Management of patients presenting with acute psychotic episodes of schizophrenia

Genetic markers of early response to lurasidone in acute schizophrenia

Prediction of treatment response by genetic biomarkers has potential for clinical use and contributes to the understanding of pathophysiology and drug mechanism of action. The purpose of this study is to detect genetic biomarkers possibly associated with response to lurasidone, during the first four weeks of treatment. One-hundred and seventy-one acutely psychotic patients from two placebo-controlled clinical trials of lurasidone were included. Genetic associations with changes in Positive and Negative Syndrome Scale total score at weeks one, two, and four were examined. Genotyping was done with the Affymetrix 6.0 microarray and associations were computed using PLINK regression model. Although genome-wide significance was not reached with a limited sample size, signals of potential interest for further studies were with genes important for neurogenesis. Possible week one marker, rs6459950 (p = 7.05 × 10-7), was close to the sonic hedgehog gene (SHH), involved in neuronal differentiation and neurogenesis. Possible week two marker, rs7435958, was a SNP of GABRB1, encoding the GABAA Receptor β1. Notably, possible week four signals included a SNP within PTCH1, a specific receptor for the SHH, the possible week one marker. Pathway analysis supported the possibility that neurogenesis might be involved in early antipsychotic response. Tissue enrichment analysis suggested that potential signals were enriched in anterior cingulate cortex, reported to be relevant in antipsychotic action. This is the first study to examine genes possibly associated with very early response to lurasidone. Further replication studies in larger sample size should be required.

Effectiveness of antipsychotic medication in patients with schizophrenia in a real world retrospective observational study in Ethiopia

Antipsychotic medications have become the cornerstone of treatment for schizophrenia. The antipsychotic drugs are high-affinity antagonists of dopamine D2 receptors that are most effective against psychotic symptoms, but antipsychotic drugs can have side effects that overshadow their advantages, like sedation, extrapyramidal symptoms, and weight gain, which are often experienced as adverse effects. In our country, the relative effectiveness of antipsychotic medication as well as their tolerance in schizophrenia patients is not fully addressed. This study aims to determine the effectiveness of antipsychotic medication and associated factors in schizophrenia patients at the psychiatry clinic. An institutional-based retrospective cohort study was conducted using administrative data of patients with schizophrenia disorder based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) that initiated or changed to a new antipsychotic treatment by clinicians assessments from April 1, 2023, to March 1, 2024 at university of Gondar specialized hospital. The effectiveness of prescribed antipsychotic medication was evaluated using the Clinical Global Impressions-Schizophrenia scale (CGI-SCH), inclusive of subscales for positive, negative, depressive, and cognitive symptoms. A total of 608 patients were receiving antipsychotic medications as follows: 118 patients (19.4%) were prescribed haloperidol, 88 patients (14.5%) were taking chlorpromazine, 48 patients (7.9%) received fluphenazine (decanoate), 126 patients (20.7%) were on risperidone, and 228 patients (37.5%) were treating with olanzapine. In total, 64.8% of patients show improvement in the prescribed medications within one year of treatment (Kaplan-Meier estimate 35.2%) for haloperidol, 31 (26.3%) for chlorpromazine, 30 (34.1%) for Fluphenazine, 19 (39.6%) for risperidone, 51 (40.5%), and 83 (36.4%) for olanzapine. Effectiveness was assessed using the Clinical Global Impressions-Improvement (CGI-I); the overall improvements like negative, positive, depressive, and cognitive symptoms were significantly higher for olanzapine, followed by haloperidol (p < .001). Good adherence (AHR = 0.63; 95% CI 0.5-0.78), history of relapse (AHR = 1.43; 95% CI 1.13-1.82), unemployment (AHR = 1.4; 95% CI 1.06-1.85), and history of suicidal ideation (AHR = 1.79; 95% CI 1.24-2.58) were significant predictors of symptoms improvement. The study found olanzapine is more effective in improving schizophrenia symptoms than other antipsychotic drugs. Medication adherence, symptom relapse, and suicidal thoughts significantly impacted antipsychotic effectiveness in individuals with schizophrenia disorder.

