Strategies for maximizing clinical effectiveness in the treatment of schizophrenia

The ultimate clinical objective in the treatment of schizophrenia is to enable affected individuals to lead maximally productive and personally meaningful lives. As with other chronic diseases that lack a definitive cure, the individual's service/recovery plan must include treatment interventions directed towards decreasing manifestations of the illness, rehabilitative services directed towards enhancing adaptive skills, and social support mobilization aimed at optimizing function and quality of life. In this review, we provide a conceptual framework for considering approaches for maximizing the effectiveness of the array of treatments and other services towards promoting recovery of persons with schizophrenia. We discuss pharmacological, psychological, and social strategies that decrease the burden of the disease of schizophrenia on affected individuals and their families while adding the least possible burden of treatment. In view of the multitude of treatments necessary to optimize outcomes for individuals with schizophrenia, effective coordination of these services is essential. In addition to providing best possible clinical assessment and pharmacological treatment, the psychiatrist must function as an effective leader of the treatment team. To do so, however, the psychiatrist must be knowledgeable about the range of available services, must have skills in clinical-administrative leadership, and must accept the responsibility of coordinating the planning and delivery of this multidimensional array of treatments and services. Finally, the effectiveness of providing optimal individualized treatment/rehabilitation is best gauged by measuring progress on multiple effectiveness domains. Approaches for efficient and reliable assessment are discussed.

Improving patient outcomes in schizophrenia: achieving remission

The Remission in Schizophrenia Working Group has recently proposed a consensus definition of remission in schizophrenia and, based on this definition, has developed specific operational criteria for the assessment of remission. The aim of this article was to assess the application of these consensus criteria and to discuss the barriers for achieving remission. An electronic literature search of studies published between January 1990 and December 2005 examining the concepts of remission, compliance and patient satisfaction in schizophrenia was performed using Medline and EMBASE. The primary research parameters were 'schizophrenia', 'remission', 'antipsychotics', 'atypicals' and 'conventional'. Abstracts and posters presented at key psychiatry congresses during this period were also reviewed, where available in the public domain. To date, the remission criteria have been applied retrospectively to a number of clinical studies, and these have demonstrated that the proposed definition of remission correlates significantly with established measures of symptom severity, functioning and quality of life, and appears achievable and sustainable for a significant proportion of patients receiving pharmacotherapy. The atypical antipsychotic agents have been shown to impact favourably upon certain factors that play an integral part in the achievement of remission, such as negative symptoms, cognitive impairment, social functioning and quality of life. However, non-compliance with medication remains widespread due to illness-, treatment- and clinician-related factors. The use of long-acting antipsychotic agents, with their assured medication delivery, may facilitate compliance and improve long-term treatment outcomes, possibly assisting patients in achieving remission. Remission may, therefore, be considered as a current goal of treatment today, not a distant future aim.

Carbamazepine and valproate for the treatment of bipolar disorder: a review of the literature

There are an increasing number of pharmacologic therapies for bipolar disorder. Two of these agents, the anticonvulsants carbamazepine (CBZ) and valproate (VPA), were first developed over 30 years ago for the treatment of epilepsy, and subsequent studies demonstrated that they are also effective in the treatment of acute mania and suggest efficacy as maintenance therapy in bipolar disorder. Because VPA and CBZ have been in use for many years, the psychiatric community is familiar with the adverse event profiles of these agents. A review of the clinical data evaluating VPA and CBZ monotherapy for the treatment of acute mania suggests that VPA and CBZ are similarly effective in acute mania. However, when their respective adverse event profiles are considered, VPA may be more tolerable than CBZ for short-term use, while CBZ may be better suited for long-term therapy. Controlled and direct comparative studies, both short and long term, are needed to further clarify the differences between VPA and CBZ.

Placebo-level incidence of extrapyramidal symptoms (EPS) with quetiapine in controlled studies of patients with bipolar mania

OBJECTIVES

To evaluate extrapyramidal symptoms (EPS), including akathisia, with quetiapine in patients with bipolar mania.

