The use of memantine in neuropsychiatric disorders: An overview

BACKGROUND

Memantine is a non-competitive N-methyl-d-aspartate receptor antagonist currently used for the treatment of Alzheimer's disease as an approved indication. However, as knowledge of signaling pathways is increasing, the therapeutic potential of memantine is being applied for the treatment of various psychiatric illnesses.

METHODS

The PubMed online database was searched for the use of memantine in various psychiatric disorders. Case studies, open-label trials, and controlled trials from the search were included.

RESULTS

Memantine monotherapy was found to exert efficacy in several neuropsychiatric conditions, including autism spectrum disorder, binge eating disorder, and attention-deficit/hyperactivity disorder. For posttraumatic stress disorder and generalized anxiety disorder, memantine was found efficacious in augmentation with other medications. In obsessive-compulsive disorder (OCD), memantine was used as both an augmentation to selective serotonin reuptake inhibitors and standalone therapy, and most published studies found it to improve OCD symptoms. For schizophrenia, memantine has been reported to be consistently effective for negative symptoms only. The manic phase of bipolar disorder also appears to benefit from memantine. The depressive phase of bipolar disorder and major depressive disorder did not respond significantly to memantine. Catatonia as a symptom of various disorders improved in several case studies when memantine was used in combination with other medications.

CONCLUSIONS

Memantine may have several therapeutic applications in psychiatry, reflecting the involvement of glutamate pathways in multiple psychiatric disorders.

Effects of nonpharmacological therapies on anxiety and cortisol: A meta-analysis

BACKGROUND

Although pharmacotherapy is considered the standard of care for the treatment of anxiety, a subset of the patients remains resistant or intolerant to iatrogenic adverse effects. Nonpharmacological and nonpsychotherapeutic interventions, sometimes referred to as "complementary treatments," have emerged as possible alternatives in the treatment of anxiety. We conducted a meta-analysis of placebo-controlled studies to assess the efficacy of nonpharmacological therapy on anxiety. In addition, because serum and salivary cortisol levels are elevated during anxiety, we conducted a separate meta-analysis of pre- and posttreatment cortisol levels.

METHODS

A search was conducted to identify randomized controlled trials published from January 2010 to May 2017 that measured the effects of nonpharmacological therapies on State Trait Anxiety Index (STAI) scores and cortisol levels before and after treatment.

RESULTS

Four studies met the criteria for inclusion. Our meta-analysis reveals that participants receiving nonpharmacological therapy had a statistically significant decrease in STAI scores (d = -.340; 95% confidence interval [CI], -.639, -.041; P = .026), but no statistically significant decrease in cortisol levels (d = -.085; 95% CI, -.396, .226; P = .591) after intervention.

CONCLUSIONS

Our meta-analysis data suggest that "complementary" therapies improved the clinical manifestations of anxiety and thus may be useful as adjunctive approaches to drug treatment.

Multiple retinal anomalies in schizophrenia

INTRODUCTION

In addition to being a critical component of the visual system, the retina provides the opportunity for an accessible and noninvasive probe of brain pathology in neuropsychiatric disorders. Several studies have reported various retinal abnormalities in schizophrenia, some primary and others iatrogenic. There is now increasing evidence supporting the existence of retinal anomalies in schizophrenia across structural, neurochemical and physiological parameters. Here, we review the types of retinal pathology in schizophrenia and discuss how these findings may provide novel insights for future research into the neurodevelopmental neurobiology of this syndrome, and possibly as useful biomarkers.

METHODS

Using the keywords schizophrenia, retina, pathology, electroretinogram (ERG), and/or optical coherence tomography (OCT) on PubMed, all studies using the English language within 30years were reviewed. Methods were examined, and common themes were identified, tabulated, and discussed.

RESULTS

We classified the reports of retinal pathology into primary and secondary. The major secondary retinal pathology is related to the iatrogenic effects of a once widely prescribed first generation antipsychotic (thioridazine), which was found to be associated with retinal pigment deposits, decreased visual acuity, and suppression of dark adapted ERG responses. The primary retinal findings were obtained via different measures primarily using ERG, OCT, and microvascular imaging. The most consistent findings were 1) decreased ERG wave amplitudes, 2) reduced macular volume, 3) thinning of retinal nerve fiber layer, and 4) widened venule caliber.