Towards full recovery with lurasidone: effective doses in the treatment of agitation, affective, positive, and cognitive symptoms in schizophrenia and of dual psychosis

The management of schizophrenia necessitates a comprehensive treatment paradigm that considers individual patient nuances and the efficacy of lurasidone in addressing schizophrenia symptoms, particularly at elevated dosages. Numerous randomized trials have affirmed the efficacy of lurasidone across various dimensions of schizophrenia, demonstrating marked enhancements in positive, negative and cognitive symptoms compared to a placebo. In addition, lurasidone exhibits potential in ameliorating agitation amongst acutely ill patients, showcasing greater efficacy at higher doses. However, despite the favourable outcomes observed with higher lurasidone doses, routine clinical practice often opts for lower doses, potentially limiting its maximal therapeutic impact. Furthermore, lurasidone also shows efficacy in reducing post-psychotic depression in dual psychosis. Moreover, practical insights into lurasidone usage encompass swift dose escalation within a 1-5-day span and recommended combination strategies with other medications such as benzodiazepines for insomnia or agitation, beta-blockers for akathisia, and antihistamines or antimuscarinic drugs for patients transitioning rapidly from antipsychotics with substantial antihistamine and/or anticholinergic effects. Finally, a series of clinical cases is presented, highlighting benefits of lurasidone in terms of cognitive function, functional recovery and other therapeutic aspects for the management of schizophrenia.

A prospective, observational study of the safety and effectiveness of intramuscular psychotropic treatment in acutely agitated patients with schizophrenia and bipolar mania

This naturalistic, observational pan-European study assessed the safety and early effectiveness of intramuscular (IM) psychotropic treatments in patients with acute agitation suffering from schizophrenia or bipolar mania. One thousand nine hundred and forty of 1945 patients completed the 24-hour observation period after initial IM treatment. Patients from 12 European countries were included (mean age 39 years; 58% male, 66% schizophrenia). IM treatment was at the physician's discretion. The primary objective was to describe the acute tolerability of IM psychotropic therapies in clinical practice, with particular emphasis on EPS. At baseline, 68% of the patients received IM monotherapy, with IM olanzapine most commonly prescribed (36%). During the first 24hours, 190 (9.8%) patients experienced EPS. The occurrence of EPS was statistically significantly lower in patients treated with IM olanzapine compared to those treated with other IM psychotropic medications (mainly typical antipsychotics and benzodiazepines): acute dystonia: 1.1%, 95% CI 0.5–2.3 and 2.9%, CI 2.0–4.0; akathisia: 2.3%, CI 1.3–3.7 and 5.5%, CI 4.3–6.9; Parkinsonism: 2.9%, CI 1.8–4.4 and 7.8%, CI 6.4–9.4, respectively. Anticholinergic treatment was given to 12% IM olanzapine versus 31% non-olanzapine treated patients. Acute agitation after 24hours was reduced by 1.68 (95% CI 1.46–1.91) points on the Clinical Global Impression of Severity (CGI-S) in IM olanzapine patients and 1.51 (95% CI 1.30–1.73) points in non-olanzapine patients. Additional psychotropic medication was required for 90% of the patients during the first 24hours of treatment. Results provide naturalistic evidence for low EPS rates and improvement of agitation with IM psychotropic medications during acute states of patients suffering from acute mania or schizophrenia.

Preventative effects of aripiprazole and quetiapine on seizure and lethality in a mice cocaine toxicity model: an experimental study

Objective

To assess the effectiveness of pre-treatment with aripiprazole and quetiapine to prevent acute cocaine toxicity in a mouse model of cocaine toxicity.

Methods

This experimental study included three groups (n = 25 per group) of mice that were intraperitoneally injected with normal saline solution, 10 mg/kg quetiapine or 10 mg/kg aripiprazole 15 min before 105 mg/kg cocaine hydrochloride. When the cocaine administration was completed, researchers blinded to the study groups observed the mice in terms of seizures and death for a further 30 min.

Results

In the cocaine + quetiapine group, the mean ± SE time to the first seizure was 10.80 ± 2.27 min and seizure activity was detected in 18 mice (72%) by the end of the 30 min. In the cocaine + aripiprazole group, the mean ± SE time to the first seizure was 18.10 ± 1.94 min and seizure activity was detected in 15 mice (60%) by the end of the 30 min. When compared with the control group, there was a significant difference between the cocaine + quetiapine and cocaine + aripiprazole groups in terms of seizure activity. Survival time was increased in the cocaine + aripiprazole group compared with the control and cocaine + quetiapine groups.

Conclusion

Quetiapine and aripiprazole pre-treatment reduced seizure activity and delayed the onset of seizures compared with the control group.