METHODS

Data were analyzed from four similarly designed, randomized, double-blind, 3- to 12-week studies. Two studies evaluated quetiapine monotherapy (up to 800 mg/day) (n = 209) versus placebo (n = 198), with lithium or haloperidol monotherapy as respective active controls. Two studies evaluated quetiapine (up to 800 mg/day) in combination with a mood stabilizer (lithium or divalproex, QTP + Li/DVP) (n = 196) compared to placebo and mood stabilizer (PBO + Li/DVP) (n = 203). Extrapyramidal symptoms were evaluated using the Simpson-Angus Scale (SAS), the Barnes Akathisia Rating Scale (BARS), adverse event reports and anticholinergic drug usage.

RESULTS

The incidence of EPS-related adverse events, including akathisia, was no different with quetiapine monotherapy (12.9%) than with placebo (13.1%). Similarly, EPS-related adverse events with QTP + Li/DVP (21.4%) were no different than with PBO + Li/DVP (19.2%). Adverse events related to EPS occurred in 59.6% of patients treated with haloperidol (n = 99) monotherapy, whereas 26.5% of patients treated with lithium (n = 98) monotherapy experienced adverse events related to EPS. The incidence of akathisia was low and similar with quetiapine monotherapy (3.3%) and placebo (6.1%), and with QTP + Li/DVP (3.6%) and PBO + Li/DVP (4.9%). Lithium was associated with a significantly higher incidence (p < 0.05) of tremor (18.4%) than quetiapine (5.6%); cerebellar tremor, which is a known adverse effect of lithium, may have contributed to the elevated rate of tremor in patients receiving lithium therapy. Haloperidol induced a significantly higher incidence (p < 0.001) of akathisia (33.3% versus 5.9%), tremor (30.3% versus 7.8%), and extrapyramidal syndrome (35.4% versus 5.9%) than quetiapine. No significant differences were observed between quetiapine and placebo on SAS and BARS scores. Anticholinergic use was low and similar with quetiapine or placebo.

CONCLUSIONS

In bipolar mania, the incidence of EPS, including akathisia, with quetiapine therapy is similar to that with placebo.

Low rates of treatment for hypertension, dyslipidemia and diabetes in schizophrenia: data from the CATIE schizophrenia trial sample at baseline

Persons diagnosed with schizophrenia have higher morbidity and mortality rates from cardiovascular disease, yet often have limited access to appropriate primary care screening or treatment. Metabolic disorders such as diabetes, hyperlipidemia and hypertension are highly prevalent in populations with schizophrenia, exceeding 50% in some studies; however, there have been few published studies on treatment rates among schizophrenia patients screened for these disorders.

METHODS

Using the baseline data from subjects (N=1460) recruited into the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) schizophrenia study, we examined the point prevalence of diabetes, hyperlipidemia and hypertension treatment at the time of enrollment for the entire cohort and those with fasting laboratory values obtained 8 or more hours since last meal.

RESULTS

Rates of non-treatment ranged from 30.2% for diabetes, to 62.4% for hypertension, and 88.0% for dyslipidemia. Nonwhite men were more likely to be treated for DM and dyslipidemia than nonwhite women.

CONCLUSIONS

These data indicate the high likelihood that metabolic disorders are untreated in patients with schizophrenia, with particularly high rates of non-treatment for hypertension and dyslipidemia. Nonwhite women may be especially vulnerable to undertreatment of dyslipidemia and diabetes compared to nonwhite men. The findings here support the need for increased attention to basic monitoring and treatment of cardiovascular risk factors in this vulnerable and often underserved psychiatric population.

Metabolic findings from the CATIE trial and their relation to tolerability

The overall effectiveness of antipsychotics for the management of schizophrenia is restricted by their side-effect profiles, particularly over an extended treatment period. Intolerable side effects can reduce patient adherence to medication and often lead to treatment discontinuation. Some side effects that result from antipsychotic use are precursors to the metabolic syndrome, which is prevalent among individuals with schizophrenia and represents a significant source of cardiovascular risk. The Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) schizophrenia study assessed the efficacy of the atypical antipsychotics olanzapine, quetiapine, risperidone, and ziprasidone relative to the conventional drug perphenazine. Additional assessments included the metabolic effects of these agents in patients with schizophrenia and the incidence of negative side effects. No significant differences were found between treatment groups for time to discontinuation due to intolerability, but the rates of side effects significantly differed (P=.04). For metabolic parameters, olanzapine was associated with greater and significant adverse effects on weight, lipids, and glucose metabolism versus the other antipsychotics tested. The CATIE results show that important distinctions exist among currently available atypical antipsychotics. Physicians should be aware of the propensity of these drugs to increase the risks of cardiovascular disease and diabetes in treated patients and tailor individual treatment decisions accordingly. This article highlights the metabolic findings from the CATIE schizophrenia study, and explores the differences shown by atypical antipsychotics, with regard to metabolic side effects that increase cardiovascular risk.