CONCLUSION

The abnormal pathobiological findings of the retina in schizophrenia may represent an important avenue for elucidating some of the neurodevelopmental aberrations in schizophrenia. The well replicated retinal anomalies could serve as biomarkers for schizophrenia and perhaps an endophenotype that may help identify at-risk individuals and to facilitate early intervention.

Multiple retinal anomalies in schizophrenia

INTRODUCTION

In addition to being a critical component of the visual system, the retina provides the opportunity for an accessible and noninvasive probe of brain pathology in neuropsychiatric disorders. Several studies have reported various retinal abnormalities in schizophrenia, some primary and others iatrogenic. There is now increasing evidence supporting the existence of retinal anomalies in schizophrenia across structural, neurochemical and physiological parameters. Here, we review the types of retinal pathology in schizophrenia and discuss how these findings may provide novel insights for future research into the neurodevelopmental neurobiology of this syndrome, and possibly as useful biomarkers.

METHODS

Using the keywords schizophrenia, retina, pathology, electroretinogram (ERG), and/or optical coherence tomography (OCT) on PubMed, all studies using the English language within 30years were reviewed. Methods were examined, and common themes were identified, tabulated, and discussed.

RESULTS

We classified the reports of retinal pathology into primary and secondary. The major secondary retinal pathology is related to the iatrogenic effects of a once widely prescribed first generation antipsychotic (thioridazine), which was found to be associated with retinal pigment deposits, decreased visual acuity, and suppression of dark adapted ERG responses. The primary retinal findings were obtained via different measures primarily using ERG, OCT, and microvascular imaging. The most consistent findings were 1) decreased ERG wave amplitudes, 2) reduced macular volume, 3) thinning of retinal nerve fiber layer, and 4) widened venule caliber.

CONCLUSION

The abnormal pathobiological findings of the retina in schizophrenia may represent an important avenue for elucidating some of the neurodevelopmental aberrations in schizophrenia. The well replicated retinal anomalies could serve as biomarkers for schizophrenia and perhaps an endophenotype that may help identify at-risk individuals and to facilitate early intervention.

A novel approach to measuring response and remission in schizophrenia in clinical trials

BACKGROUND

Pharmaceutical companies conduct clinical trials to show the efficacy and safety of new medications for the treatment of schizophrenia. After the new medications are marketed, clinicians treating patients with schizophrenia discover that a considerable number of patients do not respond to these new medications. The goals of the review are to examine the methodology and design of recent antipsychotic clinical trials, identify common flaws, and propose guidelines to fix the flaws and improve the quality of future clinical trials of antipsychotic medications.

METHODS

A review of recent antipsychotic clinical trials was conducted using a PubMed search. Ten recent trials published in the past four years were reviewed and their methods analyzed and critiqued.

RESULTS

The authors identified six major methodological flaws that may explain the suboptimal response in many patients after a drug is approved. Most of the flaws are related to eligibility criteria, the misuse of the Positive and Negative Syndromes Scale (PANSS) and the lack of consensus on how to define remission, response and exacerbation in schizophrenia. Proposed guidelines for a more rigorous use of the PANSS are presented and recommendations are proposed for using uniform criteria for remission, response and exacerbation in schizophrenia.

CONCLUSIONS

The authors recommend using standardized diagnostic interviews to screen patients for eligibility criteria and using the PANSS according to the author's recommendations and the proposed guidelines. Uniform criteria to define remission, response and exacerbation are recommended for clinical trials examining the efficacy and safety of antipsychotic drugs in schizophrenia.

The safety and tolerability of cariprazine in long-term treatment of schizophrenia: a post hoc pooled analysis

BACKGROUND

Schizophrenia is a chronic and debilitating neuropsychiatric disorder that often requires long-term pharmacotherapy to manage symptoms and prevent relapse. Cariprazine is a potent dopamine D₃ and D₂ receptor partial agonist that is FDA-approved in the US for the treatment of schizophrenia and manic or mixed episodes associated with bipolar I disorder in adults; the recommended dose range is 1.5-6 mg/d.

