to re-examine guidelines. METHODS This study was conducted as part of the Chicago follow-up study designed as a naturalistic prospective longitudinal research study to investigate the course, outcome, symptomatology, and effects of antipsychotic medication on recovery and rehospitalization in participants with serious mental illness disorders. A total of 139 participants with 734 observations were included in the analysis. GEE logistic models were applied to adjust for confounding factors measured at index hospitalization and follow-ups. RESULTS Our data show that the majority of participants with schizophrenia or affective psychosis experience future episodes of psychosis at some point during the 20-year follow-up. There was a significant diagnostic difference between groups showing an increase in the number of future episodes of psychosis in participants with schizophrenia. Participants with schizophrenia not on antipsychotics after the first 2 years have better outcomes than participants prescribed antipsychotics. The adjusted odds ratio of not on antipsychotic medication was 5.989 (95% CI 3.588-9.993) for recovery and 0.134 (95% CI 0.070-0.259) for rehospitalization. That is, regardless of diagnosis, after the second year, the absence of antipsychotics predicted a higher probability of recovery and lower probability of rehospitalization at subsequent follow-ups after adjusting for confounders. CONCLUSION This study reports multiple findings that bring into question the use of continuous antipsychotic medications, regardless of diagnosis. Even when the confound by indication for prescribing antipsychotic medication is controlled for, participants with schizophrenia and affective psychosis do better than their medicated cohorts, strongly confirming the importance of exposing the role of aiDSP and antipsychotic drug resistance.
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Affiliation(s)
- Martin Harrow
- Department of Psychiatry, University of Illinois at Chicago, Chicago, IL, USA
| | - Thomas H Jobe
- Department of Psychiatry, University of Illinois at Chicago, Chicago, IL, USA
| | - Liping Tong
- Advocoate Aurora Health, Downers Grove, IL, USA
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15
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Highgate Q, Abadey AA, Schenk S. Repeated eticlopride administration increases dopamine D 2 receptor expression and restores behavioral flexibility disrupted by methamphetamine exposure to male rats. Behav Brain Res 2022; 435:114064. [PMID: 35987306 DOI: 10.1016/j.bbr.2022.114064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 08/16/2022] [Accepted: 08/16/2022] [Indexed: 11/15/2022]
Abstract
Repeated methamphetamine exposure impairs reversal learning in laboratory animals and downregulates dopamine D2 receptor expression. In the present study, we tested the possibility that repeated exposure to the dopamine D2 antagonist, eticlopride, would increase D2 receptor expression, improve behavioral flexibility and restore behavioral flexibility that was disrupted by exposure to methamphetamine in rats. Male Sprague-Dawley rats received repeated daily pretreatment with the dopamine D2 antagonist, eticlopride (0.0 or 0.3 mg/kg/day, 14 days). Three days after the last treatment, whole brain (minus olfactory bulbs and cerebellum) dopamine D2 receptor expression was measured using flow cytometry in one group and reversal learning performance was measured in another group. Reversal learning was also measured in other groups prior to and after methamphetamine exposure (0.0 or 2.0 mg/kg, 4 injections, 2 h apart, 1 day) followed by repeated eticlopride (0.0 or 0.3 mg/kg, 14 days) treatment. Eticlopride treatment increased D2 receptor expression and improved reversal learning performance. Methamphetamine impaired reversal learning performance and eticlopride treatment reversed the deficit. These results suggest that repeated administration of eticlopride can restore behavioral flexibility and that upregulation of D2 receptors might be an effective adjunct to treatment of methamphetamine misuse.
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Affiliation(s)
- Quenten Highgate
- School of Psychology, Victoria University of Wellington, Wellington, New Zealand
| | - Afnan Al Abadey
- School of Biological Sciences, Victoria University of Wellington, Wellington, New Zealand
| | - Susan Schenk
- School of Psychology, Victoria University of Wellington, Wellington, New Zealand; Department of Zoology, University of Otago, Box 56, Dunedin 9054, New Zealand.
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16
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de Bartolomeis A, Vellucci L, Barone A, Manchia M, De Luca V, Iasevoli F, Correll CU. Clozapine's multiple cellular mechanisms: What do we know after more than fifty years? A systematic review and critical assessment of translational mechanisms relevant for innovative strategies in treatment-resistant schizophrenia. Pharmacol Ther 2022; 236:108236. [PMID: 35764175 DOI: 10.1016/j.pharmthera.2022.108236] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 06/21/2022] [Accepted: 06/21/2022] [Indexed: 12/21/2022]
Abstract
Almost fifty years after its first introduction into clinical care, clozapine remains the only evidence-based pharmacological option for treatment-resistant schizophrenia (TRS), which affects approximately 30% of patients with schizophrenia. Despite the long-time experience with clozapine, the specific mechanism of action (MOA) responsible for its superior efficacy among antipsychotics is still elusive, both at the receptor and intracellular signaling level. This systematic review is aimed at critically assessing the role and specific relevance of clozapine's multimodal actions, dissecting those mechanisms that under a translational perspective could shed light on molecular targets worth to be considered for further innovative antipsychotic development. In vivo and in vitro preclinical findings, supported by innovative techniques and methods, together with pharmacogenomic and in vivo functional studies, point to multiple and possibly overlapping MOAs. To better explore this crucial issue, the specific affinity for 5-HT2R, D1R, α2c, and muscarinic receptors, the relatively low occupancy at dopamine D2R, the interaction with receptor dimers, as well as the potential confounder effects resulting in biased ligand action, and lastly, the role of the moiety responsible for lipophilic and alkaline features of clozapine are highlighted. Finally, the role of transcription and protein changes at the synaptic level, and the possibility that clozapine can directly impact synaptic architecture are addressed. Although clozapine's exact MOAs that contribute to its unique efficacy and some of its severe adverse effects have not been fully understood, relevant information can be gleaned from recent mechanistic understandings that may help design much needed additional therapeutic strategies for TRS.
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Affiliation(s)
- Andrea de Bartolomeis
- Section of Psychiatry, Laboratory of Translational and Molecular Psychiatry and Unit of Treatment Resistant Psychosis, Department of Neuroscience, Reproductive Science and Dentistry, University Medical School of Naples "Federico II", Naples, Italy.
| | - Licia Vellucci
- Section of Psychiatry, Laboratory of Translational and Molecular Psychiatry and Unit of Treatment Resistant Psychosis, Department of Neuroscience, Reproductive Science and Dentistry, University Medical School of Naples "Federico II", Naples, Italy
| | - Annarita Barone
- Section of Psychiatry, Laboratory of Translational and Molecular Psychiatry and Unit of Treatment Resistant Psychosis, Department of Neuroscience, Reproductive Science and Dentistry, University Medical School of Naples "Federico II", Naples, Italy
| | - Mirko Manchia
- Section of Psychiatry, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy; Department of Pharmacology, Dalhousie University, Halifax, Nova Scotia, Canada
| | | | - Felice Iasevoli
- Section of Psychiatry, Laboratory of Translational and Molecular Psychiatry and Unit of Treatment Resistant Psychosis, Department of Neuroscience, Reproductive Science and Dentistry, University Medical School of Naples "Federico II", Naples, Italy
| | - Christoph U Correll
- The Zucker Hillside Hospital, Department of Psychiatry, Northwell Health, Glen Oaks, NY, USA; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Department of Psychiatry and Molecular Medicine, Hempstead, NY, USA; Charité Universitätsmedizin Berlin, Department of Child and Adolescent Psychiatry, Berlin, Germany
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17
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Long-Term Treatment With Long-Acting Injectable Antipsychotic in Schizophrenia Patients With and Without Dopamine Supersensitivity Psychosis: A 6-Year Retrospective Comparative Study. J Clin Psychopharmacol 2022; 42:357-364. [PMID: 35727084 DOI: 10.1097/jcp.0000000000001564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Dopamine supersensitivity psychosis (DSP) is an unstable psychotic state in patients with schizophrenia due to an upregulation of dopamine D2 receptors induced by antipsychotic medication. Long-acting antipsychotic injectable (LAI) could be advantageous for controlling the dopamine supersensitivity state, but it is not known if long-term treatment with LAI might ultimately lead to development or exacerbation of DSP. METHODS The present study included 58 patients who had been treated with LAI for at least 3 years, with medical records for the 3 years before its introduction. Those records were used to classify patients as having DSP (n = 30, DSP group) or not (n = 28, non-DSP group). The effects of LAI treatments on the clinical course during the 3 years after the LAI introduction were compared between the 2 groups. RESULTS Both groups demonstrated significant decreases in antipsychotic dosage (combined LAI and oral antipsychotics) and a significant improvement measured by clinical global impression-improvement. These indicators did not differ between them, suggesting similar efficacy of LAI for both groups. On average, the DSP group was treated with a higher dose of antipsychotics (1004.8 mg) before the LAI introduction compared with the non-DSP group but reduced them to within the standard dose range (662.0 mg) after the introduction of LAI. CONCLUSIONS Our results indicated the effectiveness of LAI treatment for at least 3 years for patients with DSP, suggesting that this treatment strategy is unlikely to worsen DSP. The efficacy might be explained by the large decrease in the total antipsychotic dose with the introduction of LAI.
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18
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Wada M, Noda Y, Iwata Y, Tsugawa S, Yoshida K, Tani H, Hirano Y, Koike S, Sasabayashi D, Katayama H, Plitman E, Ohi K, Ueno F, Caravaggio F, Koizumi T, Gerretsen P, Suzuki T, Uchida H, Müller DJ, Mimura M, Remington G, Grace AA, Graff-Guerrero A, Nakajima S. Dopaminergic dysfunction and excitatory/inhibitory imbalance in treatment-resistant schizophrenia and novel neuromodulatory treatment. Mol Psychiatry 2022; 27:2950-2967. [PMID: 35444257 DOI: 10.1038/s41380-022-01572-0] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 03/31/2022] [Accepted: 04/07/2022] [Indexed: 12/13/2022]
Abstract
Antipsychotic drugs are the mainstay in the treatment of schizophrenia. However, one-third of patients do not show adequate improvement in positive symptoms with non-clozapine antipsychotics. Additionally, approximately half of them show poor response to clozapine, electroconvulsive therapy, or other augmentation strategies. However, the development of novel treatment for these conditions is difficult due to the complex and heterogenous pathophysiology of treatment-resistant schizophrenia (TRS). Therefore, this review provides key findings, potential treatments, and a roadmap for future research in this area. First, we review the neurobiological pathophysiology of TRS, particularly the dopaminergic, glutamatergic, and GABAergic pathways. Next, the limitations of existing and promising treatments are presented. Specifically, this article focuses on the therapeutic potential of neuromodulation, including electroconvulsive therapy, repetitive transcranial magnetic stimulation, transcranial direct current stimulation, and deep brain stimulation. Finally, we propose multivariate analyses that integrate various perspectives of the pathogenesis, such as dopaminergic dysfunction and excitatory/inhibitory imbalance, thereby elucidating the heterogeneity of TRS that could not be obtained by conventional statistics. These analyses can in turn lead to a precision medicine approach with closed-loop neuromodulation targeting the detected pathophysiology of TRS.