Do certain atypical antipsychotics increase the risk of diabetes? A critical review of 17 pharmacoepidemiologic studies

BACKGROUND

Some atypical antipsychotics have been linked to hyperglycemia, diabetes mellitus, and diabetic ketoacidosis. We reviewed evidence comparing excess risk and relative risk of type-2 diabetes associated with atypical antipsychotics.

METHODS

Studies were identified on MEDLINE (January 1966-June 2003) using "antipsychotics and diabetes," "atypical antipsychotics and diabetes," and "schizophrenia and diabetes" as search terms. Studies presented at psychiatric scientific meetings between January 2000-June 2003 were identified via meeting attendance, conference proceedings, and published abstracts. The authors examined all retrospective epidemiologic studies including secondary data analyses addressing relative risk of developing diabetes in patients receiving atypical antipsychotics. Case reports, prospective trials, review articles, and MedWatch data were excluded. Extracted data were reviewed by all investigators according to predetermined criteria related to study design, treatment and comparison groups, definition of outcome measure, inclusion of covariates, and statistical analysis.

RESULTS

Four studies meeting criteria for acceptable methods demonstrated that olanzapine, but not risperidone, is associated with a significantly increased risk of new-onset diabetes versus untreated major psychiatric disorder. Studies of relative risk did not demonstrate greater risk of diabetes with risperidone versus conventional antipsychotics. Of nine studies comparing relative risk of diabetes with olanzapine and risperidone, six demonstrated significantly greater risk with olanzapine. Risk was higher in women in two studies. Definitive conclusions could not be reached for clozapine and quetiapine due to limited data.

CONCLUSIONS

The preponderance of current epidemiologic evidence indicates that olanzapine therapy poses a higher risk of diabetes than untreated major psychiatric illness, and that olanzapine confers greater risk of diabetes than risperidone.

Time-Dependent Effects of Haloperidol and Ziprasidone on Nerve Growth Factor, Cholinergic Neurons, and Spatial Learning in Rats

In this rodent study, we evaluated the effects of different time periods (7, 14, 45, and 90 days) of oral treatment with haloperidol (HAL; 2.0 mg/kg/day) or ziprasidone (ZIP; 12.0 mg/kg/day) on nerve growth factor (NGF) and choline acetyltransferase (ChAT) levels in the hippocampus, and we subsequently assessed water maze task performance, prepulse inhibition (PPI) of the auditory gating response, and several NGF-related proteins and cholinergic markers after 90 days of treatment. Seven and 14 days of treatment with either HAL or ZIP resulted in a notable increase in NGF and ChAT immunoreactivity in the dentate gyrus (DG), CA1, and CA3 areas of the hippocampus. After 45 days, NGF and ChAT immunoreactivity had abated to control levels in ZIP-treated animals, but it was markedly reduced in HAL-treated subjects. After 90 days of treatment, NGF and ChAT levels were substantially lower than controls in both antipsychotic groups. Furthermore, after 90 days of treatment and a drug-free washout period, water maze performance (but not PPI) was impaired in both antipsychotic groups, although the decrement was greater in the HAL group. Several NGF-related and cholinergic proteins were diminished in the brains of subjects treated with either neuroleptic as well. These data support the premise that, although ZIP (given chronically) seems somewhat superior to HAL due to less pronounced behavioral effects and a more delayed appearance of neurochemical deficits, both antipsychotics produce time-dependent deleterious effects on NGF, cholinergic markers (i.e., important neurobiological substrates of memory), and cognitive function.

