[Non-compliance and lack of indications for depot treatment as reasons for exclusion from adequate prevention of recurrence]

OBJECTIVE

The paper reports on the recruitment of a multicenter study on ambulant prophylactic treatment of schizophrenic disorders.

METHODS

For a study of the relapse-preventative effect of different dose patterns of Flupentixol, a screening phase was carried out among of 1129 schizophrenic patients. The aim of the screening phase was to establish the criteria for exclusion or inclusion in the treatment phase of the study.

RESULTS

Only 62 patients could be included. The reason for 54 patients not being included was a lack of compliance from either the patient or the clinician. The meaning of patient- and therapist-compliance in carrying out a multicenter study is also discussed.

Subjective experience of treatment, side-effects, mental state and quality of life in chronic schizophrenic out-patients treated with depot neuroleptics

Attitude towards treatment, side-effects, mental state and quality of life was assessed in 53 chronic schizophrenic out-patients on maintenance treatment with depot neuroleptics. It was found that 60% of the patients viewed depot medication positively, while only 8% viewed it negatively. Only 70% of patients complained about side-effects, even though 94% had scored as having them. Hypokinesia and hyperkinesis were the side-effects least noticed by the patients, but most noticed by the treating physician, while the opposite was the case with psychic side-effects. Only 49% of patients thought they had a psychotic illness, and there was no correlation between the patients' own evaluation of the severity of their illness and their score on the Positive and Negative Symptom Scale (PANSS) or the treating physician's evaluation. Quality of life did not correlate with either side-effect score or PANSS score. The schizophrenic patients' assessment of their condition was therefore in general different both from that of the treating physician and from that determined using rating scales.

Morphological and histochemical changes in the liver of albino Wistar rat given flupenthixol depot

Histological findings and histoenzymatic reactions have shown that Flupenthixol Depot (FPX dep.) injected to rats in therapeutic doses induced morphologically observable degenerative lesions in the liver. No significant difference in the intensity of the lesions between the groups of male and female animals was found.

Chronic dopamine antagonism facilitates opiate-induced feeding

Chronic interference with dopamine (DA) transmission has been found to facilitate opiate reward and opiate-induced behavioral activation derived from the nucleus accumbens. This study was aimed at determining the extent to which these effects are generalizable to opiate-induced feeding. Rats were tested for their feeding response to morphine following chronic interference with DAergic transmission with the long-acting neuroleptic, flupenthixol decanoate (FLU). It was found that FLU-treated animals showed an enhanced feeding response to morphine following three and four weeks of DA blockade, but not on weeks 1 and 2. Neither morphine treatment in FLU-control animals nor chronic FLU treatment alone produced any such time-dependent facilitation in feeding. The results indicate that the increased sensitivity to the rewarding effects of opiates following chronic DA blockade is generalizable to opiate-induced feeding.

Successful treatment with flupenthixol decanoate of a patient with both schizophrenia and alcoholism

There is growing evidence that substance abuse is a major problem in patients with schizophrenia. With respect to alcohol, alledegly the most frequently abused drug among schizophrenics, clinical and epidemiological studies would suggest that the risk of alcoholism is approximately four times greater (Cuffel, 1992; Mueser et al., 1990; Soyka et al., 1993; Soyka, 1994). A variety of hypotheses have been proposed to explain this phenomenon, including the so-called "self-medication hypothesis". Some authors feel that substance abuse in schizophrenics might be due to extrapyramidal and other side-effects caused by neuroleptic treatment or inadequate remission of psychotic symptoms. There remains, at present, an obvious lack of both psychosocial and psychopharmacological studies of treatment in "dual diagnosis" schizophrenics (Mueser et al., 1992). Changes in dopaminergic neurotransmission and dopamine-receptor dysfunction have been linked both to the development of psychotic symptoms and to alcoholism/substance abuse, and thus give rise to the question as to whether some dual diagnosis patients might benefit from neuroleptic treatment in both domains. A number of dopamine receptor subtypes in different regions of the brain seems to be involved in the development of schizophrenia and substance abuse. Modifications of D2-receptor subtype function have been implicated in psychotic symptoms, and changes in the D1- and D2-receptor function in substance abuse such as cocaine abuse and alcoholism (Spealman et al., 1990; 1991; 1992), especially in the mesolimbic dopaminergic reward system. Accordingly, the "ideal" neuroleptic drug for dual diagnosis schizophrenics should be effective in both receptor subtypes.(ABSTRACT TRUNCATED AT 250 WORDS)

