Pharmacotherapy of impaired affect in recovering schizophrenic patients

BACKGROUND

Prominent and persistent anxiety, depression, and/or negative features characterize a substantial minority of recovered or residually psychotic schizophrenic outpatients and contribute to poor outcome. Because extrapyramidal side effects of typical neuroleptic medications often resemble such features, we first systematically studied the contribution of extrapyramidal side effects to these problems and their treatment. For patients who remained distressed, controlled trials of supplemental thymoleptics were undertaken.

METHODS

In trial 1, 92 distressed (depressed and/or anxious) patients and 36 patients in a defect state (patients with negative symptoms) participated in a double-blind, intramuscular challenge that compared centrally acting benztropine mesylate with peripherally acting glycopyrrolate. In trial 2, 57 distressed patients and 22 patients in a defect state were randomly assigned to a double-blind, neuroleptic medication dose-reduction group. In trial 3, 57 chronically distressed patients who were maintained on a low dose of fluphenazine decanoate were randomly assigned to a supplemental desipramine hydrochloride, lithium carbonate, or placebo group under double-blind conditions for 12 weeks.

RESULTS

For patients who were already maintained on antiparkinsonian medication, impaired affect was not resolved by additional benztropine. Only distressed patients with a family history of severe mental disorder (often affective) showed improvement with neuroleptic medication dose reduction. Patients in the defect-state group reported less dysphoria on a reduced neuroleptic medication dose, but negative symptoms persisted. Desipramine improved diverse aspects of mood and residual psychoticism, possibly as a prophylaxis against minor affective exacerbations. Depression improved in women only. Lithium positively affected multiple indexes of anxiety and anxious depression.

CONCLUSION

Most often, persistent affective impairments are neither resistant extrapyramidal side effects nor characterological traits. Thymoleptics improve the nonphasic, chronic types of anxiety and depression in contrast to the acute, episodic forms, for which little support can be found in the literature.

Efficacy of risperidone on positive features of schizophrenia

Dopaminergic hyperactivity mediated via D2 receptors is implicated in the etiology of positive symptoms of schizophrenia, but selective D2 antagonists provide imperfect therapy. This article describes a subanalysis of a trial of risperidone, a combined 5-HT2A/D2 antagonist, in 513 patients with DSM-III-R chronic schizophrenia. Risperidone at 2, 6, 10, and 16 mg/day was compared with placebo and haloperidol 20 mg/day. All doses of risperidone and the 20-mg dose of haloperidol were superior to placebo (mean change from baseline on the PANSS positive and general psychopathology subscales). The 6-mg dose of risperidone also produced significantly more improvement than haloperidol 20 mg. We conclude that risperidone is an effective drug for patients with positive features of schizophrenia.

A pilot study of a structured interview addressing sexual function in men with schizophrenia

Twenty physically healthy men with schizophrenia responded to a 15-item questionnaire inquiring about their usual and their present (on medications) sexual functioning. Two summary measures of present impairment (the average of items 7-13 that detail the patients' specific complaints of impairment, and item 15, the interviewer's global judgment of impairment) were significantly correlated with each other and with the differences between usual and present reported frequencies of erection and masturbation. More severe impairment on these summary measures was significantly associated with greater biological evidence of dopamine blockade (more severe extrapyramidal side effects and higher serum prolactin levels).

Use of psychopathology vignettes by patients with schizophrenia or schizoaffective disorder and by mental health professionals to judge patients' insight

OBJECTIVE

The goal of this study was to clarify more precisely where patients with psychotic disorders and the mental health professionals who care for them disagree regarding whether the patient is ill or needs treatment.

METHOD

The authors prepared brief vignettes in everyday descriptive language that provided examples of the classical positive and negative psychopathological features of schizophrenia. Fifteen men and 11 women diagnosed as having schizophrenia or schizoaffective disorder and one physician used these vignettes as a common frame of reference to rate 1) the degree to which the patients demonstrated the features described in each vignette and 2) the degree to which the features signified the presence of mental illness.

RESULTS

Disagreements between the physician's and patients' ratings, indicating deficits in insight, were associated with the recognition of the presence of conceptual disorganization, avolition-apathy, and affective blunting in the patients by the physician but not the patients and with the conceptualization of hallucinatory behavior and suspiciousness as signs of mental illness by the physician but not the patients.

CONCLUSIONS

The authors conclude that the failure to acknowledge conceptual disorganization, avolition-apathy, and affective blunting and the failure to view hallucinatory behavior and suspiciousness as signs of mental illness, which proved to be additive in this study, contribute to deficits in insight.