Trace Amines and Their Receptors

Trace amines are endogenous compounds classically regarded as comprising β-phenylethyalmine, p-tyramine, tryptamine, p-octopamine, and some of their metabolites. They are also abundant in common foodstuffs and can be produced and degraded by the constitutive microbiota. The ability to use trace amines has arisen at least twice during evolution, with distinct receptor families present in invertebrates and vertebrates. The term "trace amine" was coined to reflect the low tissue levels in mammals; however, invertebrates have relatively high levels where they function like mammalian adrenergic systems, involved in "fight-or-flight" responses. Vertebrates express a family of receptors termed trace amine-associated receptors (TAARs). Humans possess six functional isoforms (TAAR1, TAAR2, TAAR5, TAAR6, TAAR8, and TAAR9), whereas some fish species express over 100. With the exception of TAAR1, TAARs are expressed in olfactory epithelium neurons, where they detect diverse ethological signals including predators, spoiled food, migratory cues, and pheromones. Outside the olfactory system, TAAR1 is the most thoroughly studied and has both central and peripheral roles. In the brain, TAAR1 acts as a rheostat of dopaminergic, glutamatergic, and serotonergic neurotransmission and has been identified as a novel therapeutic target for schizophrenia, depression, and addiction. In the periphery, TAAR1 regulates nutrient-induced hormone secretion, suggesting its potential as a novel therapeutic target for diabetes and obesity. TAAR1 may also regulate immune responses by regulating leukocyte differentiation and activation. This article provides a comprehensive review of the current state of knowledge of the evolution, physiologic functions, pharmacology, molecular mechanisms, and therapeutic potential of trace amines and their receptors in vertebrates and invertebrates.

Efficacy of lurasidone in the treatment of agitation: A post hoc analysis of five short-term studies in acutely ill patients with schizophrenia

OBJECTIVE

This post hoc analysis evaluated the effect of lurasidone on agitation in acutely ill patients with schizophrenia.

METHOD

Patient-level data were pooled from five 6-week, randomized, double-blind, placebo-controlled studies of fixed-dose, once-daily, oral lurasidone (40, 80, 120, or 160 mg/d). Agitation was assessed with the Positive and Negative Syndrome Scale-Excited Component (PANSS-EC) score, utilizing a mixed model for repeated measurement analysis.

RESULTS

In patients with higher levels of agitation at baseline (PANSS-EC score≥14; n=773), lurasidone was associated with significantly greater improvement in least-squares (LS) mean PANSS-EC scores versus placebo at Day 3/4 (-1.6 vs -1.0; p<0.05), Day 7 (-2.3 vs -1.6; p<0.05), and at Week 6 endpoint (-5.5 vs -3.8; p<0.001; effect size=0.43). In patients with lower agitation at baseline (PANSS-EC score<14; n=754), LS mean PANSS-EC score change was significantly greater for lurasidone compared with placebo at Day 7 (-0.8 vs -0.1; p<0. 01) through Week 6 endpoint (-1.9 vs -0.9; p<0.001; effect size=0.31). Higher doses of lurasidone were notably more effective than lower doses in patients with more severe agitation at study baseline.

CONCLUSION

In this pooled analysis of 5 short-term studies, lurasidone provided early and sustained reduction in agitation, assessed using the PANSS-EC score, in patients with an acute exacerbation of schizophrenia. Higher doses of lurasidone were particularly effective in patients with more severe agitation at study baseline. Overall, these results suggest that lurasidone may be a useful treatment option for patients exhibiting agitation associated with acute psychotic symptoms of schizophrenia. ClinicalTrials.gov Identifiers: NCT00088634 (Study D1050196); NCT00549718 (Study D1050229), NCT00615433 (Study D1050231); NCT00790192 (Study D1050233). Study D1050006 was completed prior to the requirement to register trials.