Pain insensitivity in schizophrenia: trait or state marker?

OBJECTIVES

As early as the turn of the 20th century, clinicians observed patients with schizophrenia failing to respond to the pain of a myocardial infarction, ruptured appendix, or perforated bowel. Although this pain insensitivity in individuals with psychosis has been described in the literature for many years, the phenomenon is still poorly understood. We therefore reviewed the literature for findings concerning whether pain insensitivity in schizophrenia represents a state or a trait marker.

METHODS

A comprehensive Medline search of the literature on pain insensitivity in subjects with schizophrenia was conducted.

RESULTS

While the literature contains anecdotal observations, case reports, and a few rigorous clinical studies concerning patients with schizophrenia being relatively indifferent to pain, there is a dearth of empirical, well-controlled studies in this area. Although early studies that examined the response of individuals with schizophrenia to thermal or electrical pain were constrained by a variety of methodological confounders, studies on this topic suggest that the higher pain thresholds observed in schizophrenia are best explained by a complex, multifactorial model. Most intriguing are the results of one recent study that found pain insensitivity in family members of persons with schizophrenia, suggesting that this phenomenon may be a trait or endophenotype rather than being due to a psychotic state.

CONCLUSIONS

Pain insensitivity in individuals with schizophrenia, which is associated with increased morbidity and mortality, is poorly understood. It is possible that pain insensitivity might serve as a prodromal predictor of susceptibility for schizophrenia. Future studies are needed to further clarify the neurobiology, pathophysiology, and practical clinical implications of this phenomenon.

Focus on lower risk of tardive dyskinesia with atypical antipsychotics

BACKGROUND

Tardive dyskinesia (TD) is one of the most serious iatrogenic neurological complications of the first-generation antipsychotics. Identifying the risk factors for TD is important to minimize the risk of this potentially irreversible movement disorder in susceptible populations.

METHODS

A Medline search was conducted for the literature on risk factors for TD with the first-generation antipsychotics, as well as the emerging literature of the lower risk of TD with the second-generation antipsychotics.

RESULTS

Several demographic, phenomenological, comorbidities and treatment variables have been reported to be associated with higher risk of TD. On the other hand, significantly lower rates of TD have been reported with the second-generation atypical antipsychotics, even in high risk groups such as the elderly.

CONCLUSIONS

The use of the second-generation antipsychotics as first-line treatment of psychosis appears to have lowered the overall prevalence of acute movement disorders as well as TD, and have led them to become the standard of care in part because of their safer extrapyramidal profiles.

Mood stabilizers and atypical antipsychotics: bimodal treatments for bipolar disorder

Treatment options for bipolar disorder have rapidly expanded over the last decade, but providing optimal management remains an elusive goal. The authors reviewed the literature on the efficacy of agents with the best clinical evidence supporting their use in bipolar disorder, including the mood stabilizers lithium, valproate, lamotrigine, and carbamazepine, as well as the atypical antipsychotics olanzapine, risperidone, quetiapine, ziprasidone, and aripiprazole. Most medications appear to be more effective for symptoms of mood elevation than for symptoms of depression. The efficacy, tolerability, and safety profiles of agents must be considered when making clinical decisions. Several agents, including lithium, valproate, olanzapine, quetiapine, and risperidone, can cause problematic weight gain. In addition, the use of atypical antipsychotics has been associated with an increased risk of metabolic abnormalities such as dyslipidemia, hypergylycemia, and diabetes mellitus. In most patients, monotherapy offers inadequate efficacy. Further investigation of combinations of agents such as mood stabilizers and atypical antipsychotics may yield valuable insights into the potential of combination therapies to enhance clinical outcomes in patients with bipolar disorder.

The influence of study design on the results of pharmacoepidemiologic studies of diabetes risk with antipsychotic therapy

BACKGROUND

Retrospective large patient database studies have reported conflicting findings regarding diabetes risks associated with antipsychotics. This study compared two study designs to assess antipsychotic-related diabetes risk.