An open study of the pharmacokinetics and the tolerability of raclopride extended release capsules in psychiatric patients

Following a 4-7 day drug-free washout period, eight male inpatients took an extended-release (ER) formulation of raclopride. After the initial 8 mg dose on day 1 of the study, repeated plasma samples were collected over the ensuing 36 h. Subsequently, patients received raclopride 8 mg b.i.d. through day 7, 12 mg b.i.d. through day 14, and, if tolerated, 16 mg b.i.d. through day 21. On days 7, 14, and 21, repeated plasma samples were drawn over the 12 h following the morning dose. Relative to the previously studied immediate release form of raclopride, the ER formulation delayed and extended the absorption of raclopride, and produced lower maximum raclopride concentrations. Linear kinetics were preserved across the dose range studied. Two patients could not tolerate the highest raclopride dose because of extrapyramidal side effects.

Optimal dose of neuroleptic in acute schizophrenia. A controlled study of the neuroleptic threshold and higher haloperidol dose

After individual determination of neuroleptic threshold (NT) doses of haloperidol, 106 patients with schizophrenia or schizoaffective disorder (Research Diagnostic Criteria) were treated openly at such doses (mean, 3.7 +/- 2.3 mg/d) for 2 weeks. Ten responding patients were discharged and unavailable for follow-up or refused subsequent randomization, and one non-responding patient refused randomization. The remaining 95 responding or nonresponding patients were then randomly assigned, double-blind, to a dosage of haloperidol two to 10 times higher (mean, 11.6 +/- 4.7 mg/d) or to a continuing NT dosage (mean, 3.4 +/- 2.3 mg/d) for another 2 weeks. Of the 58 patients exposed only to NT dosages of haloperidol, 72% clinically recovered within the 5-week trial. Higher dosages given to 47 patients did not lead to greater improvement in measures of psychosis, but did produce slightly greater declines in measures of hostility. Higher dosages did regularly lead to significant increases in distressing extrapyramidal side effects.

Hospitalized schizophrenic patient views about seclusion

Twenty-six of 100 consecutively admitted schizophrenic or schizoaffective patients required seclusion during their hospital stays. Seclusion episodes usually involved involuntarily committed, severely ill patients and occurred early in their hospitalizations. The recollections of the personal seclusion experiences of 17 patients were generally factually accurate, except for a tendency to play down disruptive aggressive behavior on their part. Patients described seclusion as a painful experience associated with feelings of helplessness, fear, sadness, and anger. However, patients also stated that seclusion rooms were necessary on inpatient psychiatric units and that the rooms were used for the control of disruptive aggressive patient behaviors. This study highlights not only the need for staff to clarify for patients what behavior has led to seclusion and what behavior will lead to release, but also the need for staff to acknowledge patients' distress at the experience.

The dose-response relationship for memory impairment by anticholinergic drugs

Twelve stabilized chronic schizophrenic outpatients receiving maintenance treatment with fluphenazine decanoate plus anticholinergic antiparkinsonian drugs underwent two challenge sessions receiving, in random sequence and double-blind, injections of either benztropine or glycopyrrolate (a peripherally active anticholinergic agent that penetrates the CNS poorly, used as an active placebo). Performance on free recall testing was significantly worse after benztropine than after glycopyrrolate. It has previously been shown that routine clinical doses of anticholinergic antiparkinsonian drugs impair verbal learning relative to a drug-free baseline. Our results suggest that memory impairment continues to further increase as anticholinergic drugs are pushed to the upper limit of the acceptable clinical range.

Insight and the clinical outcome of schizophrenic patients

At the time of discharge from their index hospitalizations, 52 schizophrenic patients initially admitted for acute psychotic episodes were assessed on an Insight and Treatment Attitudes Questionnaire. When these patients were followed up 2 1/2 to 3 1/2 years later, adequate information on their clinical courses and outcomes was available in 46 cases. A global assessment of aftercare environment was made in each case, reflecting the degree to which individuals other than the patient were helpfully invested in maintaining the patient in treatment, whether these individuals were in the patient's living or treatment situations. Five factual outcome variables were also assessed: a) compliance with treatment 30 days after discharge; b) long-term compliance; c) whether or not patients were readmitted; d) readmissions per year; and e) percent of time spent in the hospital. As expected, aftercare environment was significantly related to outcome (p = .039). The overall relationship between insight and the outcome variables closely approached statistical significance (p = .053). Patients with more insight were significantly less likely to be readmitted over the course of follow-up. There was a trend for patients with more insight to be compliant with treatment 30 days after discharge. No significant interaction between aftercare environment and insight was found, suggesting that insight may influence outcome independently of aftercare environment.

Insight in schizophrenia. Its relationship to acute psychopathology

The relationship between insight and acute psychopathology was explored in a group of 52 acutely psychotic, schizophrenic patients. A measure of insight, reflecting patients' recognition of their illness and need for care, was validated against ratings from a semi-structured interview and against assessments of patients' compliance with medication. Contrary to expectations, degree of insight was not consistently related to the severity of acute psychopathology, as measured on two structured scales. Nor did changes in insight during hospitalization vary consistently with changes in acute psychopathology. These data suggest that very little of the deficiency in insight seen in schizophrenic patients is explainable on the basis of acute psychopathological features. The mechanism that accounts for impairment in insight in schizophrenia may be relatively resistant to treatment with neuroleptic medication.