A single injection of either flupenthixol decanoate or haloperidol decanoate produces long-term changes in cocaine self-administration in rats

The effect of decanoate forms of flupenthixol and haloperidol on cocaine self-administration was evaluated. Forty-two male Wistar rats were implanted with chronically indwelling jugular cannulae and trained to self-administer cocaine (0.6 mg/inj) either on a fixed ratio (FR) 1 schedule or a progressive ratio (PR) schedule. After a stable response pattern was established, animals received a single i.m. injection of either flupenthixol (2.0 mg), haloperidol (2.5 mg) or vehicle (0.1 ml oil). Both neuroleptics produced a long lasting increase in cocaine intake on a FR 1 schedule which reached a peak on post-injection day three and diminished slowly over the next seven days. All animals maintained on a PR schedule showed a long lasting decline in breaking points. These data suggest that the decanoate forms of flupenthixol and haloperidol may attenuate the reinforcing effects of cocaine and indicate that the therapeutic value of depot neuroleptics as anti-cocaine treatments would depend on the economics of cocaine availability.

Correct titration of non-drugs and some other methodological issues

Doctors' prescription and dosing behaviour was investigated using data from 9 clinical trials in 550 patients treated with psychotropics. 7 trials were conducted under double- and 2 under single-blind conditions. In 3 of these trials, oral and i.m. preparations were used demanding a double-dummy design. All patients were evaluated on a weekly or 2-week basis using psychopathological rating scales (i.e. Hamilton Anxiety Scale, Hamilton Depression Scale, Clinical Global Impressions, Simpson and Angus EPS). It was found that (a) oral-medication titration was 3- to 4-fold more broad-ranging than i.m. medication titration, (b) oral placebo was titrated to the same extent as the oral investigational drugs, and (c) the titration schedule did not follow protocol requirements. Moreover, the average doses in all drug and placebo groups were the same. Concomitant medication like sleep inducers was found to be more closely related to doctors' habits than to actual medical need. Independent of trial and investigational drug, 10-33% of all patients received additional sleep inducers.

Changing the light intensity of the visual environment results in large differences in numbers of synapses and in photoreceptor size in the retina of the young adult rat

A quantitative light- and electron-microscopic study has been made of the retinae of rats which were exposed to different lighting conditions for between one and 15 weeks in young adulthood, having been reared in identical conditions during development. The width of the inner and outer segments of the photoreceptors and the width of the outer plexiform layer varied inversely with the light intensity under diurnal lighting conditions of 10 h light/14 h dark. Linear regression analysis showed that the widths were inversely related to the fourth root of the light intensity as measured in lux. Both central and peripheral areas of retina showed a similar change. No change was seen in the widths of the inner plexiform layer, or of the inner and outer nuclear cell layers. Nor was there a difference in the packing density or size of the nuclei in the nuclear cell layers. The number of ribbon synapses in the outer plexiform layer also varied inversely with the intensity of diurnal light. Linear regression analysis showed that the number of synapses was inversely correlated with the fourth root of the light intensity and was positively correlated with the width of the outer plexiform layer. The number of ribbon synapses was increased by up to two and a half times in constant darkness compared to diurnal light of 35 lux. The increase was present but not maximal after one week of exposure. The length of synaptic ribbons was unchanged. The nerve terminals forming such synapses were increased in size but not in number. After one week, there was little or no additional change in the retinal widths and number of synaptic ribbons with time. However, there was a progressive increase with time in nerve terminal size (two-fold in area) in constant darkness. There was some evidence of a slight decrease in nerve terminal number and increase in size of retinal nuclei with age. It is concluded that the adult retina responds to a different lighting environment by a relatively rapid change in the size of photoreceptor segments, by a progressive and large change in number of ribbon synapses and by a slower progressive and large change in the size of photoreceptor nerve terminals. The response is quantitatively determined by the strength of the stimulus but not in a linear fashion. These results are compared with the effects of environmental stimulation of other areas of the nervous system.

The decanoates of flupenthixol and clopenthixol in the treatment of chronic schizophrenic in-patients. Implications for community psychiatry

Vagrant chronic schizophrenic subjects in a stable untreated state received in-patient treatment with either Flupenthixol decanoate or Clopenthixol decanoate. Both drugs were found to be significantly effective and well tolerated. The apparent better response to Flupenthixol decanoate was seen as dose-dependent. The findings and their implications for Community Psychiatry, particularly in developing countries are discussed.