METHODS

To further characterize the long-term safety of cariprazine, data from two 48-week open-label, flexible-dose extension studies were pooled for post hoc analyses. Outcomes were evaluated in the pooled safety population (patients who received ≥1 dose of cariprazine during an open-label extension period); findings were summarized using descriptive statistics for the overall cariprazine group and in modal daily dose groups (1.5-3, 4.5-6, and 9 mg/d).

RESULTS

Of the 679 patients in the overall cariprazine safety population, 40.1% completed the study. The only adverse events (AEs) leading to discontinuation of ≥2% of patients in any dose group were akathisia, worsening of schizophrenia, and psychotic disorder. Treatment-emergent AEs (TEAEs) of akathisia, insomnia, weight increased, and headache were reported in ≥10% of the overall population. Mean prolactin levels decreased in all dose groups (overall, -15.4 ng/mL). Clinically insignificant changes in aminotransferase levels and alkaline phosphatase were observed; no dose-response relationship was observed across groups. Mean total (-5.3 mg/dL), low-density lipoprotein (-3.5 mg/dL), and high-density lipoprotein (-0.8 mg/dL) cholesterol levels decreased; no dose-response relationship was observed for metabolic parameters. Mean change in body weight was 1.58 kg; body weight increase and decrease ≥7% occurred in 27% and 11% of patients, respectively. Mean changes in cardiovascular parameters, including blood pressure and pulse, were generally not considered clinically significant. EPS-related TEAEs that occurred in ≥5% of patients were akathisia, tremor, restlessness, and extrapyramidal disorder.

CONCLUSION

In these post hoc pooled analyses of data from 2 long-term open-label studies, treatment with cariprazine was generally safe and well tolerated. Results support the safety and tolerability of cariprazine within the FDA-recommended dose range of 1.5-6 mg/d for schizophrenia.

CLINICAL TRIALS REGISTRATION

NCT01104792, NCT00839852.

Multiple neurotoxic effects of haloperidol resulting in neuronal death

BACKGROUND

Several published studies have reported an association between antipsychotic medications, especially first-generation agents, and a decline in gray matter volume. This prompted us to review the possible neurotoxic mechanisms of first-generation antipsychotics (FGAs), especially haloperidol, which has been widely used over the past several decades.

METHODS

A PubMed search was conducted using the keywords haloperidol, antipsychotic, neurotoxicity, apoptosis, oxidative stress, and neuroplasticity. No restrictions were placed on the date of the articles or language. Studies with a clearly described methodology were included.

RESULTS

Animal, cell culture, and human tissue studies were identified. Thirty reports met the criteria for the search. All studies included haloperidol; a few also included other FGAs (fluphenazine and perphenazine) and/or second-generation agents (SGAs) (aripiprazole, paliperidone, and risperidone). A neurotoxic effect of haloperidol and other FGAs was a common theme across all studies. Minimal (mainly at high doses) or no neurotoxic effects were noted in SGAs.

CONCLUSIONS

A review of the literature suggests that haloperidol exerts measurable neurotoxic effects at all doses via many molecular mechanisms that lead to neuronal death. A similar effect was observed in 2 other FGAs, but the effect in SGAs was much smaller and occurred mainly at high doses. A stronger binding to serotonin 5HT-2A receptors than to dopamine D2 receptors may have a neuroprotective effect among SGAs. Further studies are warranted to confirm these findings.

Metabolic and Endocrine Profiles During 1-Year Treatment of Outpatients with Schizophrenia with Aripiprazole Lauroxil

BACKGROUND

We assessed long-term metabolic and endocrine profiles of outpatients with schizophrenia participating in a one-year open-label extension study of monthly aripiprazole lauroxil (AL), a long-acting injectable antipsychotic.