Serum high-sensitivity C-reactive protein: A delicate sentinel elevated in drug-free acutely agitated patients with schizophrenia

Increased levels of high-sensitivity C reactive protein (hsCRP) have been reported in schizophrenia, but to date, no study is designed to examine serum hsCRP in acutely agitated patients with schizophrenia, an extreme state that requires immediate diagnosis and medical treatment. Serum hsCRP levels were assessed in 32 clinically acutely agitated patients and 42 healthy control subjects matched for demographic properties. Further, serum hsCRP levels in acutely agitated patients were compared with control subjects and with the levels after the patients were treated with anti-psychiatric medications. Meanwhile, the influence of clinical subtypes, family history, and gender, as well as the levels of white blood cell (WBC) counts were also considered. In results, serum hsCRP levels were significantly higher in acutely agitated patients with schizophrenia than in healthy subjects. The elevation of serum hsCRP in patients was not affected by gender, family history (P>0.05), and clinical classification of schizophrenia (P>0.05). However, the elevation of hsCRP was suppressed by the medical treatment for schizophrenia with acute agitation (P<0.05). In addition, WBC counts, another inflammation-related indicator, were also increased significantly in acutely agitated patients compared with healthy subjects, consistent with the elevation of serum hsCRP. In conclusion, hsCRP is an important indicator of immune alterations in the pathogenesis of schizophrenia and has potential to be developed into a sensitive marker for the acute agitation in schizophrenia.

[Acute agitation conditions]

Acute agitation psychiatric emergencies as frequently occur in psychiatric as well as in non-psychiatric settings, such as general hospitals, specialized clinics, emergency services and private practices. Psychiatric emergencies can be life-threatening and necessitate immediate treatment. This article presents the core symptomatology, differential diagnoses and treatment options of acute agitation emergencies. Case control studies and reliable data regarding prevalence and treatment of acute agitation in psychiatric and general hospitals or private practices are sparse. Existing evidence suggests that optimization of diagnosis and therapy of psychiatric emergencies, such as acute agitation is warranted. Treatment of acute agitation, psychological distress and other psychiatric emergencies are highly demanding regarding psychiatric expertise and concerning the personality and behavior of the therapist. The basis of therapy comprises the ability to form a stable and trustworthy relationship with the patient as well as to patiently calm down agitated patients. Unambiguous and rapid decision-making that takes effective pharmacological treatment options into account usually leads to swift amelioration of the acute symptomatology.

Medication adherence in patients with psychotic disorders: an observational survey involving patients before they switch to long-acting injectable risperidone

BACKGROUND

Maintaining antipsychotic therapy in psychosis is important in preventing relapse. Long-acting depot preparations can prevent covert non-adherence and thus potentially contribute to better patient outcomes. In this observational survey the main objective is to evaluate medication adherence and its determinants for oral treatment in a large sample of patients with psychosis.

METHODS

In this cross-sectional survey medication adherence for oral treatment was assessed by patients using the patient-rated Medication Adherence Questionnaire (MAQ). Data were collected by physicians on patients with a recent acute psychotic episode before switching to long-acting injectable risperidone. Other evaluations included disease severity (Clinical Global Impression - Severity), patients' insight (Positive and Negative Syndrome Scale item G12), treatment acceptance (clinician-rated Compliance Rating Scale), and therapeutic alliance (patient-rated 4-Point ordinal Alliance Scale).

RESULTS

A total of 399 psychiatrists enrolled 1,887 patients (mean age 36.8±11.9 years; 61.6% had schizophrenia). Adherence to oral medication was "low" in 53.2% of patients, "medium" in 29.5%, and "high" in 17.3%. Of patients with psychiatrist-rated active acceptance of treatment, 70% had "medium" or "high" MAQ scores (P<0.0001). Medication adherence was significantly associated with therapeutic alliance (4-Point ordinal Alliance Scale score; P<0.0001). Patient age was significantly associated with adherence: mean age increased with greater adherence (35.6, 36.7, and 38.6 years for patients with "low", "medium", and "high" levels of adherence, respectively; P=0.0007), while age <40 years was associated with "low" MAQ classification (P=0.0003). Poor adherence was also associated with a diagnosis of schizophrenia (P=0.0083), more severe disease (Clinical Global Impression - Severity ≥4; P<0.0001), and lower insight (Positive and Negative Syndrome Scale-G12 ≥4; P<0.0001).

CONCLUSION

Self-reported adherence was low in most patients, with a strong positive association between self-reported adherence and psychiatrists' assessment of treatment acceptance. Understanding factors associated with poor medication adherence may help physicians to better manage their patients, thereby improving outcomes.

