Comparative evaluation of conventional and novel antipsychotic drugs with reference to their subjective tolerability, side-effect profile and impact on quality of life

Comparing effectiveness of risperidone with first-generation antipsychotic medications in patients with schizophrenia-spectrum disorders

This naturalistic retrospective study aims to compare effectiveness of a second-generation antipsychotic medication, risperidone, with first-generation antipsychotic medications (haloperidol and trifluoperazine) in an Asian population with first-episode schizophrenia-spectrum disorders. A total of 261 patients were assessed for time to discontinuation for any reason and specific reasons of discontinuation, controlling for baseline differences between groups. Some 90% of patients discontinued their antipsychotic medications before 18 months. Median time to discontinuation for any reason in risperidone was 69 days versus first-generation antipsychotic medications of 27 days. Specifically, the risperidone group had a longer time to discontinuation for any reason than haloperidol (HR = 0.61, p = 0.005) and trifluoperazine groups (HR = 0.63, p = 0.03), as well as a longer time to discontinuation due to intolerability of side effects than haloperidol (HR = 0.50, p = 0.008) and trifluoperazine groups (HR = 0.26, p = 0.001). There were no significant differences between medications for time to discontinuation due to lack of efficacy, patient's/family's decisions or other reasons. We conclude that there is a very high rate of discontinuation of the initial antipsychotic medications for various reasons, with risperidone having an overall longer time to discontinuation compared with first-generation antipsychotic medications.

Adherence to treatment and therapeutic strategies in schizophrenic patients: the ADHERE study

AIM

To assess the degree of compliance and adherence to treatment during the follow-up of schizophrenic outpatients after a new therapeutic strategy had been initiated.

METHODS

A multicenter, retrospective, prospective, observational study of 1,848 outpatients with schizophrenia or schizoaffective disorders (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria) was conducted. Patients were treated either with oral or injectable conventional or second generation antipsychotics, and were followed up for 3 months at mental health centers. Patient compliance with the pharmacological treatment was assessed by the use of questionnaires, scales, medication accountability, and the Medication Event Monitoring System. Patients were considered compliant if they reported a high compliance rate (> or = 80%).

RESULTS

At baseline only 29% of patients on oral medication were compliant compared with 79% of patients on injectable medication (injection counting) (OR= 9.11; 95% CI 6.02-13.77; P<.0001). At the 3 month visit, 84% of patients had changed their treatment and in these, the compliance rate of those on injectable medication was 94% versus 87% of patients taking oral medication (OR= 2.47; 95% CI 1.21-5.05; P=.022).

CONCLUSION

The use of long-acting injectable antipsychotics, which improves compliance rates and patient follow-up, should facilitate the management of Spanish patients with schizophrenia in mental health centers.

Disruption of conditioned reward association by typical and atypical antipsychotics

Antipsychotic drugs are broadly classified into typical and atypical compounds; they vary in their pharmacological profile however a common component is their antagonist effects at the D2 dopamine receptors (DRD2). Unfortunately, diminished DRD2 activation is generally thought to be associated with the severity of neuroleptic-induced anhedonia. The purpose of this study was to determine the effect of the atypical antipsychotic olanzapine and typical antipsychotic haloperidol in a paradigm that reflects the learned transfer of incentive motivational properties to previously neutral stimuli, namely autoshaping. In order to provide a dosing comparison to a therapeutically relevant endpoint, both drugs were tested against amphetamine-induced disruption of prepulse inhibition as well. In the autoshaping task, rats were exposed to repeated pairings of stimuli that were differentially predictive of reward delivery. Conditioned approach to the reward-predictive cue (sign-tracking) and to the reward (goal-tracking) increased during repeated pairings in the vehicle treated rats. Haloperidol and olanzapine completely abolished this behavior at relatively low doses (100microg/kg). This same dose was the threshold dose for each drug to antagonize the sensorimotor gating deficits produced by amphetamine. At lower doses (3-30microg/kg) both drugs produced a dose-dependent decrease in conditioned approach to the reward-predictive cue. There was no difference between drugs at this dose range which indicates that olanzapine disrupts autoshaping at a significantly lower proposed DRD2 receptor occupancy. Interestingly, neither drug disrupted conditioned approach to the reward at the same dose range that disrupted conditioned approach to the reward-predictive cue. Thus, haloperidol and olanzapine, at doses well below what is considered therapeutically relevant, disrupts the attribution of incentive motivational value to previously neutral cues. Drug effects on this dimension of reward processing are an important consideration in the development of future pharmacological treatments for schizophrenia.