The Scottish first episode schizophrenia study. VIII. Five-year follow-up: clinical and psychosocial findings. The Scottish Schizophrenia Research Group

Forty-four schizophrenic patients were followed up for five years after their first admission to hospital for a first episode of illness. Thirteen (30%) of 43 patients had not relapsed; 28 of the 30 patients who did relapse did so within the first 42 months. The relapses occurred despite antipsychotic drug therapy. Also, 24% of patients had at least one course of ECT. Only 19% of the patients at five years were in open employment; unemployment was strongly associated with relapse. Eighteen per cent had neither relapses nor schizophrenic symptoms at follow-up. Poor outcome at five years was associated with greater psychological distress among relatives at first admission. At five years 43% of relatives continued to show case level psychological stress.

Efficacy and tolerability of flupenthixol decanoate in the treatment of depression and psychosomatic disorders: a multicenter trial in general practice

1. A number of controlled as well as uncontrolled studies indicate that flupenthixol in a low-dose regimen is effective in treating syndromes with depression, anxiety, and psychosomatic disorders. 2. In view of the low compliance rates among patients suffering from depressive syndromes, the author evaluated the efficacy and tolerability of flupenthixol decanoate i.m. in an unselected collective of such patients treated in general practices. 3. Flupenthixol decanoate i.m. induced remission in 25% of patients suffering from chronic pain, in 29% of patients with psychosomatic disorders. Patients with depression and anxiety remitted in 27% of the cases. Therapeutic benefit was seen in more than 90% of the patients. 4. The best results were observed in patients 1) who had not been treated with psychotropic drugs before, 2) whose disease had a duration of less than one year, 3) who were under 40 years of age, and 4) who were treated with a dose lower than 0.5 ml (10 mg flupenthixol decanoate).

Rationalizing neuroleptic polypharmacy in chronic schizophrenics: effects of changing to a single depot preparation

This study investigated the effects of transferring patients on combined depot and oral neuroleptics to a single depot preparation; a secondary objective was to assess the effects of transferring patients from one depot neuroleptic to another. It was found that, whereas transferring from one depot preparation (flupenthixol) to another (fluphenazine) had no clear disadvantage for the patients, changing over from a combined oral and depot (fluphenazine) regimen to equivalent doses of depot alone resulted in an unacceptably high rate of relapse. The reasons for this may relate to either the unique pharmacokinetics of these drugs or subtle qualitative differences between them. It is suggested that caution is necessary whenever attempts are made to rationalize polypharmacy in schizophrenic patients.

Perphenazine decanoate and cis(z)-flupentixol decanoate in maintenance treatment of schizophrenic outpatients. Serum levels at the minimum effective dose

Two groups of schizophrenic outpatients were treated with perphenazine decanoate (N = 20) and cis(z)-flupentixol decanoate (N = 24) respectively. Every 3 months the dose was gradually reduced until symptoms appeared that were suggestive of a prodromal phase of a psychotic episode. A slightly higher dose was then promptly reinstituted (the minimum effective dose). At each dose level, two blood samples were drawn for determination of serum concentration. The mean minimum effective dose of perphenazine decanoate was 99.3 mg/2 weeks (range 21.6-270.5), while the mean minimum effective dose of cis(z)-flupentixol decanoate was 60 mg/2 weeks (range 20-250). The corresponding mean serum level of perphenazine decanoate was 7.3 nmol/l (range 2.0-18.1) and of cis(z)-flupentixol decanoate 7.8 nmol/l (range 1.2-37.0). There was a significant correlation between the administered doses and the corresponding serum levels for both drugs (r = 0.87, P less than 0.01). A weak positive correlation was found between serum levels at the minimum effective dose and symptom intensity (BPRS total score) (r = 0.53, P less than 0.02) for perphenazine, but not cis(z)-flupentixol. No correlation was found between serum levels and side effects or length of neuroleptic treatment. It is concluded that the serum drug concentrations corresponding to the lowest effective dose are so variable that routine serum level monitoring may be of limited value in the long-term maintenance treatment of schizophrenia.