Intranasal drug delivery of olanzapine-loaded chitosan nanoparticles

The aim of this study was to investigate olanzapine (OZ) systemic absolute bioavailability after intranasal (i.n.) administration in vivo to conscious rabbits. Furthermore, the study investigated the potential use of chitosan nanoparticles as a delivery system to enhance the systemic bioavailability of olanzapine following intranasal administration. Olanzapine-loaded chitosan nanoparticles were prepared through ionotropic gelation of chitosan with tripolyphosphate anions and studied in terms of their size, drug loading, and in vitro release. The OZ nanoparticles were administered i.n. to rabbits, and OZ plasma concentration at predetermined time points was compared to i.n. administration of OZ in solution. The concentrations of OZ in plasma were analyzed by ultra performance liquid chromatography mass spectroscopy (UPLC/MS). OZ-loaded chitosan nanoparticles significantly (p < 0.05) enhanced systemic absorption with 51 ± 11.2% absolute bioavailability as compared to 28 ± 6.7% after i.n. administration of OZ solution. The results of the present study suggest that intranasal administration of OZ-loaded chitosan nanoparticles formulation could be an attractive modality for delivery of OZ systemically.

Improvement of functional independence of patients with acute schizophrenia through early occupational therapy: a pilot quasi-experimental controlled study

Objective:

To clarify whether early occupational therapy for patients with acute schizophrenia improves their functional independence.

Design:

Quasi-experimental controlled study.

Setting:

A university hospital in Japan.

Subjects:

Forty-six out of 85 eligible patients with schizophrenia.

Intervention:

Participants were allocated into an intervention group or a control group according to the month of admission. Activities in one-on-one and mainly non-verbal occupational therapy were provided for the intervention group immediately after admission, and not for the control group.

Main measures:

Functional independence was measured using the Functional Independence Measure (FIM), at admission, at one month and at three months after admission. Psychiatric symptoms were also measured by the Brief Psychiatric Rating Scale.

Results:

Patients in both groups showed improved FIM total scores at one month and three months after admission. In the intervention group, the medians (interquartile ranges) were 89.0 (44.5) at admission, 113.0 (18.5) at one month, and 121.0 (6.5) at three months. In the control group, they were 88.0 (32.0), 107.0 (39.5), and 111.0 (17.0). At three months, the total FIM scores were significantly higher in the intervention group than in the control group ( p = 0.016). In the FIM cognitive domain, the scores were significantly higher in the intervention group than in the control group at one month ( p = 0.038) and, three months ( p = 0.012). Both groups showed improvement in Brief Psychiatric Rating Scale total scores, while no significant differences were observed between the groups at any points.

Conclusion:

The results suggest that early occupational therapy may improve functional independence in patients with acute schizophrenia.

A randomized, double-blind, placebo-controlled study of rapid-acting intramuscular olanzapine in Japanese patients for schizophrenia with acute agitation

BACKGROUND

Olanzapine rapid-acting intramuscular (IM) injection is an atypical antipsychotic drug already used overseas and recently approved in Japan. The objective of this study was to confirm the efficacy of rapid-acting IM olanzapine 10 mg was greater than IM placebo in patients with exacerbation of schizophrenia with acute psychotic agitation by comparing changes from baseline to 2 hours after the first IM injection, as measured by the Positive and Negative Syndrome Scale-Excited Component (PANSS-EC) total score.

METHODS

We conducted a placebo-controlled, randomized, double-blind, parallel-group study in Japanese patients diagnosed with schizophrenia according to the diagnostic criteria specified in the DSM-IV-TR. Patients were randomized to 2 treatment groups: IM olanzapine (10 mg) or IM placebo. The primary efficacy outcome was the change in PANSS-EC from baseline to 2 hours after the first IM injection. Treatment groups were compared with an analysis of variance model which included treatment and site as factors. During the 24-hour treatment period, safety was assessed by clinical examination and laboratory investigations, electrocardiograms, extrapyramidal symptoms scales, and recording spontaneously reported adverse events.

RESULTS

Of the 91 randomized patients, 90 patients (45 IM olanzapine-group; 45 IM placebo-group) were in the full analysis set. The mean change of PANSS-EC total score from baseline to 2 hours after the first IM injection (mean±standard deviation) was -9.2±4.5 for the IM olanzapine group and -2.8±5.6 for the IM placebo group. The difference between treatment groups was statistically significant (p<.001). There were no deaths, serious adverse events, treatment-emergent adverse events (TEAEs) leading to discontinuation, severe TEAEs, or instances of oversedation in this study. There were no statistically significant differences between treatment groups in the proportion of patients with potentially clinically significant changes in laboratory tests, vital signs (blood pressure and pulse rate), electrocardiograms, and treatment-emergent extrapyramidal symptoms.