METHODS

Claims data were analyzed for over 60,000 patients with psychosis, both treated and untreated with antipsychotics, between January 1999 and April 2002. Diabetes odds ratios for patients treated with antipsychotics versus untreated patients were estimated. All patients and patients stratified by low, medium, and high antipsychotic dose were analyzed. Logistic regression controlled for age, sex, type of psychosis, length of observation/treatment, preexisting excess weight, and use of other drugs.

RESULTS

Under a less rigorous study design, diabetes risk was statistically significant with all antipsychotics versus no treatment. Under a more rigorous design, relative odds for quetiapine and risperidone declined and became statistically nonsignificant, whereas those for olanzapine and conventional antipsychotics increased and remained significant. By dose, only quetiapine showed a lack of statistical significance at all dose levels.

CONCLUSIONS

In database studies estimated risks of antipsychotic-related diabetes are affected by study design. With a more rigorous design, the risk associated with quetiapine and risperidone was not significantly different from that in untreated patients. These findings may explain inconsistent findings in pharmacoepidemiologic database studies.

Prevalence of the metabolic syndrome in patients with schizophrenia: baseline results from the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) schizophrenia trial and comparison with national estimates from NHANES III

One important risk factor for cardiovascular disease is the metabolic syndrome (MS), yet limited data exist on its prevalence in US patients with schizophrenia.

METHODS

Using baseline data from the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) Schizophrenia Trial, assessment of MS prevalence was performed based on National Cholesterol Education Program (NCEP) criteria, and also using a fasting glucose threshold of 100 mg/dl (AHA). Subjects with sufficient anthropometric data, data on use of antihypertensives, hypoglycemic medications or insulin, and fasting glucose and lipid values >8 h from last meal were included in the analysis. Comparative analyses were performed using a randomly selected sample from NHANES III matched 1:1 on the basis of age, gender and race/ethnicity.

RESULTS

Of 1460 CATIE baseline subjects, 689 met analysis criteria. MS prevalence was 40.9% and 42.7%, respectively using the NCEP and AHA derived criteria. In females it was 51.6% and 54.2% using the NCEP and AHA criteria, compared to 36.0% (p = .0002) and 36.6% (p = .0003), respectively for males. 73.4% of all females (including nonfasting subjects) met the waist circumference criterion compared to 36.6% of males. In a logistic regression model with age, race and ethnicity as covariates, CATIE males were 138% more likely to have MS than the NHANES matched sample, and CATIE females 251% more likely than their NHANES counterparts. Even when controlling for differences in body mass index, CATIE males were still 85% more likely to have MS than the NHANES male sample, and CATIE females 137% more likely to have MS than females in NHANES.

CONCLUSIONS

The metabolic syndrome is highly prevalent in US schizophrenia patients and represents an enormous source of cardiovascular risk, especially for women. Clinical attention must be given to monitoring for this syndrome, and minimizing metabolic risks associated with antipsychotic treatment.

A comparison of ten-year cardiac risk estimates in schizophrenia patients from the CATIE study and matched controls

OBJECTIVE

Standardized mortality rates are elevated in schizophrenia compared to the general population. The incidence of coronary heart disease (CHD) and the relative contribution of CHD to increased mortality in schizophrenia patients are not clear, despite recent concerns about metabolic complications of certain atypical antipsychotics.

METHOD

Ten-year risk for CHD was calculated for 689 subjects who participated in the Clinical Trials of Antipsychotic Treatment Effectiveness (CATIE) Schizophrenia Trial at baseline using the Framingham CHD risk function and were compared with age-, race- and gender-matched controls from the National Health and Nutrition Examination Survey (NHANES) III.

RESULTS

Ten-year CHD risk was significantly elevated in male (9.4% vs. 7.0%) and female (6.3% vs. 4.2%) schizophrenia patients compared to controls (p = 0.0001). Schizophrenia patients had significantly higher rates of smoking (68% vs. 35%), diabetes (13% vs. 3%), and hypertension (27% vs. 17%) and lower HDL cholesterol levels (43.7 vs. 49.3 mg/dl) compared to controls (p < 0.001). Only total cholesterol levels did not differ between groups. Ten-year CHD risk remained significantly elevated in schizophrenia patients after controlling for body mass index (p = 0.0001).