Why must some schizophrenic patients be involuntarily committed? The role of insight

Twenty-four of 52 (46%) schizophrenic patients hospitalized because of acute psychotic episodes associated with preadmission medication noncompliance required involuntary commitment. Committed patients were rated as significantly more severely ill than voluntary patients and were significantly more likely to be transferred to extended treatment facilities after acute care. However, committed patients were significantly less likely than were voluntarily admitted patients to acknowledge that they were psychiatrically ill and in need of treatment, i.e., to demonstrate insight. Although psychopathology diminished significantly in both committed and voluntary patients over the course of hospitalization, only in voluntary patients did insight increase significantly. Over a 21/2 to 31/2 year follow-up, those patients who had been involuntarily committed at the index hospitalization were significantly more likely to require involuntary admissions than were the initially voluntary patients. Inability to see the self as ill seems to be a persistent trait in some schizophrenic patients.

Dose of fluphenazine, familial expressed emotion, and outcome in schizophrenia. Results of a two-year controlled study

Issues regarding the side effects of antipsychotic medication and the possible contribution of the environment to dose requirements led to a two-year controlled dosage study of maintenance antipsychotic medication and familial environment among recently discharged schizophrenic patients. Seventy stable patients, living in high- or low-expressed emotion (EE) households, were randomized, double blind, to receive a standard dose of fluphenazine decanoate (average, 25 mg every two weeks) or a minimal dose representing 20% of the dose prescribed (average, 3.8 mg every two weeks). No differences in relapse were observed among dose, EE, or dose and EE. Patients in the minimal dose/high-EE condition experienced more minor but aborted episodes in year 2. Side effects were fewer on the minimal dose after one year, and low-EE patients were better adjusted than high-EE patients. Over time, minimal-dose recipients were significantly more improved in their instrumental and interpersonal role performance than were standard-dose recipients.

A double-blind crossover comparison of antiparkinson drug therapy: amantadine versus anticholinergics in 90 normal volunteers, with an emphasis on differential effects on memory function

Anticholinergic antiparkinson drugs administered orally at standard clinically prescribed doses impaired new memory acquisition and mood in normal volunteer subjects, based on tests of free recall, recognition memory, and time production, self-rating of memory function, and an evaluation of mood states. Elderly subjects were more severely impaired than were young adults. Amantadine did not impair new memory acquisition, and on self-report measures, it was significantly better tolerated than were anticholinergics. Among patients being treated for psychotic illness, there are two groups in which an effort to avoid anticholinergic therapy is especially worthwhile because of the severe consequences of memory dysfunction. These individuals are young neuroleptic-responsive patients who are in an early stage of their disease and elderly patients. For these two groups, amantadine should be considered as the initial mode of treatment, with low-dose anticholinergics being used for those patients who do not achieve adequate relief from extrapyramidal side effects with amantadine.

Effects of amantadine and trihexyphenidyl on memory in elderly normal volunteers

Anticholinergic drugs impair one's ability to learn new material, even at routine clinically used doses. During the trihexyphenidyl phase of this double-blind crossover trial, elderly normal subjects complained of confusion and memory impairment and demonstrated a pattern of deficits in memory function compatible with that previously reported to result from anticholinergic drugs. The subjects neither complained of nor demonstrated memory impairment while taking amantadine, which is believed to exert its pharmacological effects upon extrapyramidal disorders via dopaminergic mechanisms and does not appear to be associated with memory impairment. Anticholinergic drugs should be avoided whenever possible in the elderly and especially in those suffering dementia.

Plasma haloperidol levels drawn at neuroleptic threshold doses: a pilot study

The daily haloperidol doses of 33 newly admitted, acutely psychotic schizophrenic patients were rapidly adjusted to a point at which slight hypokinesia-rigidity first appeared on clinical examination (the neuroleptic threshold). The mean daily haloperidol dose at which the neuroleptic threshold was crossed was 4.2 +/- 2.4 mg/day. The plasma haloperidol levels obtained at these neuroleptic threshold doses clustered around a mean of 4.9 +/- 2.9 ng/ml. This plasma haloperidol level distribution extensively overlaps the proposed lower boundaries for the therapeutically effective range of plasma haloperidol levels, but it is below the range in which coarse extrapyramidal side effects appear in high frequency (greater than 10 ng/ml). Sixty-seven percent of our patients demonstrated moderate or greater therapeutic improvement within 3 weeks of treatment at neuroleptic threshold doses, a therapeutic efficacy rate identical to that expected with standard neuroleptic doses. The authors propose that the neuroleptic threshold is a readily available clinical marker which identifies a range of plasma haloperidol levels capable of producing therapeutic response with minimal associated coarse extrapyramidal side effects.