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Affiliation(s)
- Masataka Wada
- Department of Neuropsychiatry, Keio University, School of Medicine, Tokyo, Japan
| | - Yoshihiro Noda
- Department of Neuropsychiatry, Keio University, School of Medicine, Tokyo, Japan
| | - Yusuke Iwata
- Department of Neuropsychiatry, University of Yamanashi Faculty of Medicine, Yamanashi, Japan
| | - Sakiko Tsugawa
- Department of Neuropsychiatry, Keio University, School of Medicine, Tokyo, Japan
| | - Kazunari Yoshida
- Department of Neuropsychiatry, Keio University, School of Medicine, Tokyo, Japan.,Tanenbaum Centre for Pharmacogenetics, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada.,Azrieli Adult Neurodevelopmental Centre, Centre for Addiction and Mental Health, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Hideaki Tani
- Department of Neuropsychiatry, Keio University, School of Medicine, Tokyo, Japan
| | - Yoji Hirano
- Department of Neuropsychiatry, Kyushu University, Fukuoka, Japan.,Neural Dynamics Laboratory, Research Service, VA Boston Healthcare System, and Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Shinsuke Koike
- Center for Evolutionary Cognitive Sciences, Graduate School of Art and Sciences, The University of Tokyo, Tokyo, Japan
| | - Daiki Sasabayashi
- Department of Neuropsychiatry, University of Toyama Graduate School of Medicine and Pharmaceutical Sciences, Toyama, Japan.,Research Center for Idling Brain Science, University of Toyama, Toyama, Japan
| | - Haruyuki Katayama
- Department of Neuropsychiatry, Keio University, School of Medicine, Tokyo, Japan
| | - Eric Plitman
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Kazutaka Ohi
- Department of Psychiatry, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Fumihiko Ueno
- Department of Neuropsychiatry, Keio University, School of Medicine, Tokyo, Japan.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Brain Health Imaging Centre, Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada
| | - Fernando Caravaggio
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Brain Health Imaging Centre, Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada
| | - Teruki Koizumi
- Department of Neuropsychiatry, Keio University, School of Medicine, Tokyo, Japan.,Department of Psychiatry, National Hospital Organization Shimofusa Psychiatric Medical Center, Chiba, Japan
| | - Philip Gerretsen
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Brain Health Imaging Centre, Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada.,Institute of Medical Science, University of Toronto, Toronto, ON, Canada.,Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Takefumi Suzuki
- Department of Neuropsychiatry, University of Yamanashi Faculty of Medicine, Yamanashi, Japan
| | - Hiroyuki Uchida
- Department of Neuropsychiatry, Keio University, School of Medicine, Tokyo, Japan
| | - Daniel J Müller
- Tanenbaum Centre for Pharmacogenetics, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Masaru Mimura
- Department of Neuropsychiatry, Keio University, School of Medicine, Tokyo, Japan
| | - Gary Remington
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Anthony A Grace
- Departments of Neuroscience, Psychiatry and Psychology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ariel Graff-Guerrero
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Brain Health Imaging Centre, Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada.,Institute of Medical Science, University of Toronto, Toronto, ON, Canada.,Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Shinichiro Nakajima
- Department of Neuropsychiatry, Keio University, School of Medicine, Tokyo, Japan. .,Brain Health Imaging Centre, Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada.
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19
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Lugg W. Antipsychotic-induced supersensitivity - A reappraisal. Aust N Z J Psychiatry 2022; 56:437-444. [PMID: 34144649 DOI: 10.1177/00048674211025694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Tardive dyskinesia, psychotic relapse and treatment-refractory psychosis have long been associated. A common underlying mechanism involving antipsychotic-induced 'supersensitivity', albeit in different brain pathways, was proposed as early as 1978. This piece seeks to reappraise the concept and potential implications of antipsychotic-induced supersensitivity. CONCLUSIONS Evidence increasingly suggests that chronic antipsychotic exposure induces neuroadaptive physiological changes in dopaminergic, and other, neurotransmitter systems that may render some individuals more vulnerable to psychotic relapse - including those receiving continuous antipsychotic treatment. It is possible that in treating every episode of psychosis with prolonged or indefinite antipsychotic therapy, we paradoxically increase the risk of psychotic relapse in a significant proportion of people. A greater appreciation of supersensitivity may allow us to optimise any potential benefits of antipsychotics while minimising the risk of inadvertent iatrogenic harms. More research is needed to improve our understanding of the underlying neurophysiology of supersensitivity and to better identify which individuals are most vulnerable to its development. It is time we paid more attention to the concept, emerging evidence and potential implications of antipsychotic-induced supersensitivity and, where appropriate, adjusted our practice accordingly.
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Affiliation(s)
- William Lugg
- Department of Psychiatry, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
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20
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Murray RM, Bora E, Modinos G, Vernon A. Schizophrenia: A developmental disorder with a risk of non-specific but avoidable decline. Schizophr Res 2022; 243:181-186. [PMID: 35390609 DOI: 10.1016/j.schres.2022.03.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 03/08/2022] [Accepted: 03/11/2022] [Indexed: 12/31/2022]
Abstract
The onset of schizophrenia is determined by biological and social risk factors operating predominantly during development. These result in subtle deviations in brain structure and cognitive function. Striatal dopamine dysregulation follows, causing abnormal salience and resultant psychotic symptoms. Most people diagnosed as having schizophrenia do not progressively deteriorate; many improve or recover. However, poor care can allow a cycle of deterioration to be established, stress increasing dopamine dysregulation, leading to more stress consequent on continuing psychotic experiences, and so further dopamine release. Additionally, long-term antipsychotics can induce dopamine supersensitivity with resultant relapse and eventually treatment resistance. Some patients suffer loss of social and cognitive function, but this is a consequence of the hazards that afflict the person with schizophrenia, not a direct consequence of genetic predisposition. Thus, brain health and cognition can be further impaired by chronic medication effects, cardiovascular and cerebrovascular events, obesity, poor diet, and lack of exercise; drug use, especially of tobacco and cannabis, are likely to contribute. Poverty, homelessness and poor nutrition which become the lot of some people with schizophrenia, can also affect cognition. Regrettably, the model of progressive deterioration provides psychiatry and its funders with an alibi for the effects of poor care.
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Affiliation(s)
- R M Murray
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, United Kingdom.
| | - E Bora
- Dokuz Eylül Üniversitesi, Izmir, Izmir, Turkey
| | - G Modinos
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, United Kingdom
| | - A Vernon
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, United Kingdom
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21
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Hui CLM, Chen EYH, Swapna V, Tagata H, Mizuno M, Liu C, Takeuchi H, Kim SW, Chung YC. Guidelines for Discontinuation of Antipsychotics in Patients Who Recover From First-Episode Schizophrenia Spectrum Disorders: Derived From the Aggregated Opinions of Asian Network of Early Psychosis Experts and Literature Review. Int J Neuropsychopharmacol 2022; 25:737-758. [PMID: 35451023 PMCID: PMC9515132 DOI: 10.1093/ijnp/pyac002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 12/01/2021] [Accepted: 04/20/2022] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE Antipsychotic discontinuation has been a long-standing clinical and medicolegal issue. The Asian Network of Early Psychosis developed guidelines for antipsychotic discontinuation in patients who recover from first-episode non-affective psychosis. We reviewed the existing studies and guidelines on antipsychotic discontinuation to develop guidelines for antipsychotic discontinuation in such patients. METHODS We reviewed the relevant studies, reviews, guidelines, and ongoing trials related to antipsychotic discontinuation in patients with first-episode psychosis or schizophrenia. The quality of randomized controlled trials was assessed using the Grading of Recommendations Assessment, Development, and Evaluation approach. RESULTS Most studies had low to very low quality, and 2 had moderate quality. All studies, except 1, advised against antipsychotic discontinuation because of higher relapse rates in the antipsychotic discontinuation group (19%-82% at 1-year follow-up) than the treatment maintenance group compared with the maintenance group. Based on expert opinion and Grading of Recommendations Assessment, Development, and Evaluation evidence of trials, guidelines have been recommended for future discontinuation studies on patients with first-episode schizophrenia spectrum disorders. CONCLUSIONS Currently, there are no recommendations for antipsychotic discontinuation in patients with first-episode schizophrenia spectrum disorders. However, there is a pressing need to conduct more rigorous research in remitted patients using more stringent criteria of full recovery, which can form the basis of guidelines on when and how antipsychotics should be tapered and discontinued. Studies that evaluate the patient characteristics and biomarkers that predict successful antipsychotic discontinuation are also needed.
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Affiliation(s)
| | - Christy L M Hui
- Department of Psychiatry Unive, University of Hong Kong , Hong Kong, SAR , China
| | - Eric Y H Chen
- Department of Psychiatry Unive, University of Hong Kong , Hong Kong, SAR , China
- State Key Laboratory of Brain and Cognitive Sciences, University of Hong Kong , Hong Kong, SAR , China
| | - Verma Swapna
- Institute of Mental Health , Singapore
- Duke-NUS Medical School , Singapore
| | - Hiromi Tagata
- Department of Neuropsychiatry, Toho University School of Medicine , Tokyo , Japan
| | - Masafumi Mizuno
- Department of Neuropsychiatry, Toho University School of Medicine , Tokyo , Japan
- Tokyo Metropolitan Matsuzawa Hospital , Tokyo , Japan
| | - Chen‑Chung Liu
- Department of Psychiatry, National Taiwan University Hospital , Taipei , Taiwan
- Department of Psychiatry, College of Medicine, National Taiwan University , Taipei , Taiwan
| | - Hiroyoshi Takeuchi
- Department of Neuropsychiatry, Keio University School of Medicine , Tokyo , Japan
- Schizophrenia Program, Centre for Addiction and Mental Health , Toronto, ON , Canada
| | - Sung-Wan Kim
- Mindlink, Gwangju Bukgu Mental Health Center , Gwangju , Korea
- Department of Psychiatry, Chonnam National University Medical School , Gwangju , Korea
| | - Young-Chul Chung
- Department of Psychiatry, Jeonbuk National University Medical School , Jeonju , Korea
- Research Institute of Clinical Medicine of Jeonbuk National University – Biomedical Research Institute of Jeonbuk National University Hospital , Jeonju , Korea
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22
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Effect of add-on alpha lipoic acid on psychopathology in patients with treatment-resistant schizophrenia: a pilot randomized double-blind placebo-controlled trial. Psychopharmacology (Berl) 2022; 239:3525-3535. [PMID: 36069950 PMCID: PMC9449282 DOI: 10.1007/s00213-022-06225-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 08/25/2022] [Indexed: 11/16/2022]
Abstract
RATIONALE Alpha lipoic acid is known to reverse NMDA receptor hypofunction in addition to dopamine receptor blockade activity. It also enhances neurotrophic factors and has antioxidant potential. These properties combined together may be beneficial for treatment-resistant schizophrenia (TRS). OBJECTIVES This study evaluates the effect of alpha lipoic acid (ALA) on psychopathological scores (positive, negative, cognitive), neurotrophic factors and oxidative stress in TRS. METHODS A pilot randomized double-blind placebo-controlled parallel design trial was conducted in 20 patients with TRS. After initial screening, participants were randomized into test (add-on ALA) and control (add-on placebo) groups. After recruitment, clinical evaluations with scale for assessment of positive symptoms and negative symptoms (SAPS and SANS), schizophrenia cognitive rating scale (SCoRS), UKU side effect rating scale were done. Serum levels of BDNF, MDA, and GSH were estimated. Patients were followed up for 8 weeks, and clinical and biochemical evaluations were repeated. Adherence to medication was evaluated at follow-up. RESULTS A significantly greater improvement was found in SANS score in the test group when compared to control (Mann-Whitney U = 17.0; p = 0.021), whereas there was no significant improvement in SAPS score (Mann-Whitney U = 41.5; p = 0.780). A significant increase in BDNF levels was observed in the control group when compared to ALA (U = 20.0; p = 0.041). No significant differences were found between the test and control groups in serum MDA (U = 30.0; p = 0.221), serum GSH (U = 40.0; p = 0.683), and medication adherence rating scale (MARS) scores (U = 44.0; p = 0.934). CONCLUSIONS ALA supplementation improved psychopathology and decreased oxidative stress in patients with TRS. This study thus shows the potential of adjunctive ALA in TRS. TRIAL REGISTRATION The study was prospectively registered in Clinical Trial Registry of India (CTRI/2020/03/023707 dated 02.03.2020).