METHODS

Patients (N = 478) were enrolled in a 52-week, open-label extension study of AL monotherapy administered by intramuscular injection every 4 weeks. Of these, most (368) received AL 882 mg and the remainder AL 441 mg as their fixed-dose regimen. Among the patients entering the long-term study, 181 (38%) had already received three prior AL injections. The baseline values for this analysis were obtained from the visit before the first AL injection. Patients were followed for the full year of the extension study unless they discontinued early. Changes in metabolic parameters (weight, fasting blood sugar, lipids) and serum prolactin were assessed over the duration of AL exposure, which could extend to a total of 16 AL injections. Data presented are last observation carried forward from baseline to last visit.

RESULTS

Most patients remained for most of the follow-up period, with 409 (86%) remaining at 6 months and 326 (68%) completing the one-year treatment period. The mean (standard deviation) changes from baseline in the overall population were: +1.1 (27.5) mg/dL for glucose, +0.07 (0.6)% for glycated hemoglobin (HbA_1c), -3.3 (35.8) mg/dL for total cholesterol and -5.3 (101.9) mg/dL for triglycerides. Prolactin change from baseline was -8.7 ng/mL (14.7) for men and -14.9 (43.4) ng/mL for women. Overall, the mean weight change was +0.8 (5.9) kg. In terms of categorical weight change, 88 patients (18%) gained ≥7% body weight, and 59 (12%) lost ≥7% body weight. Overall, there was no clinically meaningful difference between any of these variables and AL dose.

CONCLUSION

Long-term treatment with AL in outpatients with schizophrenia was associated with a modest lowering of serum prolactin for both genders and relatively modest changes in average weight, fasting glucose, and HbA_1c values. There appeared to be little net change in lipid parameters. This presentation extends a recently published report on the short-term metabolic and endocrine effects of AL over a period of 12 weeks. The present study increased the follow-up period to more than a year and was careful to use the first exposure to AL as the baseline. Limitations include lack of a comparison group and difficulty disentangling effects of medication treatment versus factors. Overall, the metabolic, weight, and endocrine effects reported here are consistent with other long-term effects of oral aripiprazole treatment. This study was funded by Alkermes, Inc.

Examining the reliability and validity of the Clinical Assessment Interview for Negative Symptoms within the Management of Schizophrenia in Clinical Practice (MOSAIC) multisite national study

The current study sought to expand on prior reports of the validity and reliability of the CAINS (CAINS) by examining its performance across diverse non-academic clinical settings as employed by raters not affiliated with the scale's developers and across a longer test-retest follow-up period. The properties of the CAINS were examined within the Management of Schizophrenia in Clinical Practice (MOSAIC) schizophrenia registry. A total of 501 participants with a schizophrenia spectrum diagnosis who were receiving usual care were recruited across 15 national Patient Assessment Centers and evaluated with the CAINS, other negative symptom measures, and assessments of functioning, quality of life and cognition. Temporal stability of negative symptoms was assessed across a 3-month follow-up. Results replicated the two-factor structure of the CAINS reflecting Motivation and Pleasure and expression symptoms. The CAINS scales exhibited high internal consistency and temporal stability. Convergent validity was supported by significant correlations between the CAINS subscales with other negative symptom measures. Additionally, the CAINS was significantly correlated with functioning and quality of life. Discriminant validity was demonstrated by small to moderate associations between the CAINS and positive symptoms, depression, and cognition (and these associations were comparable to those found with other negative symptom scales). Findings suggest that the CAINS is a reliable and valid tool for measuring negative symptoms in schizophrenia across diverse clinical samples and settings.

New drug developments in psychosis: Challenges, opportunities and strategies

All currently approved drugs for schizophrenia work mainly by dopaminergic antagonism. While they are efficacious for psychotic symptoms, their efficacy is limited for negative symptoms and cognitive deficits which underlie the substantive disability in this illness. Recent insights into the biological basis of schizophrenia, especially in relation to non-dopaminergic mechanisms, have raised the efforts to find novel and effective drug targets, though with relatively little success thus far. Potential impediments to novel drug discovery include the continued use of symptom based disease definitions which leads to etiological and pathophysiological heterogeneity, lack of valid preclinical models for drug testing, and design limitations in clinical trials. These roadblocks can be addressed by (i) characterizing trans-diagnostic, translational pathophysiological dimensions as potential treatment targets, (ii) efficiency, accountability and, transparency in approaches to the clinical trials process, and (iii) leveraging recent advances in genetics and in vitro phenotypes. Accomplishing these goals is urgent given the significant unmet needs in the pharmacological treatment of schizophrenia. As this happens, it is imperative that clinicians employ optimal dosing, measurement-based care, and other best practices in utilizing existing treatments to optimize outcomes for their patients today.