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

BACKGROUND

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

SCOPE

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

FINDINGS

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

CONCLUSIONS

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

Clinician-rated functioning and patient-rated quality of life in schizophrenia: implications of their correspondence for psychopathology and side effects

OBJECTIVE

Past studies have found inconsistent associations between subjective and objective measures of quality of life (QOL) in schizophrenia. We hypothesized that this may be due to heterogeneity in the demographic and/or clinical variables inherent in the samples and we investigated this possibility.

METHODS

We stratified the patients according to a descriptive measure of correspondence between self-reported QOL and clinician-rated functioning. We then examined whether heterogeneous patterns existed among the subgroups in terms of demographic variables, symptom severity, associations between self-reported and clinician-rated psychopathology and associations between side effects, QOL and functioning.

RESULTS

The subgroups significantly differed with respect to clinician-rated positive symptoms (F=3.075, p<.05), subjective symptoms (somatization, F=5.768, p<.01; obsessive-compulsive, F=3.885, p<.05; interpersonal sensitivity, F=8.278, p<.001; depression, F=9.368, p<.001; anxiety, F=6.909, p<.01; hostility, F=7.787, p<.01; phobic anxiety, F=9.551, p<.001; paranoia, F=5.304, p<.01; psychoticism, F=5.071, p<.01) and in- and outpatient ratio (Chi(2)=11.58, p<.01). Only the subgroup with relatively good correspondence between clinician-rated functioning and self-reported QOL showed significant low to moderate associations between the aforementioned measures and side effects. In addition, they showed similar levels of significant associations between the positive and subjective symptoms. In contrast, other discordant subgroups lacked overall associations between side effects, functioning and QOL as well as between subjective and objective measures of psychopathology.

CONCLUSION

Low to moderate levels of correspondence between subjective QOL and objective functioning were partly supportive of the independence of the constructs. Insight is likely to be a mediating variable of the correspondence between self-report and clinician-rated measures and should be considered in studies using self-report measures.

Switching stable patients with schizophrenia from depot and oral antipsychotics to long-acting injectable risperidone: reasons for switching and safety

OBJECTIVE

An international, non-randomised study evaluated efficacy and safety of risperidone long-acting injectable (RLAI) compared to previous treatment. To investigate generizability of the European data set to the UK subset safety and switching data are reported here.

METHODS

Patients with schizophrenia or other psychotic disorder, symptomatically stable on antipsychotic medication, received intramuscular injections of RLAI 25 mg (to a maximum of 50 mg) every 2 weeks for 6 months.

RESULTS

Of 182 UK patients enrolled, 79% had schizophrenia, 21% other psychotic disorders. Insufficient efficacy (43%), side effects (45%), and non-compliance (25%) were the most common reasons for switching. Sixty-nine per cent of patients completed the trial; 8% discontinued due to adverse events (AEs). Most frequent treatment-emergent AEs were headache (8.2%), relapse (7.7%) and insomnia (7.1%); 8 (4.4%) patients reported injection-related AEs. There were significant improvements in extrapyramidal symptom rating scale total and subscale (particularly Parkinsonism) scores, regardless of previous medication (total cohort, p < or = 0.0001). There was a small but significant increase in body weight at endpoint (1.2 kg, p = 0.0023). One patient suffered a myocardial infarction and died (not treatment-related). There were no substantial differences between the full data set and the UK sub-population

CONCLUSION

Switch to RLAI was well-tolerated in stable patients over 6 months. The European data set is generalizable to the UK patient population.