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23
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Kruyer A, Parrilla-Carrero J, Powell C, Brandt L, Gutwinski S, Angelis A, Chalhoub RM, Jhou TC, Kalivas PW, Amato D. Accumbens D2-MSN hyperactivity drives antipsychotic-induced behavioral supersensitivity. Mol Psychiatry 2021; 26:6159-6169. [PMID: 34349226 PMCID: PMC8760070 DOI: 10.1038/s41380-021-01235-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 07/05/2021] [Accepted: 07/07/2021] [Indexed: 02/07/2023]
Abstract
Antipsychotic-induced dopamine supersensitivity, or behavioral supersensitivity, is a problematic consequence of long-term antipsychotic treatment characterized by the emergence of motor abnormalities, refractory symptoms, and rebound psychosis. The underlying mechanisms are unclear and no approaches exist to prevent or reverse these unwanted effects of antipsychotic treatment. Here we demonstrate that behavioral supersensitivity stems from long-lasting pre, post and perisynaptic plasticity, including insertion of Ca2+-permeable AMPA receptors and loss of D2 receptor-dependent inhibitory postsynaptic currents (IPSCs) in D2 receptor-expressing medium spiny neurons (D2-MSNs) in the nucleus accumbens core (NAcore). The resulting hyperexcitability, prominent in a subpopulation of D2-MSNs (21%), caused locomotor sensitization to cocaine and was associated with behavioral endophenotypes of antipsychotic treatment resistance and substance use disorder, including disrupted extinction learning and augmented cue-induced cocaine-seeking behavior. Chemogenetic restoration of IPSCs in D2-MSNs in the NAcore was sufficient to prevent antipsychotic-induced supersensitivity, pointing to an entirely novel therapeutic direction for overcoming this condition.
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Affiliation(s)
- Anna Kruyer
- Department of Neuroscience, Medical University of South Carolina, Charleston, SC, USA
| | | | - Courtney Powell
- Department of Neuroscience, Medical University of South Carolina, Charleston, SC, USA
| | - Lasse Brandt
- Department of Psychiatry and Psychotherapy, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Stefan Gutwinski
- Department of Psychiatry and Psychotherapy, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Ariana Angelis
- Department of Neuroscience, Medical University of South Carolina, Charleston, SC, USA
| | - Reda M Chalhoub
- Department of Neuroscience, Medical University of South Carolina, Charleston, SC, USA
| | - Thomas C Jhou
- Department of Neuroscience, Medical University of South Carolina, Charleston, SC, USA
| | - Peter W Kalivas
- Department of Neuroscience, Medical University of South Carolina, Charleston, SC, USA
| | - Davide Amato
- Department of Neuroscience, Medical University of South Carolina, Charleston, SC, USA.
- Department of Psychiatry and Psychotherapy, Charité - Universitätsmedizin Berlin, Berlin, Germany.
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24
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Kimura M, Oda Y, Hirose Y, Kimura H, Yoshino K, Niitsu T, Kanahara N, Shirayama Y, Hashimoto K, Iyo M. Upregulation of heat-shock protein HSP-70 and glutamate transporter-1/glutamine synthetase in the striatum and hippocampus in haloperidol-induced dopamine-supersensitivity-state rats. Pharmacol Biochem Behav 2021; 211:173288. [PMID: 34653399 DOI: 10.1016/j.pbb.2021.173288] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 10/07/2021] [Accepted: 10/07/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND The excessive blockade of dopamine D2 receptors (DRD2s) with long-term antipsychotic treatment is known to induce a dopamine supersensitivity state (DSS). The mechanism of DSS is speculated to be a compensatory up-regulation of DRD2s, but an excess blockade of DRD2s can also cause glutamatergic neuronal damage. Herein, we investigated whether antipsychotic-induced neuronal damage plays a role in the development of DSS. METHODS Haloperidol (HAL; 0.75 mg/kg/day for 14 days) or vehicle was administered to rats via an osmotic mini-pump. Haloperidol-treated rats were divided into groups of DSS rats and non-DSS rats based on their voluntary locomotion data. We then determined the tissue levels of glutamate transporter-1 (GLT-1)/glutamine synthetase (GS) and heat shock protein-70 (HSP-70) in the rats' brain regions. RESULTS The levels of HSP-70 in the striatum and CA-3 region of the DSS rats were significantly higher than those of the control and non-DSS rats, whereas the dentate gyrus HSP-70 levels in both the DSS and non-DSS rats were increased versus the controls. The levels of GLT-1/GS in the CA-3 and nucleus accumbens were increased in the DSS rats. CONCLUSIONS These results suggest that the DSS rats experienced striatal neuronal damage and indicate that a HAL-induced upregulation of HSP-70 and the GLT-1/GS system in the CA3 may be involved in the development of DSS. It remains unknown why the non-DSS rats did not suffer neuronal damage. In view of the need for therapeutic strategies for treatment-resistant schizophrenia, dopamine supersensitivity psychosis, and tardive dyskinesia, further investigations of our findings are warranted.
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Affiliation(s)
- Makoto Kimura
- Department of Psychiatry, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuou-ku, Chiba, Chiba 260-8670, Japan
| | - Yasunori Oda
- Department of Psychiatry, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuou-ku, Chiba, Chiba 260-8670, Japan.
| | - Yuki Hirose
- Department of Psychiatry, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuou-ku, Chiba, Chiba 260-8670, Japan
| | - Hiroshi Kimura
- Department of Psychiatry, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuou-ku, Chiba, Chiba 260-8670, Japan; Department of Psychiatry, School of Medicine, International University of Health and Welfare, 4-3 Kozunomori, Narita, Chiba 286-8686, Japan
| | - Kouhei Yoshino
- Department of Psychiatry, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuou-ku, Chiba, Chiba 260-8670, Japan
| | - Tomihisa Niitsu
- Department of Psychiatry, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuou-ku, Chiba, Chiba 260-8670, Japan
| | - Nobuhisa Kanahara
- Division of Medical Treatment and Rehabilitation, Chiba University Center for Forensic Mental Health, 1-8-1 Inohana, Chuou-ku, Chiba, Chiba 260-8670, Japan
| | - Yukihiko Shirayama
- Department of Psychiatry, Teikyo University Chiba Medical Center, 3426-3 Anesaki, Ichihara, Chiba 290-0111, Japan
| | - Kenji Hashimoto
- Division of Clinical Neuroscience, Chiba University Center for Forensic Mental Health, 1-8-1 Inohana, Chuou-ku, Chiba, Chiba 260-8670, Japan
| | - Masaomi Iyo
- Department of Psychiatry, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuou-ku, Chiba, Chiba 260-8670, Japan
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25
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Servonnet A, Allain F, Gravel-Chouinard A, Hernandez G, Bourdeau Caporuscio C, Legrix M, Lévesque D, Rompré PP, Samaha AN. Dopaminergic mechanisms underlying the expression of antipsychotic-induced dopamine supersensitivity in rats. Neuropharmacology 2021; 197:108747. [PMID: 34364897 DOI: 10.1016/j.neuropharm.2021.108747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 07/23/2021] [Accepted: 08/03/2021] [Indexed: 10/20/2022]
Abstract
Antipsychotic treatment can produce a dopamine-supersensitive state, potentiating the response to dopamine receptor stimulation. In both schizophrenia patients and rats, this is linked to tolerance to ongoing antipsychotic treatment. In rodents, dopamine supersensitivity is often confirmed by an exaggerated psychomotor response to d-amphetamine after discontinuation of antipsychotic exposure. Here we examined in rats the dopaminergic mechanisms mediating this enhanced behavioural response, as this could uncover pathophysiological processes underlying the expression of antipsychotic-evoked dopamine supersensitivity. Rats received 0.5 mg/kg/day haloperidol via osmotic minipump for 2 weeks, before treatment was discontinued. After cessation of antipsychotic treatment, rats showed a supersensitive psychomotor response to the D2 agonist quinpirole, but not to the D1 partial agonist SKF38393 or the dopamine reuptake blocker GBR12783. Furthermore, acute D1 receptor blockade (using SCH39166) decreased the exaggerated psychomotor response to d-amphetamine in haloperidol-pretreated rats, whereas acute D2 receptor blockade (using sulpiride) enhanced it. Thus, after discontinuation of antipsychotic treatment, D1- and D2-mediated transmission differentially modulate the expression of a supersensitive response to d-amphetamine. This supersensitive behavioural response was accompanied by enhanced GSK3β activity and suppressed ERK1/2 activity in the nucleus accumbens (but not caudate-putamen), suggesting increased mesolimbic D2 transmission. Finally, after discontinuing haloperidol treatment, neither increasing ventral midbrain dopamine impulse flow nor infusing d-amphetamine into the cerebral ventricles triggered the expression of already established dopamine supersensitivity, suggesting that peripheral effects are required. Thus, while dopamine receptor-mediated signalling regulates the expression of antipsychotic-evoked dopamine supersensitivity, a simple increase in central dopamine neurotransmission is insufficient to trigger this supersensitivity.
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Affiliation(s)
- Alice Servonnet
- Department of Neurosciences, Faculty of Medicine, Université de Montréal, 2900 Edouard-Montpetit boulevard, Montreal, H3T 1J4, Quebec, Canada.
| | - Florence Allain
- Department of Pharmacology and Physiology, Faculty of Medicine, Université de Montréal, 2900 Edouard-Montpetit boulevard, Montreal, H3T 1J4, Quebec, Canada
| | - Alice Gravel-Chouinard
- Department of Neurosciences, Faculty of Medicine, Université de Montréal, 2900 Edouard-Montpetit boulevard, Montreal, H3T 1J4, Quebec, Canada
| | - Giovanni Hernandez
- Department of Neurosciences, Faculty of Medicine, Université de Montréal, 2900 Edouard-Montpetit boulevard, Montreal, H3T 1J4, Quebec, Canada; Faculty of Pharmacy, Université de Montréal, 2900 Edouard-Montpetit boulevard, Montreal, H3T 1J4, Quebec, Canada
| | - Casey Bourdeau Caporuscio
- Department of Pharmacology and Physiology, Faculty of Medicine, Université de Montréal, 2900 Edouard-Montpetit boulevard, Montreal, H3T 1J4, Quebec, Canada
| | - Mathilde Legrix
- Department of Neurosciences, Faculty of Medicine, Université de Montréal, 2900 Edouard-Montpetit boulevard, Montreal, H3T 1J4, Quebec, Canada
| | - Daniel Lévesque
- Faculty of Pharmacy, Université de Montréal, 2900 Edouard-Montpetit boulevard, Montreal, H3T 1J4, Quebec, Canada
| | - Pierre-Paul Rompré
- Department of Neurosciences, Faculty of Medicine, Université de Montréal, 2900 Edouard-Montpetit boulevard, Montreal, H3T 1J4, Quebec, Canada
| | - Anne-Noël Samaha
- Department of Pharmacology and Physiology, Faculty of Medicine, Université de Montréal, 2900 Edouard-Montpetit boulevard, Montreal, H3T 1J4, Quebec, Canada; Groupe de recherche sur le système nerveux central, Faculty of Medicine, Université de Montréal, 2900 Edouard-Montpetit boulevard, Montrea, H3T 1J4, Quebec, Canada.