The intense desire for healthy limb amputation: A dis-proprioceptive neuropsychiatric disorder

BACKGROUND

The first mention of a condition in which apparently nonpsychotic individuals have a strong, unrelenting desire to amputate ≥1 of their healthy limbs was published nearly 4 decades ago. Once dismissed as a paraphilia, the condition in recent years has been re-investigated with neurologic testing and imaging, yielding evidence suggesting it may be attributable to a neuroanatomical anomaly.

METHODS

A literature review of data was conducted of recently published studies with pinprick testing, magnetic resonance imaging (MRI)/functional MRI imaging, magnetoencephalography, and interviews of individuals with a desire for limb amputation.

RESULTS

Published literature on this condition features studies with a limited number of participants. However, the results indicate that affected individuals predominantly desire amputation of the left lower limb, and correspondingly, usually have changes in cortical thickness in the right parietal lobe.

CONCLUSIONS

Further investigation of this condition is warranted, particularly, more research into the precise nature of the anomalous neuroanatomy, biopsychosocial background of those with the condition, and longitudinal perspective of the childhood onset and evolution of symptoms. Large sample studies involving a collaborative effort across multiple sites are required.

Exploring the long-term safety of asenapine in adults with schizophrenia in a double-blind, fixed-dose, extension study

PURPOSE

The primary objective of this study was to assess long-term safety with sublingual asenapine 2.5 or 5 mg twice daily (BID) in patients with schizophrenia.

PATIENTS AND METHODS

Actively treated patients on asenapine 2.5 mg BID, asenapine 5 mg BID, or olanzapine 15 mg once daily (QD) who completed a 6-week randomized, double-blind, placebo- and olanzapine-controlled study continued lead-in treatment in this 26-week, multicenter, double-blind, double-dummy, olanzapine-controlled Phase IIIB extension study; placebo patients were assigned to asenapine 2.5 mg BID treatment. Safety analyses were based on the all treated set (patients who received one or more doses of extension trial medication); change from baseline analyses used the acute study baseline. Treatment-emergent adverse events (TEAEs) and changes in laboratory parameters were monitored; weight change for asenapine versus olanzapine was the key secondary objective. Descriptive statistics were used; weight change was analyzed using a mixed-model repeated-measure approach.

RESULTS

Of the 120 patients in the all-treated set, 60% completed treatment (asenapine 2.5 mg BID 66.1% overall, asenapine 5 mg BID 52.4%, olanzapine 15 mg QD 56.3%). The incidence of TEAEs was higher for placebo patients from the lead-in study who switched to asenapine 2.5 mg BID for extension treatment (71.0%) versus patients continuing asenapine 2.5 mg BID (38.7%), asenapine 5 mg BID (38.1%), or olanzapine 15 mg QD (25.0%). The most common TEAE (≥5% in every group) was worsening of schizophrenia. Least squares mean change in body weight from the acute study baseline to week 26 was +0.6 kg for overall asenapine 2.5 mg BID, +0.8 kg for asenapine 5 mg BID, and +1.2 kg for olanzapine 15 mg QD. There were no clinically relevant changes in metabolic parameters; values were generally similar across treatment groups.

CONCLUSION

Asenapine 2.5 mg BID and 5 mg BID were generally well tolerated in long-term treatment. Weight gain was less for overall asenapine 2.5 mg BID and 5 mg BID than for olanzapine 15 mg QD.

Effect of Aripiprazole Lauroxil on Metabolic and Endocrine Profiles and Related Safety Considerations Among Patients With Acute Schizophrenia

OBJECTIVE

Aripiprazole lauroxil, a long-acting injectable antipsychotic, demonstrated safety and efficacy in treating symptoms of schizophrenia in a double-blind, placebo-controlled trial. Because the metabolic profile of antipsychotics is an important safety feature, the effects of aripiprazole lauroxil on body weight, endocrine and metabolic profiles, and safety were examined in a secondary analysis.