CONCLUSION

The efficacy of IM olanzapine 10 mg in patients with exacerbation of schizophrenia with acute psychotic agitation was greater than IM placebo in the primary efficacy measure, PANSS-EC. Intramuscular olanzapine 10 mg was shown to be generally safe and tolerable, and could be a new option for treatment of schizophrenia in Japan.

TRIAL REGISTRATION

NCT00970281.

Antipsychotic agents: efficacy and safety in schizophrenia

Antipsychotics have provided a great improvement in the management of people with schizophrenia. The first generation antipsychotics could establish the possibility of managing many psychotic subjects in an outpatient setting. With the advent of the second (SGA) and third generation antipsychotics (TGA), other psychiatric disorders such as bipolar depression, bipolar mania, autism, and major depressive disorder have now been approved for the use of these drugs for their treatment. Also, the administration of more specific assessment tools has allowed for better delineation of the repercussions of these drugs on symptoms and the quality of life of patients who use antipsychotic agents. In general, the SGA share similar mechanisms of action to achieve these results: dopamine-2 receptor antagonism plus serotonin-2A receptor antagonism. The TGA (eg, aripiprazole) have partial agonist activity at the dopamine-2 receptor site, and are also called dopaminergic stabilizers. The pharmacological profile of SGA and TGA may provide better efficacy against negative symptoms, and are less likely to produce extrapyramidal symptoms; however, the SGA and TGA are associated with many other adverse events. The clinician has to balance the risks and benefits of these medications when choosing an antipsychotic for an individual patient.

Medical evaluation and triage of the agitated patient: consensus statement of the american association for emergency psychiatry project Beta medical evaluation workgroup

Numerous medical and psychiatric conditions can cause agitation; some of these causes are life threatening. It is important to be able to differentiate between medical and nonmedical causes of agitation so that patients can receive appropriate and timely treatment. This article aims to educate all clinicians in nonmedical settings, such as mental health clinics, and medical settings on the differing levels of severity in agitation, basic triage, use of de-escalation, and factors, symptoms, and signs in determining whether a medical etiology is likely. Lastly, this article focuses on the medical workup of agitation when a medical etiology is suspected or when etiology is unclear.

Aripiprazole: a review of its use in the management of schizophrenia in adults

Oral aripiprazole (Abilify®) is an atypical antipsychotic agent that is approved worldwide for use in adult patients with schizophrenia. It is a quinolinone derivative that has a unique receptor binding profile as it exhibits both partial agonist activity at dopamine D(2) receptors and serotonin 5-HT(1A) receptors and antagonist activity at 5-HT(2A) receptors. In several well designed, randomized, clinical trials of 4-6 weeks duration, aripiprazole provided symptomatic control for patients with acute, relapsing schizophrenia or schizoaffective disorder. Furthermore, following 26 weeks' treatment, the time to relapse was significantly longer for patients with chronic, stabilized schizophrenia receiving aripiprazole compared with those receiving placebo. Using a variety of efficacy outcomes, aripiprazole showed a mixed response when evaluated against other antipsychotic agents in randomized clinical trials. Longer-term data showed that improvements in remission rates and response rates favoured aripiprazole over haloperidol, although, the time to failure to maintain a response was not significantly different between the treatment arms. On the other hand, improvements in positive and negative symptom scores mostly favoured olanzapine over aripiprazole, although, the time to all-cause treatment discontinuation was not significantly different between the two treatments. Several open-label, switching trials showed that aripiprazole provided continued control of symptoms in patients with schizophrenia or schizoaffective disorder. Using a variety of efficacy outcomes or quality-of-life scores, longer-term treatment generally favoured patients switched to receive aripiprazole compared with standard-of-care oral antipsychotics. Aripiprazole was generally well tolerated in patients with schizophrenia. In particular, its use seems to be associated with a lower incidence of extrapyramidal symptoms than haloperidol and fewer weight-gain issues than olanzapine. Aripiprazole also showed a favourable cardiovascular tolerability profile and its use was associated with a reduced risk of metabolic syndrome than placebo or olanzapine. As a consequence, aripiprazole may provide a more cost-effective treatment option compared with other atypical antipsychotics. In conclusion, oral aripiprazole provides an effective and well tolerated treatment alternative for the acute and long-term management of patients with schizophrenia.