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26
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Horowitz MA, Jauhar S, Natesan S, Murray RM, Taylor D. A Method for Tapering Antipsychotic Treatment That May Minimize the Risk of Relapse. Schizophr Bull 2021; 47:1116-1129. [PMID: 33754644 PMCID: PMC8266572 DOI: 10.1093/schbul/sbab017] [Citation(s) in RCA: 63] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The process of stopping antipsychotics may be causally related to relapse, potentially linked to neuroadaptations that persist after cessation, including dopaminergic hypersensitivity. Therefore, the risk of relapse on cessation of antipsychotics may be minimized by more gradual tapering. There is converging evidence that suggests that adaptations to antipsychotic exposure can persist for months or years after stopping the medication-from animal studies, observation of tardive dyskinesia in patients, and the clustering of relapses in this time period after the cessation of antipsychotics. Furthermore, PET imaging demonstrates a hyperbolic relationship between doses of antipsychotic and D2 receptor blockade. We, therefore, suggest that when antipsychotics are reduced, it should be done gradually (over months or years) and in a hyperbolic manner (to reduce D2 blockade "evenly"): ie, reducing by one quarter (or one half) of the most recent dose of antipsychotic, equivalent approximately to a reduction of 5 (or 10) percentage points of its D2 blockade, sequentially (so that reductions become smaller and smaller in size as total dose decreases), at intervals of 3-6 months, titrated to individual tolerance. Some patients may prefer to taper at 10% or less of their most recent dose each month. This process might allow underlying adaptations time to resolve, possibly reducing the risk of relapse on discontinuation. Final doses before complete cessation may need to be as small as 1/40th a therapeutic dose to prevent a large decrease in D2 blockade when stopped. This proposal should be tested in randomized controlled trials.
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Affiliation(s)
- Mark Abie Horowitz
- Division of Psychiatry, University College London, Maple House, 149 Tottenham Court Road, Fitzrovia, London W1T 7BN, UK
- North East London Foundation Trust. Goodmayes Hospital, 157 Barley Lane, Goodmayes, Ilford IG3 8XJ, UK
| | - Sameer Jauhar
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, 16 De Crespigny Park, Camberwell, London SE5 8AF, UK
| | - Sridhar Natesan
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, 16 De Crespigny Park, Camberwell, London SE5 8AF, UK
| | - Robin M Murray
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, 16 De Crespigny Park, Camberwell, London SE5 8AF, UK
| | - David Taylor
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, 16 De Crespigny Park, Camberwell, London SE5 8AF, UK
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London SE5 8AZ, UK
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27
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Kim S, Shin SH, Santangelo B, Veronese M, Kang SK, Lee JS, Cheon GJ, Lee W, Kwon JS, Howes OD, Kim E. Dopamine dysregulation in psychotic relapse after antipsychotic discontinuation: an [ 18F]DOPA and [ 11C]raclopride PET study in first-episode psychosis. Mol Psychiatry 2021; 26:3476-3488. [PMID: 32929214 DOI: 10.1038/s41380-020-00879-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 08/24/2020] [Accepted: 09/03/2020] [Indexed: 01/09/2023]
Abstract
Although antipsychotic drugs are effective for relieving the psychotic symptoms of first-episode psychosis (FEP), psychotic relapse is common during the course of the illness. While some FEPs remain remitted even without medication, antipsychotic discontinuation is regarded as the most common risk factor for the relapse. Considering the actions of antipsychotic drugs on presynaptic and postsynaptic dopamine dysregulation, this study evaluated possible mechanisms underlying relapse after antipsychotic discontinuation. Twenty five FEPs who were clinically stable and 14 matched healthy controls were enrolled. Striatal dopamine activity was assessed as Kicer value using [18F]DOPA PET before and 6 weeks after antipsychotic discontinuation. The D2/3 receptor availability was measured as BPND using [11C]raclopride PET after antipsychotic discontinuation. Healthy controls also underwent PET scans according to the corresponding schedule of the patients. Patients were monitored for psychotic relapse during 12 weeks after antipsychotic discontinuation. 40% of the patients showed psychotic relapse after antipsychotic discontinuation. The change in Kicer value over time significantly differed between relapsed, non-relapsed patients and healthy controls (Week*Group: F = 4.827, df = 2,253.193, p = 0.009). In relapsed patients, a significant correlation was found between baseline striatal Kicer values and time to relapse after antipsychotic discontinuation (R2 = 0.518, p = 0.018). BPND were not significantly different between relapsed, non-relapsed patients and healthy controls (F = 1.402, df = 2,32.000, p = 0.261). These results suggest that dysfunctional dopamine autoregulation might precipitate psychotic relapse after antipsychotic discontinuation in FEP. This finding could be used for developing a strategy for the prevention of psychotic relapse related to antipsychotic discontinuation.
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Affiliation(s)
- Seoyoung Kim
- Department of Psychiatry, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
| | - Sang Ho Shin
- Department of Psychiatry, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
| | - Barbara Santangelo
- Centre for Neuroimaging Science, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Mattia Veronese
- Centre for Neuroimaging Science, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Seung Kwan Kang
- Department of Nuclear Medicine, College of Medicine, Seoul National University, Seoul, Republic of Korea.,Department of Biomedical Sciences, College of Medicine, Seoul National University, Seoul, Republic of Korea
| | - Jae Sung Lee
- Department of Nuclear Medicine, College of Medicine, Seoul National University, Seoul, Republic of Korea.,Department of Biomedical Sciences, College of Medicine, Seoul National University, Seoul, Republic of Korea
| | - Gi Jeong Cheon
- Department of Nuclear Medicine, College of Medicine, Seoul National University, Seoul, Republic of Korea.,Institute of Radiation Medicine, College of Medicine, Seoul National University, Seoul, Republic of Korea
| | - Woojoo Lee
- Department of Public Health Science, Graduate School of Public Health, Seoul National University, Seoul, Republic of Korea
| | - Jun Soo Kwon
- Department of Psychiatry, College of Medicine, Seoul National University, Seoul, Republic of Korea.,Department of Brain & Cognitive Sciences, College of Natural Sciences, Seoul National University, Seoul, Republic of Korea
| | - Oliver D Howes
- Department of Psychosis studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.,Psychiatric Imaging, Medical Research Council Clinical Sciences Centre, Imperial College London, Hammersmith Hospital Campus, London, UK
| | - Euitae Kim
- Department of Psychiatry, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea. .,Department of Psychiatry, College of Medicine, Seoul National University, Seoul, Republic of Korea. .,Department of Brain & Cognitive Sciences, College of Natural Sciences, Seoul National University, Seoul, Republic of Korea.
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28
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Takao N, Murai T, Fujiwara H. Treatment-resistant schizophrenia characterised by dopamine supersensitivity psychosis and efficacy of asenapine. BMJ Case Rep 2021; 14:e242495. [PMID: 33849886 PMCID: PMC8051386 DOI: 10.1136/bcr-2021-242495] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2021] [Indexed: 11/21/2022] Open
Abstract
Dopamine supersensitivity psychosis (DSP) frequently arises with long-term antipsychotic treatment and accounts for a significant proportion of treatment-resistant schizophrenia. The mechanism underlying DSP is thought to be a compensatory increase in dopamine receptor density in the striatum caused by long-term antipsychotic treatment. Previous animal studies have reported that antipsychotics increase serotonin 5-HT2A receptor density in the striatum and that 5-HT2A receptor blockers suppress dopamine-sensitive psychomotor activity, which may be linked to the pathophysiology of DSP. In this paper, we describe a patient who was hospitalised with treatment-resistant schizophrenia. Following treatment with high-dose antipsychotic polypharmacy for 10 weeks, the patient experienced worsening of psychotic and extrapyramidal symptoms. The patient was then started on second-generation antipsychotic asenapine while other antipsychotics were tapered off, resulting in improvement of these symptoms. Retrospectively, we presumed that the high-dose antipsychotic polypharmacy caused DSP, which was effectively treated by the potent 5-HT2A receptor antagonism of asenapine.
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Affiliation(s)
- Nagara Takao
- Psychiatry, Kyoto University Hospital, Kyoto, Japan
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29
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Wong MMC, Chung AKK, Yeung TMH, Wong DTW, Lee CK, Lai E, Chan GFY, Mak GKL, Wong JOY, Ng RMK, Tam KL, Mak KY. Consensus statements on the clinical usage and characteristics of aripiprazole for Hong Kong. Intern Med J 2021; 50 Suppl 3:6-14. [PMID: 32985093 DOI: 10.1111/imj.14896] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Aripiprazole, a dopamine partial agonist, is a second-generation anti-psychotic that is widely used for the treatment of schizophrenia and other psychotic disorders. A group of psychiatric experts in Hong Kong developed a set of consensus statements, aiming to facilitate the understanding of clinical properties and usages of aripiprazole among local physicians. Of note, because aripiprazole long-acting injectable has been available locally not long before the establishment of the consensus panel, which limited the discussion on its use in the local context, the consensus statements were focused primarily on oral aripiprazole. To draft the consensus statements, the panellists discussed the published evidence and their clinical experience regarding aripiprazole in a series of meetings based on several areas. At the final meeting, each drafted statement was voted on anonymously by all panellists based on its practicability of recommendation in Hong Kong. A set of consensus statements on the characteristics and clinical use of aripiprazole was established and accepted by the panel. These statements serve to provide a practical reference for physicians in Hong Kong, and possibly other parts of the Asia-Pacific region, on the use of aripiprazole in people with schizophrenia spectrum disorders and other psychotic problems.
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Affiliation(s)
| | | | | | | | - C K Lee
- Asian Association of Neuropsychopharmacology
| | - Eric Lai
- Asian Association of Neuropsychopharmacology
| | | | | | | | | | - K L Tam
- Asian Association of Neuropsychopharmacology
| | - K Y Mak
- Asian Association of Neuropsychopharmacology
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30
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Effects of repeated electroconvulsive shocks on dopamine supersensitivity psychosis model rats. Schizophr Res 2021; 228:1-6. [PMID: 33429150 DOI: 10.1016/j.schres.2020.11.062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 08/26/2020] [Accepted: 11/27/2020] [Indexed: 01/08/2023]
Abstract
While the long-term administration of antipsychotics is known to cause dopamine supersensitivity psychosis (DSP), recent studies revealed that DSP helps form the foundation of treatment resistance. Electroconvulsive shock (ES) is one of the more effective treatments for treatment-resistant schizophrenia. The objective of this study was to examine whether repeated ES can release rats from dopamine supersensitivity states such as striatal dopamine D2 receptor (DRD2) up-regulation and voluntary hyperlocomotion following chronic administration of haloperidol (HAL). HAL (0.75 mg/kg/day) was administered for 14 days via mini-pumps implanted in rats, and DRD2 density and voluntary locomotion were measured one day after drug cessation to confirm the development of dopamine supersensitivity. The rats with or without dopamine supersensitivity received repeated ES or sham treatments, and then DRD2 density was assessed and a voluntary locomotion test was performed. Chronic treatment with HAL led to the up-regulation of striatal DRD2 and hyperlocomotion in the rats one day after drug cessation. We thus confirmed that these rats experienced a dopamine supersensitivity state. Moreover, after repeated ES, locomotor activity and DRD2 density in the DSP model rats fell to the control level, while an ES sham operation had no effect on the dopamine supersensitivity state. The present study suggests that repeated ES could release DSP model rats from dopamine supersensitivity states. ES may be helpful for patients with DSP.
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31
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Chestnykh DA, Amato D, Kornhuber J, Müller CP. Pharmacotherapy of schizophrenia: Mechanisms of antipsychotic accumulation, therapeutic action and failure. Behav Brain Res 2021; 403:113144. [PMID: 33515642 DOI: 10.1016/j.bbr.2021.113144] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 01/21/2021] [Accepted: 01/22/2021] [Indexed: 12/13/2022]
Abstract
Schizophrenia is a multi-dimensional disorder with a complex and mostly unknown etiology, leading to a severe decline in life quality. Antipsychotic drugs (APDs) remain beneficial interventions in the treatment of the disorder, but vary significantly in binding profile, clinical effects and adverse reactions. The present review summarizes the main principles of APD mechanisms of action with a particular focus on recent findings in APD accumulation and its role in the therapeutic efficacy and treatment failure. High and low doses of APDs were shown to be effective in different dimensions of antipsychotic-like behaviour in rodent models. Efficacy of the APDs correlates with high dopamine D2 receptor occupancy, which occurs quickly after drug administration. However, onset and peak of action are delayed up to several days or weeks. APD accumulation via acidic trapping in synaptic vesicles is considered to underlie the time course of APD action. Use-dependent exocytosis, co-release with dopamine and serotonin and inhibition of ion channels impact on the neuronal transmission and determine effects of APDs. Disruption in accumulating properties leads to diminished APD effects. In addition, long-term APD administration at therapeutic doses leads to treatment failure both in animal models and in humans. APD failure was associated with treatment induced neuroadaptations, including a decline in extracellular dopamine levels, dopamine transporter upregulation, and altered neuronal firing. However, enhanced synaptic vesicle release has also been reported. APD loss of efficacy may be reversed through inhibition of the dopamine transporter or switching the administration regimen from continuous to intermittent. Thus, manipulating the accumulation properties of APDs, changes in the administration regimen and doses, or co-administration with dopamine transporter inhibitors may be considered to yield benefits in the development of new effective strategies in the treatment of schizophrenia.