The Scottish first episode schizophrenia study. VII. Two-year follow-up. Scottish Schizophrenia Research Group

Of 49 schizophrenic patients followed up 2 years after their first admission to hospital, 37% were well, 47% had been readmitted to hospital at some time over the 2 years, and 38% showed schizophrenic symptoms at follow-up. A poor outcome at 2 years was associated with male sex, poor outcome after the first 5 weeks of the first admission, negative schizophrenic symptoms on first admission, and a diagnosis of definite or probable schizophrenia using the Feighner criteria. Only 23% were in employment. A small double-blind discontinuation study of maintenance antipsychotic medication during the second year found more relapses in those switched to placebo medication. Repeat psychometric assessment at 2 years confirmed modest improvements found at 12 months; that is, there was no evidence of intellectual decline. Relatives showed no more psychosocial distress than that found in a normal community sample; what distress there was correlated with patients' schizophrenic symptoms.

Neuroleptic malignant syndrome: another medical cause of acute abdomen

We present a patient with neuroleptic malignant syndrome and intestinal pseudo-obstruction misdiagnosed as being secondary to septicaemia. The management of the patient is discussed with emphasis on the role of creatine kinase and liver function tests.

Two cases of agranulocytosis on addition of a butyrophenone to a long-standing course of phenothiazine treatment

Two cases of agranulocytosis occurring after addition of a butyrophenone to a course of phenothiazine treatment are reported and possible mechanisms for this interaction are discussed.

Outpatient treatment of 'crack' cocaine smoking with flupenthixol decanoate. A preliminary report

"Crack" cocaine abuse often produces severe cocaine dependence that is refractory to available pharmacological and outpatient psychotherapeutic treatments. We conducted two preliminary investigations evaluating the efficacy of flupenthixol decanoate, a depot xanthene requiring infrequent intramuscular administration, in the treatment of cocaine withdrawal. Ten outpatient crack cocaine smokers with poor prognoses were administered flupenthixol decanoate in an open-label, open-ended trial. Flupenthixol decanoate was well tolerated and appeared to decrease cocaine craving and use markedly and rapidly, producing a 260% increase in the average time retained in treatment among these subjects. These promising but preliminary data, combined with the magnitude of problems presented by crack, warrant rapid, expanded double-blind assessment of flupenthixol decanoate in cocaine-abuse treatment.

The Scottish First Episode Schizophrenia Study V. One-year follow-up. The Scottish Schizophrenia Research Group

Of 49 schizophrenic patients followed up 12 months after their first admission to hospital, only about 45% had experienced no relapse and had no schizophrenic symptoms; a poorer outcome was more often found in Feighner positive than Feighner negative schizophrenic patients. The patients' overall level of unemployment had more than doubled to 51%. In patients whose acute episodes responded to treatment, pimozide taken once weekly as maintenance therapy was as effective as intramuscular flupenthixol decanoate, but tardive dyskinesia appeared in two patients receiving weekly pimozide; the repeat psychometric assessment at 12 months found modest improvements, i.e. no evidence of intellectual decline, in Matrices, Block Design, and Digit Copying tests. Forty per cent of relatives still showed significant psychological distress, which correlated with patients' schizophrenic symptoms, and the relatives' social functioning remained poorer than that of a normal community sample.

Radioreceptor assay in checking serum concentration in long-term treatment with cis(z)-flupenthixol decanoate

24 patients have been treated with cis(z)-flupenthixol decanoate for 6-12 months. Intramuscular injections were given about every 3 weeks. Before treatment and on each day of injection the mental state was assessed by BPRS and registration of side effects was performed. Blood samples were taken 7 days after each injection and on the last day of the dosage interval. Neuroleptic activity was determined in serum by RRA and expressed in cis(z)-flupenthixol equivalents. The drug level was significantly correlated to the dose. No clear relationship between drug level and clinical results as well as side effects was found. Less pronounced variations of the drug level between subsequent injections resulted in a positive therapeutic response.

Double-blind comparison of half-dose and standard-dose flupenthixol decanoate in the maintenance treatment of stabilised out-patients with schizophrenia

A double-blind controlled trial of 50% dose reduction in maintenance treatment in stable out-patients with low BPRS scores and good social function shows a significantly higher relapse rate in the low-dose group at 12 months (P less than 0.05). After an interval of 24-36 months from dose reduction, 56-76% had experienced a relapse and 76-79% had resumed their former dosage. No clear advantage was shown for the lower dose in either a reduction of side-effects or improved social function, but a reduced prevalence or lower rate of symptom emergence for tardive dyskinesia was suggested.