METHODS

Patients with schizophrenia (DSM-IV-TR criteria) were randomly assigned to aripiprazole lauroxil 441 mg, aripiprazole lauroxil 882 mg, or placebo intramuscularly once monthly between December 2011 and March 2014. Changes in body weight, body mass index, fasting blood glucose and serum lipids, glycosylated hemoglobin (HbA1c), and prolactin over 12 weeks were assessed. The incidence of treatment-emergent adverse events (AEs) was evaluated.

RESULTS

Among 622 randomized patients, no clinically relevant changes from baseline to week 12 were observed for any serum lipid, lipoprotein, plasma glucose, or HbA1c value with placebo or either dose of aripiprazole lauroxil. Both doses of aripiprazole lauroxil were associated with reductions in mean prolactin levels, whereas placebo treatment was not. The mean (standard deviation) change from baseline for body weight was 0.74 (3.9) kg, 0.86 (3.7) kg, and 0.01 (3.6) kg for aripiprazole lauroxil 441 mg, aripiprazole lauroxil 882 mg, and placebo groups, respectively. AEs related to metabolic parameters were reported in 2.4%, 1.4%, and 2.4% of patients in the aripiprazole lauroxil 441 mg, aripiprazole lauroxil 882 mg, and placebo groups, respectively.

CONCLUSIONS

Aripiprazole lauroxil was well tolerated, with a low-risk metabolic profile relative to published data for other antipsychotics. Changes similar to those observed with placebo were observed in the aripiprazole lauroxil groups for metabolic parameters, with modest weight gain in the active treatment groups over the 12-week course.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01469039.

Long-term cariprazine treatment for the prevention of relapse in patients with schizophrenia: A randomized, double-blind, placebo-controlled trial

Cariprazine, a dopamine D3/D2 receptor partial agonist with preference for D3 receptors, has demonstrated efficacy in randomized controlled trials in schizophrenia. This multinational, randomized, double-blind, placebo-controlled, parallel-group study evaluated the efficacy, safety, and tolerability of cariprazine for relapse prevention in adults with schizophrenia; total study duration was up to 97weeks. Schizophrenia symptoms were treated/stabilized with cariprazine 3-9mg/d during 20-week open-label treatment consisting of an 8-week, flexible-dose run-in phase and a 12-week fixed-dose stabilization phase. Stable patients who completed open-label treatment could be randomized to continued cariprazine (3, 6, or 9mg/d) or placebo for double-blind treatment (up to 72weeks). The primary efficacy parameter was time to relapse (worsening of symptom scores, psychiatric hospitalization, aggressive/violent behavior, or suicidal risk); clinical measures were implemented to ensure safety in case of impending relapse. A total of 264/765 patients completed open-label treatment; 200 eligible patients were randomized to double-blind placebo (n=99) or cariprazine (n=101). Time to relapse was significantly longer in cariprazine- versus placebo-treated patients (P=.0010, log-rank test). Relapse occurred in 24.8% of cariprazine- and 47.5% of placebo-treated patients (hazard ratio [95% CI]=0.45 [0.28, 0.73]). Akathisia (19.2%), insomnia (14.4%), and headache (12.0%) were reported in ≥10% of patients during open-label treatment; there were no cariprazine adverse events ≥10% during double-blind treatment. Long-term cariprazine treatment was significantly more effective than placebo for relapse prevention in patients with schizophrenia. The long-term safety profile in this study was consistent with the safety profile observed in previous cariprazine clinical trials. ClincalTrials.gov identifier: NCT01412060.

Placebo-controlled augmentation trials of the antioxidant NAC in schizophrenia: A review

BACKGROUND

Several studies have reported that schizophrenia is associated with mitochondrial abnormalities, glutathione deficit, and increased brain oxidative stress (free radicals). N-acetylcysteine (NAC) is a strong antioxidant with potential therapeutic benefit in schizophrenia, according to some reports. We conducted a review of the published controlled studies, with the goal of determining the efficacy profile of NAC as an adjunctive treatment for schizophrenia.