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Affiliation(s)
- Daria A Chestnykh
- Department of Psychiatry and Psychotherapy, University Clinic, Friedrich-Alexander-University Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Davide Amato
- Department of Psychiatry and Psychotherapy, University Clinic, Friedrich-Alexander-University Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany; Department of Neuroscience, Medical University of South Carolina, Charleston, SC, USA
| | - Johannes Kornhuber
- Department of Psychiatry and Psychotherapy, University Clinic, Friedrich-Alexander-University Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Christian P Müller
- Department of Psychiatry and Psychotherapy, University Clinic, Friedrich-Alexander-University Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany.
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32
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Reduction of dopamine and glycogen synthase kinase-3 signaling in rat striatum after continuous administration of haloperidol. Pharmacol Biochem Behav 2021; 202:173114. [PMID: 33485878 DOI: 10.1016/j.pbb.2021.173114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 01/13/2021] [Accepted: 01/14/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Some individuals with schizophrenia present with a dopamine supersensitivity state (DSS) induced by a long-term administration of excessive antipsychotics; this is recognized as dopamine supersensitivity psychosis (DSP). The mechanisms underlying DSP are not established. Here, we investigated dopamine signaling in DSS rats. METHODS Haloperidol (HAL; 0.75 mg/kg/day for 14 days) or vehicle was administered to rats via an osmotic mini-pump. We then screened DSS rats from HAL-treated rats by a voluntary locomotion test. The striatal levels of dopamine (DA) and its metabolites 3,4-hydroxyphenylacetic acid (DOPAC) and homovanillic acid (HVA) were determined, as were the levels of protein kinase v-akt murine thymoma viral oncogene homolog (AKT), glycogen synthase kinase-3 (GSK-3), and phosphorylated GSK-3 in the striatal regions. RESULTS In the DSS rats, the DA, DOPAC, and HVA levels were significantly decreased. In a western blot analysis, the DSS rats exhibited a significant decrease in GSK-3α/β and an increase in the pGSK-3β/GSK-3β ratio, whereas AKT was not changed. CONCLUSIONS Our results indicated that the DSS rats had hypofunction of the basal dopamine release and AKT/GSK-3 signaling even at 7 days after the antipsychotic was discontinued. Protracted reductions in pre- and post-dopamine D2 receptor signaling might cause prolonged DSS.
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33
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Rubio JM, Malhotra AK, Kane JM. Towards a framework to develop neuroimaging biomarkers of relapse in schizophrenia. Behav Brain Res 2021; 402:113099. [PMID: 33417996 DOI: 10.1016/j.bbr.2020.113099] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 12/16/2020] [Accepted: 12/27/2020] [Indexed: 12/31/2022]
Abstract
Schizophrenia is a chronic disorder that often requires long-term relapse-prevention treatment. This treatment is effective for most individuals, yet approximately 20-30 % of them may still relapse despite confirmed adherence. Alternatively, for about 15 % it may be safe to discontinue medications over the long term, but since there are no means to identify who those individuals will be, the recommendation is that all individuals receive long-term relapse-prevention treatment with antipsychotic maintenance. Thus, the current approach to prevent relapse in schizophrenia may be suboptimal for over one third of individuals, either by being insufficient to protect against relapse, or by unnecessarily exposing them to medication side effects. There is great need to identify biomarkers of relapse in schizophrenia to stratify treatment according to the risk and develop therapeutics targeting its pathophysiology. In order to develop a line of research that meets those needs, it is necessary to create a framework by identifying the challenges to this type of study as well as potential areas for biomarker identification and development. In this manuscript we review the literature to create such a framework.
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Affiliation(s)
- Jose M Rubio
- The Zucker Hillside Hospital, Department of Psychiatry, Northwell Health, Glen Oaks, NY, USA; Zucker School of Medicine at Hofstra/Northwell, Department of Psychiatry and Molecular Medicine, Hempstead, NY, USA; The Feinstein Institute for Medical Research, Center for Psychiatric Neuroscience, Manhasset, NY, USA.
| | - Anil K Malhotra
- The Zucker Hillside Hospital, Department of Psychiatry, Northwell Health, Glen Oaks, NY, USA; Zucker School of Medicine at Hofstra/Northwell, Department of Psychiatry and Molecular Medicine, Hempstead, NY, USA; The Feinstein Institute for Medical Research, Center for Psychiatric Neuroscience, Manhasset, NY, USA
| | - John M Kane
- The Zucker Hillside Hospital, Department of Psychiatry, Northwell Health, Glen Oaks, NY, USA; Zucker School of Medicine at Hofstra/Northwell, Department of Psychiatry and Molecular Medicine, Hempstead, NY, USA; The Feinstein Institute for Medical Research, Center for Psychiatric Neuroscience, Manhasset, NY, USA
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34
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Uzuneser TC, Weiss EM, Dahlmanns J, Kalinichenko LS, Amato D, Kornhuber J, Alzheimer C, Hellmann J, Kaindl J, Hübner H, Löber S, Gmeiner P, Grömer TW, Müller CP. Presynaptic vesicular accumulation is required for antipsychotic efficacy in psychotic-like rats. J Psychopharmacol 2021; 35:65-77. [PMID: 33274688 PMCID: PMC7770212 DOI: 10.1177/0269881120965908] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND The therapeutic effects of antipsychotic drugs (APDs) are mainly attributed to their postsynaptic inhibitory functions on the dopamine D2 receptor, which, however, cannot explain the delayed onset of full therapeutic efficacy. It was previously shown that APDs accumulate in presynaptic vesicles during chronic treatment and are released like neurotransmitters in an activity-dependent manner triggering an auto-inhibitory feedback mechanism. Although closely mirroring therapeutic action onset, the functional consequence of the APD accumulation process remained unclear. AIMS Here we tested whether the accumulation of the APD haloperidol (HAL) is required for full therapeutic action in psychotic-like rats. METHODS We designed a HAL analog compound (HAL-F), which lacks the accumulation property of HAL, but retains its postsynaptic inhibitory action on dopamine D2 receptors. RESULTS/OUTCOMES By perfusing LysoTracker fluorophore-stained cultured hippocampal neurons, we confirmed the accumulation of HAL and the non-accumulation of HAL-F. In an amphetamine hypersensitization psychosis-like model in rats, we found that subchronic intracerebroventricularly delivered HAL (0.1 mg/kg/day), but not HAL-F (0.3-1.5 mg/kg/day), attenuates psychotic-like behavior in rats. CONCLUSIONS/INTERPRETATION These findings suggest the presynaptic accumulation of HAL may serve as an essential prerequisite for its full antipsychotic action and may explain the time course of APD action. Targeting accumulation properties of APDs may, thus, become a new strategy to improve APD action.
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Affiliation(s)
- Taygun C Uzuneser
- Department of Psychiatry and Psychotherapy, University Clinic, Friedrich-Alexander University of Erlangen-Nuremberg, Erlangen, Germany,Department of Anatomy and Cell Biology, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada
| | - Eva-Maria Weiss
- Department of Psychiatry and Psychotherapy, University Clinic, Friedrich-Alexander University of Erlangen-Nuremberg, Erlangen, Germany
| | - Jana Dahlmanns
- Department of Psychiatry and Psychotherapy, University Clinic, Friedrich-Alexander University of Erlangen-Nuremberg, Erlangen, Germany
| | - Liubov S Kalinichenko
- Department of Psychiatry and Psychotherapy, University Clinic, Friedrich-Alexander University of Erlangen-Nuremberg, Erlangen, Germany
| | - Davide Amato
- Department of Psychiatry and Psychotherapy, University Clinic, Friedrich-Alexander University of Erlangen-Nuremberg, Erlangen, Germany,Department of Neuroscience, Medical University of South Carolina, Charleston, USA
| | - Johannes Kornhuber
- Department of Psychiatry and Psychotherapy, University Clinic, Friedrich-Alexander University of Erlangen-Nuremberg, Erlangen, Germany
| | - Christian Alzheimer
- Institute of Physiology and Pathophysiology, Friedrich-Alexander University of Erlangen-Nuremberg, Erlangen, Germany
| | - Jan Hellmann
- Department of Chemistry and Pharmacy, Medicinal Chemistry, Friedrich-Alexander University of Erlangen-Nuremberg, Erlangen, Germany
| | - Jonas Kaindl
- Department of Chemistry and Pharmacy, Medicinal Chemistry, Friedrich-Alexander University of Erlangen-Nuremberg, Erlangen, Germany
| | - Harald Hübner
- Department of Chemistry and Pharmacy, Medicinal Chemistry, Friedrich-Alexander University of Erlangen-Nuremberg, Erlangen, Germany
| | - Stefan Löber
- Department of Chemistry and Pharmacy, Medicinal Chemistry, Friedrich-Alexander University of Erlangen-Nuremberg, Erlangen, Germany
| | - Peter Gmeiner
- Department of Chemistry and Pharmacy, Medicinal Chemistry, Friedrich-Alexander University of Erlangen-Nuremberg, Erlangen, Germany
| | - Teja W Grömer
- Department of Psychiatry and Psychotherapy, University Clinic, Friedrich-Alexander University of Erlangen-Nuremberg, Erlangen, Germany
| | - Christian P Müller
- Department of Psychiatry and Psychotherapy, University Clinic, Friedrich-Alexander University of Erlangen-Nuremberg, Erlangen, Germany,Christian P Müller, Department of Psychiatry and Psychotherapy, University Clinic, Friedrich-Alexander University of Erlangen-Nuremberg, Schwabachanlage 6, Erlangen 91054, Germany.
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Servonnet A, Uchida H, Samaha AN. Continuous versus extended antipsychotic dosing in schizophrenia: Less is more. Behav Brain Res 2020; 401:113076. [PMID: 33345826 DOI: 10.1016/j.bbr.2020.113076] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 12/09/2020] [Accepted: 12/11/2020] [Indexed: 11/28/2022]
Abstract
Antipsychotic drugs temper psychotic symptoms by interacting with dopamine D2 receptors to reduce dopamine neurotransmission. Currently, the standard of care involves antipsychotic treatment protocols that achieve steady-state levels of medication. Maintaining patients on continuous treatment is thought to be necessary to keep them stabilised. However, continuous antipsychotic exposure increases the risk of adverse effects over time. These effects include metabolic and cardiovascular disorders, extrapyramidal complications, and dopamine receptor supersensitivity, the latter of which could potentially promote both treatment tolerance and psychosis relapse. In the present review, we describe evidence showing that continuous exposure to antipsychotic drugs can not only worsen long-term outcome, but-past acute phase treatment-it is also unnecessary to effectively manage schizophrenia symptoms. We also describe evidence that regular but extended dosing, allowing predictable periods of lower antipsychotic levels/D2 occupancy, is both safe and effective in patients, and it greatly reduces drug exposure overall. Studies in laboratory animals show that compared to continuous antipsychotic exposure, regular but extended dosing actually has superior antipsychotic-like efficacy, and it also substantially reduces the likelihood of both motor side effects and dopamine receptor supersensitivity. We propose that regular, but extended dosing should be considered in the long-term treatment of people with schizophrenia, because the available evidence suggests it can be just as effective as continuous treatment, while decreasing overall drug exposure and potentially reducing harmful side effects.