CONCLUSIONS

These results are consistent with recent evidence of increased cardiac mortality in schizophrenia patients. While the impact of cigarette smoking is clear, the relative contributions to cardiac risk of specific antipsychotic agents, diet, exercise, and quality of medical care remain to be clarified.

The Clinical Antipsychotic Trials Of Intervention Effectiveness (CATIE) Schizophrenia Trial: clinical comparison of subgroups with and without the metabolic syndrome

The metabolic syndrome (MS) is highly prevalent among patients with schizophrenia (current estimates 35-40%), yet no data exist on the correlation of this diagnosis with illness severity, neurocognitive or quality of life measures in this population.

METHODS

Using baseline data from the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) Schizophrenia Trial, assignment of MS status was performed using an updated definition derived from the National Cholesterol Education Program (NCEP) criteria. Those with and without MS were compared on the basis of primary and secondary variables of interest from baseline data encompassing psychiatric, neurocognitive and quality of life measures.

RESULTS

Of 1460 subjects enrolled at baseline, MS status could be reliably assigned for 1231 subjects, with a prevalence of 35.8% using the NCEP derived criteria. After adjustment for age, gender, race, ethnicity and site variance, those with MS rated themselves significantly lower on physical health by SF-12 (p < .001), and scored higher on somatic preoccupation (PANSS item G1) (p = .03). There were no significant differences between the two cohorts on measures of symptom severity, depression, quality of life, neurocognition, or self-rated mental health. Neither years of antipsychotic exposure nor alcohol usage were significant predictors of MS status when adjusted for age, gender, race, and ethnicity.

CONCLUSIONS

The metabolic syndrome is highly prevalent in this large cohort of schizophrenia patients and is strongly associated with a poor self-rating of physical health and increased somatic preoccupation. These results underscore the need for mental health practitioners to take an active role in the health monitoring of patients with schizophrenia to minimize the impact of medical comorbidity on long-term mortality and on daily functioning. Outcomes data from CATIE will provide important information on the metabolic and clinical impact of antipsychotic treatment for those subjects with MS and other medical comorbidities.

Neurologic comorbidities in schizophrenia

Brain abnormalities have long been assumed to be involved in the pathophysiology of schizophrenia. Magnetic resonance imaging studies have identified numerous structural and functional imaging abnormalities, such as reduced brain volume, frontal lobe volume, and hippocampal volume, in patients with schizophrenia. Neurologic disorders, such as movement disorders, neurologic abnormalities, and cognitive deficits, are often seen years before the onset of schizophrenia. Many of these abnormalities may be predictive of the development of schizophrenia, but unfortunately, they are usually overlooked. In addition, treatment with antipsychotics may affect brain structure, further complicating the ability to detect changes due to the neuropathology of psychosis. This article reviews the structural and functional imaging abnormalities found in patients with schizophrenia and the neurologic disorders that commonly coexist with the disorder. The role that treatment with atypical antipsychotics may or may not have in contributing to neurologic abnormalities is also discussed. Through increased awareness of these abnormalities, the importance of obtaining a complete neurologic history and examination of patients with schizophrenia at the onset of their illness and before initiating pharmacotherapy will become evident. Such recognition may permit earlier identification and treatment of schizophrenia, thus potentially improving long-term outcome.

Defining and measuring clinical effectiveness in the treatment of schizophrenia

OBJECTIVES

Expectations in treating schizophrenia are expanding beyond just controlling psychotic symptoms to include functional recovery. This report describes an approach to define and measure the clinical effectiveness of treatment in achieving these objectives.

METHODS

A comprehensive literature review established that there is limited information about the meaning of the term "clinical effectiveness." To address this gap a consensus conference of schizophrenia researchers was held to consider the components of clinical effectiveness in real-world community practice and how these components can best be measured.

RESULTS

The consensus of the researchers was that effective clinical treatment is characterized by four outcome domains: symptoms of disease, treatment burden, disease burden, and health and wellness. A clinical instrument to measure these four domains was constructed: Global Outcome Assessment of Life in Schizophrenia (GOALS). In using GOALS, clinicians rate each of the four domains on a scale of 1, very much improved, to 7, very much worse. Field-testing of this instrument is planned.