METHODS

An online search was conducted for all placebo-controlled, double-blind, randomized clinical trials of NAC in schizophrenia, and a review was conducted.

RESULTS

Two studies met the criteria for inclusion. Berk et al (2008) used NAC as an adjunctive treatment to atypical antipsychotics in subjects with chronic schizophrenia who were stable on antipsychotic medications. Treatment at 8 weeks was less efficacious than placebo, but at 24 weeks produced significant reductions vs placebo in Positive and Negative Syndrome Scale (PANSS) negative (d = 0.52), general (d = 0.46), and total (d = 0.57) scores. Farokhnia et al (2013) used NAC as an adjunctive treatment to risperidone in subjects with chronic schizophrenia who were experiencing an acute exacerbation episode. Eight weeks of treatment led to clinically significant reductions vs placebo in PANSS negative (d = 0.96), general (d = 0.59), and total (d = 0.88) scores.

CONCLUSIONS

The data suggest that adjunctive NAC may be efficacious in reducing negative and general symptoms in schizophrenia.

Transcending Psychosis: The Complexity of Comorbidity in Schizophrenia

Schizophrenic illness encompasses diverse clinical phenomena and consists of unclear underlying pathogeneses. For the past century, the comorbidities in schizophrenia have drawn persistent interest and debate due to its high prevalence rate and a need for better management. However, its clinical and biological diversity continue to challenge both the practicing clinicians and researchers. Emerging clinical and research evidence in the past decade suggest a distinct biopsychosocial pathogenesis and unique clinical attributes in some comorbid disorders in patients with schizophrenia. In addition, current evidence also supports improved outcomes with specific assessment and treatment of these subgroup of schizophrenia. The recent changes in DSV-5 and shift in the NIMH focus towards the real world clinical practice and research provide increased impetus to explore the pathogeneses and treatment of schizophrenia with comorbid disorders.

Perspectives on the Positive and Negative Syndrome Scale (PANSS): Use, misuse, drawbacks, and a new alternative for schizophrenia research

BACKGROUND

In 1987, Kay et al published the Positive and Negative Syndrome Scale (PANSS) and the PANSS manual to address the limitations of existing instruments for schizophrenia research. The PANSS has been one of the most widely used instruments in schizophrenia research-until now. Because of recent advances in neuroscience research, it has become essential to reevaluate the performance of the PANSS since its development 3 decades ago.

METHODS

A comprehensive literature review of the PANSS from 1987 to 2015 using a PubMed search was conducted.

RESULTS

Five drawbacks to the PANSS have been cited in the literature. Although several authors have pointed out flaws of the PANSS, no revisions or modifications have been attempted to address them. In addition, some researchers do not use the PANSS as intended by the authors, and other researchers misuse it.

CONCLUSIONS

The PANSS is a reliable and valid instrument that has served the scientific research community well for decades. New advances in experimental psychopathology and personalized psychiatry and the new National Institute of Mental Health paradigm of Research Domain Criteria necessitate a new instrument compatible with advances in clinical neuroscience research.

Pathological laughter and crying: A case series and proposal for a new classification

BACKGROUND

Disorders of laughter and crying (DLC) are seen in several neuropsychiatric conditions. Their nomenclature remains under debate.

METHODS

We present the clinical and imaging findings of 17 patients with DLC and introduce a new classification based on phenomenology and pathogenesis. According to intensity and frequency of laughter and crying (observed behavioral output), patients were divided into hypoactive or hyperactive DLC and subdivided into 5 subtypes: sensory (positive and negative), motor (positive and negative), and mixed. The sensory subtype is represented by disorders of "feeling processing," whereas the motor subtype is represented by disorders of "emotion processing." "Positive" and "negative" describe elicitation by irritative vs destructive lesions, respectively.