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Affiliation(s)
- Alice Servonnet
- Department of Neurosciences, Faculty of Medicine, Université de Montréal, Montreal, Canada
| | - Hiroyuki Uchida
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Anne-Noël Samaha
- Department of Pharmacology and Physiology, Faculty of Medicine, Université de Montréal, Montreal, Canada; Groupe de recherche sur le système nerveux central, Faculty of Medicine, Université de Montréal, Montreal, Canada.
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Dinesh AA, Islam J, Khan J, Turkheimer F, Vernon AC. Effects of Antipsychotic Drugs: Cross Talk Between the Nervous and Innate Immune System. CNS Drugs 2020; 34:1229-1251. [PMID: 32975758 DOI: 10.1007/s40263-020-00765-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2020] [Indexed: 12/11/2022]
Abstract
Converging lines of evidence suggest that activation of microglia (innate immune cells in the central nervous system [CNS]) is present in a subset of patients with schizophrenia. The extent to which antipsychotic drug treatment contributes to or combats this effect remains unclear. To address this question, we reviewed the literature for evidence that antipsychotic exposure influences brain microglia as indexed by in vivo neuroimaging and post-mortem studies in patients with schizophrenia and experimental animal models. We found no clear evidence from clinical studies for an effect of antipsychotics on either translocator protein (TSPO) radioligand binding (an in vivo neuroimaging measure of putative gliosis) or markers of brain microglia in post-mortem studies. In experimental animals, where drug and illness effects may be differentiated, we also found no clear evidence for consistent effects of antipsychotic drugs on TSPO radioligand binding. By contrast, we found evidence that chronic antipsychotic exposure may influence central microglia density and morphology. However, these effects were dependent on the dose and duration of drug exposure and whether an immune stimulus was present or not. In the latter case, antipsychotics were generally reported to suppress expression of inflammatory cytokines and inducible inflammatory enzymes such as cyclooxygenase and microglia activation. No clear conclusions could be drawn with regard to any effect of antipsychotics on brain microglia from current clinical data. There is evidence to suggest that antipsychotic drugs influence brain microglia in experimental animals, including possible anti-inflammatory actions. However, we lack detailed information on how these drugs influence brain microglia function at the molecular level. The clinical relevance of the animal data with regard to beneficial treatment effects and detrimental side effects of antipsychotic drugs also remains unknown, and further studies are warranted.
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Affiliation(s)
- Ayushi Anna Dinesh
- School of Medicine, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Juned Islam
- School of Medicine, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Javad Khan
- School of Medicine, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Federico Turkheimer
- Department of Neuroimaging, Institute of Psychiatry, Psychology and Neuroscience, King's College London, Centre for Neuroimaging Sciences, De Crespigny Park, London, SE5 8AF, United Kingdom
- MRC Centre for Neurodevelopmental Disorders, King's College London, London, SE1 1UL, United Kingdom
| | - Anthony C Vernon
- MRC Centre for Neurodevelopmental Disorders, King's College London, London, SE1 1UL, United Kingdom.
- Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King's College London, Maurice Wohl Clinical Neuroscience Institute, 5 Cutcombe Road, London, SE5 9RT, United Kingdom.
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Emsley R, Asmal L, Rubio JM, Correll CU, Kane JM. Predictors of psychosis breakthrough during 24 months of long-acting antipsychotic maintenance treatment in first episode schizophrenia. Schizophr Res 2020; 225:55-62. [PMID: 31767510 DOI: 10.1016/j.schres.2019.11.025] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 11/11/2019] [Accepted: 11/13/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Some patients develop breakthrough psychotic symptoms on antipsychotic maintenance medication (BAMM), despite receiving therapeutic antipsychotic doses to which they previously responded. METHODS We examined the occurrence of BAMM in previously minimally treated first-episode patients with schizophrenia-spectrum disorders who were treated according to a standard protocol with a long-acting injectable antipsychotic and regularly assessed over 24 months. RESULTS Of 99 patients (age = 24.1 ± 6.5 years, male = 73.7%) who received treatment for ≥6 months (mean follow-up = 20.0 ± 6.5 months) and had responded well to treatment, 21 (21.2%) developed BAMM using operationally defined criteria, after a mean of 17.4 ± 6.1 months. Baseline risk factors for BAMM included lower baseline Positive and Negative Syndrome Scale positive symptoms, poorer quality of life in social relationships and higher blood - high-density lipoprotein-cholesterol. Regarding intra-treatment-factors, BAMM was independently predicted by an increase in low-density lipoprotein-cholesterol and current cannabis use. We did not find a relationship between BAMM and cumulative antipsychotic exposure or dose escalation. While symptoms of the BAMM episode were less severe than during the first episode, the post-BAMM treatment response was poorer than that for the first psychotic episode, suggesting a relationship between BAMM and emergent treatment refractoriness. CONCLUSIONS About one in five patients with first-episode schizophrenia developed BAMM during the first two years of treatment, despite assured antipsychotic LAI treatment, indicating that this phenomenon is not restricted to the chronic stages of illness. The role of cannabis use and a possible link between BAMM and blood lipids should be further explored.
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Affiliation(s)
- Robin Emsley
- Department of Psychiatry, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, 8000 Cape Town, South Africa.
| | - Laila Asmal
- Department of Psychiatry, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, 8000 Cape Town, South Africa
| | - Jose M Rubio
- The Zucker Hillside Hospital, Department of Psychiatry, Northwell Health, Glen Oaks, NY, USA; Zucker School of Medicine at Hofstra/Northwell, Department of Psychiatry and Molecular Medicine, Hempstead, NY, USA; The Feinstein Institute for Medical Research, Center for Psychiatric Neuroscience, Manhasset, NY, USA
| | - Christoph U Correll
- The Zucker Hillside Hospital, Department of Psychiatry, Northwell Health, Glen Oaks, NY, USA; Zucker School of Medicine at Hofstra/Northwell, Department of Psychiatry and Molecular Medicine, Hempstead, NY, USA; The Feinstein Institute for Medical Research, Center for Psychiatric Neuroscience, Manhasset, NY, USA; Charité Universitätsmedizin Berlin, Department of Child and Adolescent Psychiatry, Berlin, Germany
| | - John M Kane
- The Zucker Hillside Hospital, Department of Psychiatry, Northwell Health, Glen Oaks, NY, USA; Zucker School of Medicine at Hofstra/Northwell, Department of Psychiatry and Molecular Medicine, Hempstead, NY, USA; The Feinstein Institute for Medical Research, Center for Psychiatric Neuroscience, Manhasset, NY, USA
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Rubio JM, Schoretsanitis G, John M, Tiihonen J, Taipale H, Guinart D, Malhotra AK, Correll CU, Kane JM. Psychosis relapse during treatment with long-acting injectable antipsychotics in individuals with schizophrenia-spectrum disorders: an individual participant data meta-analysis. Lancet Psychiatry 2020; 7:749-761. [PMID: 32828165 DOI: 10.1016/s2215-0366(20)30264-9] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 04/16/2020] [Accepted: 05/12/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Most individuals with schizophrenia-spectrum disorders have relapses, which increase the risk of morbidity and mortality. Because non-adherence to antipsychotic maintenance treatment could affect more than half of individuals with schizophrenia-spectrum disorders, psychosis relapse can often be confounded by unnoticed treatment interruption. Research of relapse during confirmed antipsychotic exposure has basic clinical and neurobiological implications, but data are scarce. We aimed to generate reliable estimates of incidence and predictors of relapse during assured antipsychotic treatment. METHODS We did a systematic review and individual participant data (IPD) meta-analysis of clinical trials of long-acting injectable antipsychotics (LAIs) for psychosis relapse-prevention, following IPD-PRISMA guidelines. Datasets were identified by searching relevant repositories from inception to Aug 1, 2019. Each LAI group was reanalysed as a separate cohort, further identifying subcohorts of individuals with and without prospectively determined symptom remission (PSR). Summary incidence rate of relapse, incidence rate ratios (IRRs) of relapse between individuals with and without PSR, hazard ratios (HRs) of covariates on risk of relapse, and standardised mean difference (SMDs) in changes in overall functioning associated with relapse were generated by pooling results from the harmonised reanalysis of each study. This study is registered with PROSPERO, number CRD42019137439. FINDINGS 19 treatment cohorts consisting of 5130 individuals (2938 with PSR, 2192 without PSR), with 3959·53 observed participant-years, were meta-analysed. Pooled incidence of relapse was 22·97 per 100 participant-years (14·76 per 100 participant-years for the PSR subcohort, 31·51 per 100 participant-years for the non-PSR subcohort), with an IRR of 0·19 (95% CI 0·07 to 0·54). Relapse was associated with functional decline (overall SMD -0·76, 95% CI -1·14 to -0·37; PSR SMD -0·52, 95% CI -0·80 to -0·21; non-PSR SMD -0·72, 95% CI -1·18 to -0·26). The strongest predictor of relapse was tardive dyskinesia at treatment onset (HR 2·39, 95% CI 1·05 to 5·42). INTERPRETATION Despite the established efficacy of antipsychotics in preventing relapse, these data indicate that these drugs might not prevent subsequent exacerbations for a proportion of individuals whose illness is stabilised on continuous antipsychotic treatment. Tardive dyskinesia in particular might have pathophysiological implications for relapse. FUNDING Northwell Health.
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Affiliation(s)
- Jose M Rubio
- Department of Psychiatry, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, USA; Department of Psychiatry and Molecular Medicine, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA; Center for Psychiatric Neuroscience, The Feinstein Institute for Medical Research, Manhasset, NY, USA.
| | - Georgios Schoretsanitis
- Center for Psychiatric Neuroscience, The Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - Majnu John
- Department of Psychiatry and Molecular Medicine, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA; Center for Psychiatric Neuroscience, The Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - Jari Tiihonen
- Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Kuopio, Finland; Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Center for Psychiatry Research, Stockholm City Council, Stockholm, Sweden
| | - Heidi Taipale
- Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Kuopio, Finland; Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | - Daniel Guinart
- Center for Psychiatric Neuroscience, The Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - Anil K Malhotra
- Department of Psychiatry, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, USA; Department of Psychiatry and Molecular Medicine, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA; Center for Psychiatric Neuroscience, The Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - Christoph U Correll
- Department of Psychiatry, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, USA; Department of Psychiatry and Molecular Medicine, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA; Center for Psychiatric Neuroscience, The Feinstein Institute for Medical Research, Manhasset, NY, USA; Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - John M Kane
- Department of Psychiatry, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, USA; Department of Psychiatry and Molecular Medicine, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA; Center for Psychiatric Neuroscience, The Feinstein Institute for Medical Research, Manhasset, NY, USA
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Luykx JJ, Stam N, Tanskanen A, Tiihonen J, Taipale H. In the aftermath of clozapine discontinuation: comparative effectiveness and safety of antipsychotics in patients with schizophrenia who discontinue clozapine. Br J Psychiatry 2020; 217:498-505. [PMID: 31910911 PMCID: PMC7511905 DOI: 10.1192/bjp.2019.267] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Although clozapine is often discontinued, there is a paucity of guidelines and evidence on treatment options after clozapine discontinuation. Moreover, it is currently unknown whether reinstating clozapine in patients formerly using clozapine should be avoided. AIMS To compare the real-world effectiveness of antipsychotics after clozapine cessation. METHOD From Finnish registry data (1995-2017), we identified 2250 patients with schizophrenia who had been using clozapine for ≥1 year before treatment cessation. The primary analysis consisted of adjusted within-individual analyses of psychiatric ward readmission owing to psychosis and treatment failure. Secondary analyses concerned between-individual mortality differences. RESULTS Compared with no use of antipsychotics, risk of psychiatric ward readmission was lowest for reinitiation of clozapine (adjusted hazard ratio (aHR) 0.49; 95% CI 0.40-0.61; P < 0.0001), oral olanzapine (aHR 0.58; 95% CI 0.48-0.71; P < 0.0001) and antipsychotic polypharmacy (aHR 0.62; 95% CI 0.53-0.72; P < 0.0001). Risk of treatment failure was lowest for aripiprazole long acting injectable (aHR 0.42; 95% CI 0.27-0.65; P < 0.0001), reinitiation of clozapine (aHR 0.49; 95% CI 0.43-0.57; P < 0.0001) and oral olanzapine (aHR 0.69; 95% CI 0.61-0.77; P < 0.0001). Mortality risk was lowest for reinitiation of clozapine (aHR 0.18; 95% CI 0.09-0.36; P < 0.0001) and oral olanzapine (aHR 0.26; 95% CI 0.17-0.40; P < 0.0001). CONCLUSIONS Clozapine and olanzapine are the most effective and safest treatment options in those discontinuing clozapine for undefined reasons. Clozapine should therefore be reconsidered in patients with schizophrenia who previously discontinued this compound.