CONCLUSIONS

Effective treatment interventions that combine optimal pharmacotherapy and targeted psychosocial treatments are raising expectations about the prospects of functional recovery among patients with schizophrenia. GOALS is proposed as one tool that can provide busy clinicians with a simple, objective measure of the effectiveness and outcomes of the clinical treatment they provide to patients with schizophrenia.

Efficacy and safety of long-acting risperidone in stable patients with schizoaffective disorder

BACKGROUND

The treatment of schizoaffective disorder is often complicated by the variety of symptoms that contribute to its pathology. Data from a large study (n=725), which included schizoaffective patients to assess the effect of long-acting risperidone, are presented.

METHOD

A multicenter, open-label study enrolled non-acute, clinically stable patients with schizoaffective disorder (n=110). Patients on a stable dose of antipsychotic for at least 4 weeks at study entry were switched to long-acting risperidone every 2 weeks for 50 weeks.

RESULTS

Mean Positive and Negative Syndrome Scale (PANSS) total scores (+/-S.E.) improved significantly (p<0.001) at each measured time point, including endpoint (-9.0+/-1.6), compared with baseline. Significant reductions were observed on mean PANSS cluster scores for both anxiety/depression (-1.3+/-0.4, p<0.001) and uncontrolled hostility/excitement (-0.7+/-0.3, p<0.05). In addition, scores improved significantly for positive symptoms (-2.2+/-0.5, p<0.001), negative symptoms (-3.1+/-0.5, p<0.001), and disorganized thoughts (-1.7+/-0.4, p<0.001). The overall subjective score of movement disorders was low at baseline (3.6+/-4.1) and had significantly decreased at endpoint (2.75; p<0.05). Patients were previously treated with antipsychotics for 398+/-790 days before being switched to long-acting risperidone.

LIMITATIONS

Although this was a 50-week study, which included over 100 patients with schizoaffective disorder, limitations include the open-label design and that it was not designed specifically to assess patients with this disorder. PANSS symptom domains previously defined by factor analytic methods were used for mood symptom measures. No specific mood symptom scales were administered in this study.

CONCLUSION

Patients with schizoaffective disorder, considered stable on their antipsychotic medication at study entry, experienced additional significant clinical improvements and minimal side effects with injections of long-acting risperidone over a 50-week study period.

Atypical antipsychotics and metabolic dysregulation: evaluating the risk/benefit equation and improving the standard of care

Atypical antipsychotics are a major advance in the management of schizophrenia. The reevaluation of widely held risk/benefit assessments of the various atypical antipsychotics provides an opportunity to improve treatment patterns. The best available clinical trial evidence indicates that efficacy among the atypical antipsychotics (at equivalent doses) is very similar, but safety and tolerability profiles differ significantly. Atypical antipsychotics differ markedly in their potential to cause metabolic disturbances, including obesity, diabetes, dyslipidemia, and the metabolic syndrome; clozapine and olanzapine carry the greatest risks, atypical antipsychotics like risperidone and quetiapine have lower risks, and newer agents like ziprasidone and aripiprazole are associated with minimal metabolic risks. Results from the Atypical Antipsychotic Therapy and Metabolic Issues (AtAMI) survey define important opportunities for improving medical and psychiatric outcomes during atypical antipsychotic therapy. (See accompanying article by Newcomer et al) Additional educational and research efforts are required to increase understanding of common conditions such as the metabolic syndrome, increase awareness of uncommon but serious events like diabetic ketoacidosis, and pancreatitis, and identify appropriate strategies for monitoring the risks/benefits of atypical antipsychotic therapy. As clinicians refine practice patterns regarding the atypical antipsychotics, they may require additional knowledge and resources to fully incorporate risk/benefit considerations and optimize long-term psychiatric and medical outcomes.