RESULTS

Among the patients studied, DLC resulted from ischemic stroke (n = 12), intracerebral hemorrhage (n = 2), gunshot wound (n = 1), amyotrophic lateral sclerosis (n = 1), or vestibular migraine (n = 1). Ten patients had lesions in the brainstem, 4 in the cerebral hemispheres, and 2 in sub-cortical-diencephalic structures. Six patients had negative motor DLC, 5 had positive sensory DLC, 4 had negative sensory DLC, and 2 had positive motor DLC. Phenomenology changed or progressed to mixed DLC in 7 patients.

CONCLUSIONS

This novel phenomenological and pathomechanistic nomenclature explains all subtypes of DLC in neurologic, medical, and psychiatric conditions. Future studies are needed to validate it prospectively.

Racial differences in antipsychotic use: Claims database analysis of Medicaid-insured patients with schizophrenia

BACKGROUND

Database analyses have indicated that medical treatment for schizophrenia varies among racial groups. This study assessed antipsychotic use and healthcare utilization across races in Medicaid-insured patients with schizophrenia.

METHODS

A Medicaid database of inpatient/outpatient medical claims and outpatient prescription claims for more than 28 million enrollees in 11 geographically diverse states was analyzed. The primary outcome, racial differences in antipsychotic use in 2012, was examined in 5 multivariable logistic regression models: (1) any antipsychotic, (2) first-generation (FG) long-acting injectables (LAIs), (3) FG oral antipsychotics, (4) second-generation (SG) LAIs, and (5) SG oral antipsychotics.

RESULTS

Odds ratios and adjusted predicted probabilities were comparable for any antipsychotic use between black and white patients. Black patients were less likely to receive SG oral antipsychotics (P < .001) and more likely to receive SG or FG LAIs (P = .001 and P < .001, respectively) and FG oral antipsychotics (P = .003) vs white patients. Further, black patients had a higher mean number of emergency room visits (P < .001) and a lower mean number of hospitalizations (P < .05) vs white patients; the mean number of physician visits was comparable.

CONCLUSIONS

Disparities in antipsychotic use and healthcare utilization across races in patients with schizophrenia warrant further investigation and elimination of these disparities should be a national goal.

A meta-analysis of placebo-controlled trials of omega-3 fatty acid augmentation in schizophrenia: Possible stage-specific effects

BACKGROUND

Omega-3 fatty acids have shown promise as an adjunctive treatment for schizophrenia. However, efficacy across studies has been inconsistent. We conducted a meta-analysis of published controlled studies with the goal of detecting different efficacy profiles at various stages of schizophrenia.

METHODS

An online search was conducted for randomized, double-blind, placebo-controlled clinical trials, and a meta-analysis was conducted.

RESULTS

Ten studies met the criteria for inclusion. Among patients in the prodromal phase of schizophrenia, omega-3 supplementation reduced psychotic symptom severity and lowered conversion rates to first-episode psychosis. In patients with first-episode schizophrenia, omega-3 decreased nonpsychotic symptoms, required lower antipsychotic medication dosages, and improved early treatment response rates. Omega-3 had mixed results in patients with stable chronic schizophrenia, with only some patients experiencing significant benefits. Among patients with chronic schizophrenia, use of omega-3 fatty acids both by those experiencing acute exacerbations and those who had discontinued antipsychotic medications resulted in worsening of psychotic symptoms.

CONCLUSIONS

The data suggest that omega-3 fatty acids may be efficacious in reducing clinical symptoms for patients in the earlier stages of schizophrenia (prodrome and first episode), while producing mixed results for patients in the chronic stages. Based on these results, omega-3 fatty acids would not be recommended for acute exacerbations in patients with chronic schizophrenia nor for relapse prevention after discontinuation of antipsychotics.

Consequences of misdiagnosis: inaccurate treatment and poor patient outcomes in bipolar disorder

Bipolar depression is difficult to diagnose and is often mistaken for unipolar depression. Unfortunately, this misdiagnosis creates a cascade of negative outcomes. Patients will probably receive inadequate or inappropriate treatment that will not alleviate the symptoms or impairment of the disorder and may even further destabilize their mood. These individuals are then at risk for experiencing numerous social and occupational impairments, alcohol or substance abuse, and suicidal behavior. An accurate diagnosis and appropriate treatment of bipolar disorder are necessary to prevent this chain of potentially disastrous events.