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Affiliation(s)
- Jurjen J. Luykx
- Assistant Professor, Departmentsof Psychiatry and Translational Neuroscience, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University; and Department of Outpatient Psychiatry, GGNet Mental Health, The Netherlands,Correspondence: Jurjen J. Luykx.
| | - Noraly Stam
- Researcher, Department of Psychiatry, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Antti Tanskanen
- Researcher, Department of Clinical Neuroscience, Karolinska Institutet, Sweden; Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital; and Public Health Solutions, National Institute for Health and Welfare, Finland
| | - Jari Tiihonen
- Professor, Department of Clinical Neuroscience, Karolinska Institutet, Sweden; Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Finland; and Center for Psychiatric Research, Stockholm City Council, Sweden
| | - Heidi Taipale
- Assistant Professor, Department of Clinical Neuroscience, Karolinska Institutet, Sweden; Academy Research Fellow, Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital; and Associate Professor, School of Pharmacy, University of Eastern Finland, Finland
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Bardgett ME, Downnen T, Crane C, Baltes Thompson EC, Muncie B, Steffen SA, Yates JR, Pauly JR. Chronic risperidone administration leads to greater amphetamine-induced conditioned place preference. Neuropharmacology 2020; 179:108276. [PMID: 32814089 DOI: 10.1016/j.neuropharm.2020.108276] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 07/15/2020] [Accepted: 08/14/2020] [Indexed: 11/17/2022]
Abstract
Risperidone is an atypical antipsychotic drug used increasingly in children to manage symptoms of ADHD and conduct disorder. In rats, developmental risperidone administration is accompanied by increased locomotor activity during adulthood, as well as heightened sensitivity to the locomotor stimulating effects of amphetamine. This study compared sensitivity to the rewarding effects of amphetamine, as measured by conditioned place preference (CPP), between groups of rats administered chronic risperidone (3.0 mg/kg, s.c.) during development (postnatal days 14-42) or adulthood (postnatal days 77-105). Locomotor activity in a novel test cage and amphetamine-induced CPP were measured beginning three and four weeks, respectively, after the final risperidone injection. Female rats administered risperidone early in life were more active than any other group tested. Previous risperidone administration enhanced amphetamine CPP regardless of sex, and this effect appeared more prominent in the developmentally treated group. The density of forebrain dopamine transporters, a primary target of amphetamine, was also quantified in rats administered risperidone early in life and found to be reduced in the medial anterior, posterior, and ventral caudate nucleus. These results suggest that chronic risperidone treatment modifies later locomotor activity and sensitivity to the reinforcing effects of amphetamine, perhaps via a mechanism related to decreased forebrain dopamine transporter density.
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Affiliation(s)
- Mark E Bardgett
- Department of Psychological Science, Northern Kentucky University, Highland Heights, 41076, KY, USA.
| | - Tyler Downnen
- Department of Psychological Science, Northern Kentucky University, Highland Heights, 41076, KY, USA
| | - Casey Crane
- Department of Psychological Science, Northern Kentucky University, Highland Heights, 41076, KY, USA
| | - Emily C Baltes Thompson
- Department of Psychological Science, Northern Kentucky University, Highland Heights, 41076, KY, USA
| | - Brittany Muncie
- Department of Psychological Science, Northern Kentucky University, Highland Heights, 41076, KY, USA
| | - Sara A Steffen
- Department of Psychological Science, Northern Kentucky University, Highland Heights, 41076, KY, USA
| | - Justin R Yates
- Department of Psychological Science, Northern Kentucky University, Highland Heights, 41076, KY, USA
| | - James R Pauly
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Kentucky, Lexington, KY, 40508, USA
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Melo-Thomas L, Tonelli LC, Müller CP, Wöhr M, Schwarting RKW. Playback of 50-kHz ultrasonic vocalizations overcomes psychomotor deficits induced by sub-chronic haloperidol treatment in rats. Psychopharmacology (Berl) 2020; 237:2043-2053. [PMID: 32419116 PMCID: PMC7306038 DOI: 10.1007/s00213-020-05517-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Accepted: 04/01/2020] [Indexed: 01/05/2023]
Abstract
RATIONALE In rodents, acute haloperidol treatment induces psychomotor impairments known as catalepsy, which models akinesia in humans and is characterized as an animal model of acute Parkinsonism, whereas sub-chronic haloperidol reduces exploratory behavior, which resembles bradykinesia. Haloperidol-induced catalepsy in rats can be ameliorated by playback of 50-kHz ultrasonic vocalizations (USV), an emotionally and motivationally relevant appetitive auditory stimulus, representing an animal model of paradoxical kinesia. In a condition like PD where patients suffer from chronic motor impairments, it is paramount to assess the long-term symptom relief in an animal model of Parkinsonism. OBJECTIVES We investigated whether 50-kHz USV playback ameliorates psychomotor deficits induced by haloperidol in a sub-chronic dosing regimen. METHODS In phase 1, distance traveled and number of rearing behavior were assessed in an activity chamber in order to investigate whether sub-chronic haloperidol treatment induced psychomotor impairments. In phase 2, we investigated whether 50-kHz USV playback could overcome these impairments by assessing exploratory behaviors and approach behavior towards the sound source in the 50-kHz USV radial maze playback paradigm. RESULTS Sub-chronic haloperidol treatment led to psychomotor deficits since the distance traveled and number of rearing behavior were reduced as compared to saline control group or baseline. These psychomotor impairments were ameliorated during playback of 50-kHz USV, with haloperidol treated rats showing a clear social approach behavior towards the sound source exclusively during playback. CONCLUSIONS This study provides evidence that 50-kHz USV playback induces paradoxical kinesia in rats exhibiting motor deficits after sub-chronic haloperidol, as we previously showed after acute haloperidol treatment.
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Affiliation(s)
- Liana Melo-Thomas
- Experimental and Biological Psychology, Behavioral Neuroscience, Faculty of Psychology, Philipps-University of Marburg, Gutenbergstraße 18, 35032, Marburg, Germany.
- Center for Mind, Brain, and Behavior (CMBB), Hans-Meerwein-Straße 6, 35032, Marburg, Germany.
- Institute of Neuroscience and Behavior (INeC), Av. do Café, 2450, Monte Alegre, Ribeirão Preto, São Paulo, 14050-220, Brazil.
| | - Luan C Tonelli
- Experimental and Biological Psychology, Behavioral Neuroscience, Faculty of Psychology, Philipps-University of Marburg, Gutenbergstraße 18, 35032, Marburg, Germany
| | - Christian P Müller
- Section of Addiction Medicine, Department of Psychiatry and Psychotherapy, University Clinic, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Markus Wöhr
- Experimental and Biological Psychology, Behavioral Neuroscience, Faculty of Psychology, Philipps-University of Marburg, Gutenbergstraße 18, 35032, Marburg, Germany
- Center for Mind, Brain, and Behavior (CMBB), Hans-Meerwein-Straße 6, 35032, Marburg, Germany
| | - Rainer K W Schwarting
- Experimental and Biological Psychology, Behavioral Neuroscience, Faculty of Psychology, Philipps-University of Marburg, Gutenbergstraße 18, 35032, Marburg, Germany
- Center for Mind, Brain, and Behavior (CMBB), Hans-Meerwein-Straße 6, 35032, Marburg, Germany
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Fountoulakis KN, Moeller HJ, Kasper S, Tamminga C, Yamawaki S, Kahn R, Tandon R, Correll CU, Javed A. The report of the joint WPA/CINP workgroup on the use and usefulness of antipsychotic medication in the treatment of schizophrenia. CNS Spectr 2020; 26:1-25. [PMID: 32594935 DOI: 10.1017/s1092852920001546] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
This is a report of a joint World Psychiatric Association/International College of Neuropsychopharmacology (WPA/CINP) workgroup concerning the risk/benefit ratio of antipsychotics in the treatment of schizophrenia. It utilized a selective but, within topic, comprehensive review of the literature, taking into consideration all the recently discussed arguments on the matter and avoiding taking sides when the results in the literature were equivocal. The workgroup's conclusions suggested that antipsychotics are efficacious both during the acute and the maintenance phase, and that the current data do not support the existence of a supersensitivity rebound psychosis. Long-term treated patients have better overall outcome and lower mortality than those not taking antipsychotics. Longer duration of untreated psychosis and relapses are modestly related to worse outcome. Loss of brain volume is evident already at first episode and concerns loss of neuropil volume rather than cell loss. Progression of volume loss probably happens in a subgroup of patients with worse prognosis. In humans, antipsychotic treatment neither causes nor worsens volume loss, while there are some data in favor for a protective effect. Schizophrenia manifests 2 to 3 times higher mortality vs the general population, and treatment with antipsychotics includes a number of dangers, including tardive dyskinesia and metabolic syndrome; however, antipsychotic treatment is related to lower mortality, including cardiovascular mortality. In conclusion, the literature strongly supports the use of antipsychotics both during the acute and the maintenance phase without suggesting that it is wise to discontinue antipsychotics after a certain period of time. Antipsychotic treatment improves long-term outcomes and lowers overall and specific-cause mortality.
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Affiliation(s)
- Konstantinos N Fountoulakis
- 3rd Department of Psychiatry, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Hans-Jurgen Moeller
- Department of Psychiatry, Ludwig Maximilian University of Munich, Munich, Germany
| | - Siegfried Kasper
- Universitätsklinik für Psychiatrie und Psychotherapie, Medizinische Universität Wien, Vienna, Austria
| | - Carol Tamminga
- Department of Psychiatry, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Shigeto Yamawaki
- Center for Brain, Mind and KANSEI Sciences Research, Hiroshima University, Hiroshima, Japan
| | - Rene Kahn
- Department of Psychiatry and Behavioral Health System, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Rajiv Tandon
- Department of Psychiatry, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Michigan, USA
| | - Christoph U Correll
- Department of Psychiatry, Northwell Health, The Zucker Hillside Hospital, Glen Oaks, New York, USA
- Department of Psychiatry and Molecular Medicine, Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
- Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Afzal Javed
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
- Pakistan Psychiatric Research Centre, Fountain House, Lahore, Pakistan
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Rubio JM, Taipale H, Correll CU, Tanskanen A, Kane JM, Tiihonen J. Psychosis breakthrough on antipsychotic maintenance: results from a nationwide study. Psychol Med 2020; 50:1356-1367. [PMID: 31190660 DOI: 10.1017/s0033291719001296] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND There is uncertainty about the incidence of breakthrough psychosis in treatment adherent patients, and the role that factors, such as cumulative antipsychotic exposure, play in this phenomenon. METHODS In a nationwide cohort of individuals treated for schizophrenia-spectrum disorders in Finland between 1 January 1996 and 31 December 2015, 'Breakthrough Psychosis on Antipsychotic Maintenance Medication' (BAMM) was defined as hospitalization for psychosis despite ongoing continuous treatment with long-acting injectable antipsychotics (LAIs) or oral antipsychotics (OAPs) for ⩾8 weeks. Incidence rates, survival curves, and risk factors were presented. RESULTS In a cohort of 16 031 continuous LAI treatment episodes with virtually assured adherence [median duration = 441 days, interquartile range (IQR) = 155-1277], BAMM incidence was 31.5%. For 42 867 OAPs treatment episodes (median duration = 483 days, IQR = 167-1491), for whom adherence was modeled by the PRE2DUP method, BAMM incidence was 31.1%. Factors related to illness instability at treatment onset were associated with BAMM, although median time to BAMM was 291 days (IQR = 121-876) for LAIs and 344 days (IQR = 142-989) for OAPs, and 27.4% (N = 1386) of the BAMM events in the LAI, and 32.9% (N = 4378) in the OAP group occurred despite >1 year since last hospitalization at treatment onset. Cumulative antipsychotic exposure was not a consistent risk factor. CONCLUSION BAMM was relatively common even when adherence was confirmed with LAIs. Illness instability at treatment onset accounted for most cases, but relapse after years of continuous treatment was still prevalent. There was insufficient evidence to support causality between cumulative antipsychotic exposure and BAMM. Future research needs to address the role of symptom severity and neurobiology in BAMM.