The Atypical Antipsychotic Therapy and Metabolic Issues National Survey: practice patterns and knowledge of psychiatrists

A nationwide survey in 2003 of 300 randomly selected psychiatrists who routinely treat schizophrenia with atypical antipsychotic therapy was conducted to ascertain practice patterns and attitudes regarding metabolic disturbances during atypical antipsychotic therapy with an emphasis on how these perceptions impact therapeutic decision making. Psychiatrists generally believe that some atypical antipsychotic drugs are associated with metabolic disturbances and that atypical antipsychotics differ in their risk for metabolic disturbances. A majority of respondents (82%) believed that patients with schizophrenia-even those not receiving atypical antipsychotic therapy-are at greater risk for metabolic abnormalities than the general population. A majority of respondents recognized weight gain and diabetes mellitus (59% and 51%, respectively) as potential metabolic complications of atypical antipsychotic therapy, while only some recognized dyslipidemia and certain acute metabolic decompensations like diabetic ketoacidosis (22% and 2%, respectively). Large minorities of respondents (48% and 43%) indicated a willingness to risk weight gain and/or diabetes for the benefits of atypical antipsychotics, possibly because metabolic issues were regarded as long-term issues. However, large majorities also stated that they considered metabolic issues when selecting atypical antipsychotic therapy for some or all of their patients (90%), and that emergence of metabolic dysfunction prompted them to change atypical antipsychotic treatment regimens (85%). Additional efforts at continuing education and communication regarding metabolic outcomes associated with atypical antipsychotic therapy, as well as critical reviews in this area, may help clarify atypical antipsychotic treatment risks and benefits. The results from the survey indicate that psychiatrists are aware of and concerned about metabolic risks and how they differ across the atypical antipsychotic class. The impact of additional data and educational efforts in this area, such as a recently published consensus statement from the American Diabetes Association and other organizations, remains to be assessed.

Lower mortality in geriatric patients receiving risperidone and olanzapine versus haloperidol: preliminary analysis of retrospective data

OBJECTIVE

The authors examined the mortality rate in geriatric patients receiving either haloperidol or atypical antipsychotics.

METHODS

Authors tracked mortality over a 2-year period in patients age 65 years or older receiving haloperidol (N=299) or the atypical antipsychotics risperidone or olanzapine (N= 1,254).

RESULTS

Sixty-four patients in the haloperidol group (21.4%) and 61 patients in the atypical group (4.75%) died during the 2-year study period. The difference was statistically significant.

CONCLUSIONS

The findings suggest that mortality in elderly patients receiving haloperidol is significantly higher than in those receiving the atypical antipsychotics risperidone or olanzapine. Authors discuss possible causal mechanisms.

Risperidone in the treatment of delirium: results from a prospective open-label trial

BACKGROUND

Effective treatment is necessary to reverse delirium and prevent potentially serious consequences.

METHOD

Patients were identified for screening by initial chart review of all consecutive admissions to the general medical or surgical wards at the Department of Veterans Affairs hospital and the University of Mississippi Medical Center in Jackson, Mississippi, between November 2000 and April 2002. Medically ill patients with delirium defined by DSM-IV criteria and a Delirium Rating Scale (DRS) score of >or= 13 were given risperidone, 0.5 mg, twice daily, with additional doses permitted on day 1 for target symptoms. Total day 1 dosage was given daily until the DRS score was <or= 12; dosage was then decreased by 50% (maintenance dose) and continued until day 6. Daily assessment included DRS, Cognitive Test for Delirium (CTD), and modified Extrapy-ramidal Symptom Rating Scale. Functional status (Karnofsky Scale of Performance Status; KSPS) and medical burden (Cumulative Illness Rating Scale) were assessed at baseline and day 6.

RESULTS

Ten patients (mean age = 64.7 years) were enrolled. Mean daily maintenance risperidone dosage was 0.75 mg. Mean CTD scores improved from day 1 to the day maintenance dose was initiated (p <.0005) and remained improved at day 6 (7.1 +/- 2.0 and 16.9 +/- 3.0, days 1 and 6, respectively; p =.0078). Mean DRS scores improved from day 1 to the day maintenance dose was initiated (p <.0001) and remained improved at day 6 (25.2 +/- 0.9 and 11.3 +/- 1.5, days 1 and 6, respectively; p <.0001). Mean KSPS scores improved from 32.0 on day 1 to 45.5 on day 6 (p =.044). No patient developed movement disorders. One patient each discontinued because of sedation and hypotension.

CONCLUSION

Low-dose risperidone can improve cognitive and behavioral symptoms of delirium in medically ill patients.