Nonaffective acute psychoses: uncertainties on the way to DSM-V and ICD-11

Since the early 20th century, a group of nonaffective psychoses with acute onset and brief duration have been described in different countries under various names, including cycloid psychosis, bouffée délirante, and reactive psychosis. These psychoses share several characteristics, including benign course, greater prevalence in women than men and in developing countries than in industrialized countries, and high prevalence of premorbid psychological and physiologic stressors. However, the variations in names and minute details of symptomatology have overshadowed the basic similarities across these various descriptions. Confusion in classification persists in the two contemporary diagnostic systems, the DSM-IV and the ICD-10. We believe that most cases of these psychoses could be captured under a broad, unified category of nonaffective psychosis with acute onset and brief duration, and urge the authors of the upcoming revisions of the DSM and ICD to create such a category. A unified diagnostic category for these disorders would reduce unnecessary fragmentation in the diagnostic systems and assist in the progress of research on these rare conditions.

The management of psychiatric emergencies

BACKGROUND

Psychiatric emergencies such as acute psychomotor agitation or suicidality often arise in non-psychiatric settings such as general hospitals, emergency services, or doctors' offices and give rise to stress for all persons involved. They may be life-threatening and must therefore be treated at once. In this article, we discuss the main presenting features, differential diagnoses, and treatment options for the main types of psychiatric emergency, as an aid to their rapid and effective management.

METHOD

Selective literature review.

RESULTS AND CONCLUSION

The frequency of psychiatric emergencies in non-psychiatric settings, such as general hospitals and doctors' offices, and their treatment are poorly documented by the few controlled studies and sparse reliable data that are now available. The existing evidence suggests that the diagnosis and treatment of psychiatric emergencies need improvement. The treatment of such cases places high demands on the physician's personality and conduct, aside from requiring relevant medical expertise. Essential components of successful treatment include the establishment of a stable, trusting relationship with the patient and the ability to "talk down" agitated patients calmly and patiently. A rapid and unambiguous decision about treatment, including consideration of the available options for effective pharmacotherapy, usually swiftly improves the acute manifestations.

Patient perspectives on antipsychotic treatments and their association with clinical outcomes

This analysis examined patient-reported attitudes toward antipsychotic medication and the relationship of these attitudes with clinical outcomes and pharmacotherapy adherence. The analysis included three randomized, double-blind studies in patients with schizophrenia, schizoaffective disorder, or schizophreniform disorder diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders 4th Edition and randomly assigned to treatment with olanzapine 5-20 mg/day or another antipsychotic (haloperidol 2-20 mg/day, risperidone 2-10 mg/day, or ziprasidone 80-160 mg/day). Patient-reported improvements were significantly greater for olanzapine (n = 488) versus other treatments (haloperidol n = 145, risperidone n = 158, or ziprasidone n = 271) on multiple Drug Attitude Inventory items. A positive attitude toward medication reported by patients was significantly associated with greater clinical improvement on the Positive and Negative Syndrome Scale and lower discontinuation rates. These results suggest that patients' perceptions of treatment benefits are associated with objective clinical measures, including reduction of symptom severity and lower discontinuation rates. Furthermore, olanzapine may be associated with more positive treatment attitudes. These findings may contribute to a better understanding of reasons for treatment adherence from patients' own perspectives.

Schizophrenia, "just the facts" 5. Treatment and prevention. Past, present, and future

The introduction of second-generation antipsychotics and cognitive therapies for schizophrenia over the past two decades generated considerable optimism about possibilities for recovery. To what extent have these developments resulted in better outcomes for affected individuals? What is the current state of our science and how might we address the many unmet needs in the prevention and treatment of schizophrenia? We trace the evolution of various treatments for schizophrenia and summarize current knowledge about available pharmacological and psychosocial treatments. We consider the widely prevalent efficacy-effectiveness gap in the application of available treatments and note the significant variability in individual treatment response and outcome. We outline an individualized treatment approach which emphasizes careful monitoring and collaborative decision-making in the context of ongoing benefit-risk assessment. We note that the evolution of both pharmacological and psychosocial treatments thus far has been based principally on serendipity and intuition. In view of our improved understanding of the etiology and pathophysiology of schizophrenia, there is an opportunity to develop prevention strategies and treatments based on this enhanced knowledge. In this context, we discuss potential psychopathological treatment targets and enumerate current pharmacological and psychosocial development efforts directed at them. Considering the stages of schizophrenic illness, we review approaches to prevent progression from the pre-symptomatic high-risk to the prodrome to the initial psychotic phase to chronicity. In view of the heterogeneity of risk factors, we summarize approaches towards targeted prevention. We evaluate the potential contribution of pharmacogenomics and other biological markers in optimizing individual treatment and outcome in the future.