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Affiliation(s)
- Jose M Rubio
- Division of Psychiatry Research, The Zucker Hillside Hospital, 75-59 263rd St, Glen Oaks, NY11004, USA
- Department of Psychiatry and Molecular Medicine, Hofstra Northwell School of Medicine, Hempstead, NY11550, USA
- The Feinstein Institute for Medical Research, Manhasset, NY11030, USA
| | - Heidi Taipale
- Department of Forensic Psychiatry, Niuvanniemi Hospital, University of Eastern Finland, Niuvankuja 65, FI-70240Kuopio, Finland
- Department of Clinical Neuroscience, Karolinska Institutet, Tomtebodavägen 18A, 5th floor, SE-171 77Stockholm, Sweden
- School of Pharmacy, University of Eastern Finland, PO Box 1627, SE-70211Kuopio, Finland
| | - Christoph U Correll
- Division of Psychiatry Research, The Zucker Hillside Hospital, 75-59 263rd St, Glen Oaks, NY11004, USA
- Department of Psychiatry and Molecular Medicine, Hofstra Northwell School of Medicine, Hempstead, NY11550, USA
- The Feinstein Institute for Medical Research, Manhasset, NY11030, USA
- Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin, Germany
| | - Antti Tanskanen
- Department of Forensic Psychiatry, Niuvanniemi Hospital, University of Eastern Finland, Niuvankuja 65, FI-70240Kuopio, Finland
- Department of Clinical Neuroscience, Karolinska Institutet, Tomtebodavägen 18A, 5th floor, SE-171 77Stockholm, Sweden
| | - John M Kane
- Division of Psychiatry Research, The Zucker Hillside Hospital, 75-59 263rd St, Glen Oaks, NY11004, USA
- Department of Psychiatry and Molecular Medicine, Hofstra Northwell School of Medicine, Hempstead, NY11550, USA
- The Feinstein Institute for Medical Research, Manhasset, NY11030, USA
| | - Jari Tiihonen
- Department of Forensic Psychiatry, Niuvanniemi Hospital, University of Eastern Finland, Niuvankuja 65, FI-70240Kuopio, Finland
- Department of Clinical Neuroscience, Karolinska Institutet, Tomtebodavägen 18A, 5th floor, SE-171 77Stockholm, Sweden
- Stockholm County Council, Stockholm Health Care Services, Norra Stationsgatan 69, SE-113 64Stockholm, Sweden
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Takase M, Kimura H, Kanahara N, Nakata Y, Iyo M. Plasma monoamines change under dopamine supersensitivity psychosis in patients with schizophrenia: A comparison with first-episode psychosis. J Psychopharmacol 2020; 34:540-547. [PMID: 31961236 DOI: 10.1177/0269881119900982] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Patients with first-episode psychosis respond well to initial antipsychotic treatment, but among patients experiencing a relapse of psychosis, the response rate falls to approximately 30%. The mechanism of this discrepancy has not been clarified, but the development of dopamine supersensitivity psychosis with the underlying up-regulation of post-synaptic dopamine D2 receptors could be involved in this lesser response. It is uncertain whether elevated dopamine synthesis and release occurs in patients with dopamine supersensitivity psychosis, in contrast to those with first-episode psychosis. PATIENTS AND METHODS We examined a first-episode psychosis group (n=6) and a chronic schizophrenia group, i.e. patients experiencing relapse (n=23) including those who relapsed due to dopamine supersensitivity psychosis (n=18). Following the initiation of treatment, we measured the patients' blood concentrations of homovanillic acid and 3-methoxy-4-hydroxyphenylglycol at two weeks and four weeks after the baseline measurements. RESULTS The first-episode psychosis group tended to show decreased homovanillic acid, accompanied by an improvement of symptoms. The chronic schizophrenia group showed no alteration of homovanillic acid or 3-methoxy-4-hydroxyphenylglycol over the treatment period. These results were the same in the dopamine supersensitivity psychosis patients alone. CONCLUSIONS Our findings suggest that unlike first-episode psychosis, the release of dopamine from presynaptic neurons did not increase in relapse episodes in the patients with dopamine supersensitivity psychosis. This indirectly indicates that the development of supersensitivity of post-synapse dopamine D2 receptor is involved in relapse in dopamine supersensitivity psychosis patients.
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Affiliation(s)
- Masayuki Takase
- Department of Psychiatry, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Hisoshi Kimura
- Department of Psychiatry, Chiba University Graduate School of Medicine, Chiba, Japan.,Department of Psychiatry, Gakuji-kai Kimura Hospital, Chiba, Japan
| | - Nobuhisa Kanahara
- Department of Psychiatry, Chiba University Graduate School of Medicine, Chiba, Japan.,Center for Forensic Mental Health, Chiba University, Chiba, Japan
| | - Yusuke Nakata
- Department of Psychiatry, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Masaomi Iyo
- Department of Psychiatry, Chiba University Graduate School of Medicine, Chiba, Japan
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Abstract
PURPOSE OF REVIEW Recently, it has been questioned whether the re-emergence of psychotic symptoms following antipsychotic discontinuation or dose reduction is attributable to underlying psychotic vulnerability or to rebound effects of chronic use of antipsychotic medication. It was repeatedly shown that relapse rates are high after discontinuation of maintenance treatment. A potential contributing factor could be the increase in density of postsynaptic dopamine D2 receptors in the striatum and the higher affinity of D2 receptors for dopamine after chronic blockade. RECENT FINDINGS To date, little clinical evidence is available for the mechanisms involved in postsynaptic striatal D2 receptor up-regulation after use of antipsychotic medication, and most knowledge comes from animal studies. SUMMARY Further research is needed to investigate whether antipsychotic medication causes neuroadaptations leading to a dopamine supersensitive state in humans, how long such hypersensitive states may last and what differences exist between high and low D2 affinity antipsychotic drugs. Further, information is needed on discontinuation schedules that provide optimal protection for relapse during hypersensitive periods.
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Abstract
The effect of antipsychotic medication is poor in 30-40% of patients with schizophrenia; treatment resistance is usually met with shifts to new drugs or drug augmentation strategies or a trial of clozapine. The purpose of this review was to examine the potential role of intestinal bacteria in the bioavailability of antipsychotic medication and the possibility that parenterally administered antipsychotics might be able to overcome treatment resistance. Databases were searched with appropriate terms to locate relevant papers dealing with the effect of antipsychotic drugs on the gut microbiome and the effect of bacterial metabolizing enzymes on antipsychotic drugs. Also searched were papers addressing the various current parenteral formulations of antipsychotic drugs. Sixty-five recent pertinent papers were reviewed and the results are suggestive of the premise that there is a drug refractory form of psychosis for which the composition of gut bacteria is responsible, and that parenteral drug administration could overcome the problem.
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Affiliation(s)
- Mary V Seeman
- Department of Psychiatry, University of Toronto, 260 Heath St. West Suite #605, Toronto, Ontario, M5P 3L6, Canada.
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Neurotensin in reward processes. Neuropharmacology 2020; 167:108005. [PMID: 32057800 DOI: 10.1016/j.neuropharm.2020.108005] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 02/06/2020] [Accepted: 02/09/2020] [Indexed: 12/18/2022]
Abstract
Neurotensin (NTS) is a neuropeptide neurotransmitter expressed in the central and peripheral nervous systems. Many studies over the years have revealed a number of roles for this neuropeptide in body temperature regulation, feeding, analgesia, ethanol sensitivity, psychosis, substance use, and pain. This review provides a general survey of the role of neurotensin with a focus on modalities that we believe to be particularly relevant to the study of reward. We focus on NTS signaling in the ventral tegmental area, nucleus accumbens, lateral hypothalamus, bed nucleus of the stria terminalis, and central amygdala. Studies on the role of NTS outside of the ventral tegmental area are still in their relative infancy, yet they reveal a complex role for neurotensinergic signaling in reward-related behaviors that merits further study. This article is part of the special issue on 'Neuropeptides'.
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Antipsychotic-evoked dopamine supersensitivity. Neuropharmacology 2020; 163:107630. [DOI: 10.1016/j.neuropharm.2019.05.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 04/29/2019] [Accepted: 05/07/2019] [Indexed: 12/15/2022]
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McCutcheon RA, Krystal JH, Howes OD. Dopamine and glutamate in schizophrenia: biology, symptoms and treatment. World Psychiatry 2020; 19:15-33. [PMID: 31922684 PMCID: PMC6953551 DOI: 10.1002/wps.20693] [Citation(s) in RCA: 283] [Impact Index Per Article: 70.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Glutamate and dopamine systems play distinct roles in terms of neuronal signalling, yet both have been proposed to contribute significantly to the pathophysiology of schizophrenia. In this paper we assess research that has implicated both systems in the aetiology of this disorder. We examine evidence from post-mortem, preclinical, pharmacological and in vivo neuroimaging studies. Pharmacological and preclinical studies implicate both systems, and in vivo imaging of the dopamine system has consistently identified elevated striatal dopamine synthesis and release capacity in schizophrenia. Imaging of the glutamate system and other aspects of research on the dopamine system have produced less consistent findings, potentially due to methodological limitations and the heterogeneity of the disorder. Converging evidence indicates that genetic and environmental risk factors for schizophrenia underlie disruption of glutamatergic and dopaminergic function. However, while genetic influences may directly underlie glutamatergic dysfunction, few genetic risk variants directly implicate the dopamine system, indicating that aberrant dopamine signalling is likely to be predominantly due to other factors. We discuss the neural circuits through which the two systems interact, and how their disruption may cause psychotic symptoms. We also discuss mechanisms through which existing treatments operate, and how recent research has highlighted opportunities for the development of novel pharmacological therapies. Finally, we consider outstanding questions for the field, including what remains unknown regarding the nature of glutamate and dopamine function in schizophrenia, and what needs to be achieved to make progress in developing new treatments.
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Affiliation(s)
- Robert A McCutcheon
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- MRC London Institute of Medical Sciences, Imperial College London, Hammersmith Hospital, London, UK
- South London and Maudsley Foundation NHS Trust, Maudsley Hospital, London, UK
| | - John H Krystal
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT, USA
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
- VA National Center for PTSD, VA Connecticut Healthcare System, West Haven, CT, USA
| | - Oliver D Howes
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- MRC London Institute of Medical Sciences, Imperial College London, Hammersmith Hospital, London, UK
- South London and Maudsley Foundation NHS Trust, Maudsley Hospital, London, UK
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