Antipsychotic medication, functional outcome and quality of life in schizophrenia: focus on amisulpride

BACKGROUND

Restoration of quality of life is considered as the ultimate treatment goal in the management of schizophrenia and is important for destigmatising the disease. However, few studies, including the most recent, have collected quality of life data prospectively or evaluated the relationship of treatment with quality of life.

SCOPE

Amisulpride is an atypical antipsychotic drug which has been described to have potency in improving negative symptoms of chronic schizophrenia and whose use is associated with a relatively low rate of emergence of extrapyramidal side-effects. These properties may contribute to a beneficial effect on quality of life. A systematic literature review of functional outcome in clinical trials with amisulpride was performed in order to assess the effect of this drug on quality of life and social functioning in patients. The Medline database was searched for all studies of amisulpride in schizophrenia which reported functional and quality of life outcomes up until 30 September 2009.

FINDINGS

Only one dedicated study assessing functional outcome or quality of life as a primary outcome criterion was identified. This demonstrated significant improvement in subjective well-being in patients with schizophrenia initiating treatment with amisulpride, and a correlation between this improvement and amelioration of psychopathology. In addition, functional outcome rating scales were used as secondary outcome measures in eight randomised clinical trials, and two naturalistic observational studies. Amisulpride treatment was associated with improvement in functional outcome, with effect sizes that were comparable between studies. Improvements in functional outcome are consistently greater than those observed in patients treated with haloperidol and similar in magnitude to those seen with three other atypical antipsychotics, namely olanzapine, ziprasidone and risperidone. A patient-reported outcome measure was used in only one comparative study, and demonstrated perception of a superior benefit with amisulpride compared to haloperidol. These findings could to some extent be replicated in several large naturalistic studies under standard conditions of care.

CONCLUSIONS

The data from studies on functional outcome and subjective well-being provide consistent information supporting the use of amisulpride for the treatment of schizophrenia in order to improve social functioning, integration into the community and autonomy, which are critical for the overall quality of life of patients with schizophrenia.

Research in people with psychosis risk syndrome: a review of the current evidence and future directions

After decades of research, schizophrenia and related psychotic disorders are still among the most debilitating disorders in medicine. The chronic illness course in most individuals, greater treatment responsiveness during the first episode, progressive gray matter decline during early disease stages, and retrospective accounts of 'prodromal' or early illness signs and symptoms formed the basis for research on the psychosis risk syndrome (PRS), known variably as 'clinical high risk' (CHR), or 'ultra-high risk' (UHR), or 'prodromal'. The pioneering era of research on PRS focused on the development and validation of specific assessment tools and the delineation of high risk criteria. This was followed by the examination of conversion rates in psychosis risk cohorts followed naturalistically, identification of predictors of conversion to psychosis, and investigation of interventions able to abort or delay the development of full psychosis. Despite initially encouraging results concerning the predictive validity of PRS criteria, recent findings of declining conversion rates demonstrate the need for further investigations. Results from intervention studies, mostly involving second-generation antipsychotics and cognitive behavioral therapy, are encouraging, but are currently still insufficient to make treatment recommendations for this early, relatively non-specific illness phase. The next phase of research on PRS, just now beginning, has moved to larger, 'multisite' projects to increase generalizability and to ensure that sufficiently large samples at true risk for psychosis are included. Emphasis in these emerging studies is on: 1) identification of biomarkers for conversion to psychosis; 2) examination of non-antipsychotic, neuroprotective and low-risk pharmacologic and non-pharmacologic interventions; 3) testing of potentially phase-specific interventions; 4) examination of the relationship between treatment response during PRS and prognosis for the course of illness; 5) follow-up of patients who developed schizophrenia despite early interventions and comparison of illness trajectories with patients who did not receive early interventions; 6) characterization of individuals with outcomes other than schizophrenia-spectrum disorders, such as bipolar disorder and remission from PRS, including false positive cases; and 7) assessment of meaningful social and role functioning outcomes. While the research conducted to date has already yielded crucial information, the translation of the concept of a clinically identifiable PRS into clinical practice does not seem justified at this point.