The CATIE and CUtLASS studies in schizophrenia: results and implications for clinicians

Numerous double-blind studies have compared second-generation antipsychotics (SGAs) with first-generation antipsychotics (FGAs), with most finding better efficacy and tolerability for SGAs. However, these 'efficacy trials' were generally short term and included only highly selected patients. Mostly because of weight gain and other metabolic effects of the SGAs, as well as their high acquisition price, the debate on the (cost) effectiveness of the SGAs led to two pragmatic clinical trials with no sponsorship by industry. Both trials had broad inclusion criteria and long follow-up, and tried to mimic clinical routine: CATIE (Clinical Antipsychotic Trials of Intervention Effectiveness) and CUtLASS (Cost Utility of the Latest Antipsychotic drugs in Schizophrenia Study). 1493 patients participated in CATIE, an 18-month, double-blind trial comparing the SGAs olanzapine, quetiapine, risperidone and ziprasidone with the FGA perphenazine. If efficacy or tolerability was insufficient, patients were re-randomized to a medication other than the one they previously received. Improvement of psychopathology and of quality of life was only moderate. Overall, 74% of patients discontinued study medication before 18 months, and the median time to discontinuation was 4.6 months. Aside from olanzapine (time to discontinuation 9.2 months), the other SGAs did not differ from each other or from perphenazine. Except for adverse effects as a reason for discontinuation, differences between the SGAs and the FGA were minimal. In CUtLASS, a 12-month open-label trial, 277 patients were randomized to receive an FGA or a SGA. Again, efficacy was rather similar between the two groups, with only limited improvement of psychopathology and quality of life. The authors of both trials concluded that SGAs do not markedly differ from FGAs regarding compliance, quality of life and effectiveness. The methodological problems of both trials have been discussed extensively. Patients had psychotic symptoms that were moderate in severity and were at least partially treatment resistant. The marginal improvement observed indicated that this population might not be appropriate to detect differences between FGAs and SGAs. Specific issues of CATIE include the exclusion of patients with tardive dyskinesia in the perphenazine arm and the high discontinuation rate. In CUtLASS, the concept of including 13 different FGAs and four SGAs in the respective classes was problematic. It is of interest that the most widely prescribed drug was sulpiride--of the FGAs, this is probably the 'most atypical' drug. Aside from the finding that the advantages of the SGAs are not as strong as early trials and marketing suggested or promised, the trials do not provide much helpful information regarding everyday practice. For tardive dyskinesia, no conclusions at all can be drawn. Similarly, methodological problems inhibited the detection of the other major advantage of the SGAs, i.e. the improved subjective well-being/quality of life while receiving these agents. It is well known that patients' and doctors' perspectives differ markedly, and the Quality of Life Scale (QLS), an expert-rated scale used in both trials, might not be sensitive enough to detect the subjective advantages reported by the majority of patients in other trials. CATIE and CUtLASS suggest that SGAs do not live up to all the previous expectations. However, even if most of these advantages are debatable, the lower risk of tardive dyskinesia and the better subjective effects should be strong enough reasons to favour these drugs. There is no single antipsychotic that is best for every schizophrenia patient, as individual responses differ markedly. For successfully individualized treatment, a multitude of antipsychotic options are needed.

The subjective experience of taking antipsychotic medication: a content analysis of Internet data

OBJECTIVE

We explored the subjective effects associated with olanzapine, risperidone and older antipsychotics.

METHOD

We conducted a content analysis of an Internet database of comments about prescribed medications.

RESULTS

We analysed 223 comments on risperidone, 170 on olanzapine and 46 relating to three older antipsychotics. The predominant subjective effects produced by all drugs consisted of sedation, cognitive impairment and emotional flattening or indifference. Connections appeared between these effects and Parkinsonian-like symptoms with the older drugs, sexual impairment with risperidone and metabolic effects with olanzapine. The experience of akathisia was frequently linked to suicidal thoughts. Some respondents described how the drugs' subjective effects helped to reduce symptoms of mania, psychosis and anxiety.

CONCLUSION

The generalisability of Internet data is uncertain. However, the data suggest that adverse subjective effects play a central role in the experience of taking antipsychotic drugs and may be related to the drugs' desired benefits.

Tolerability of antipsychotic drugs: does patient perspective deserve consideration?

This contribution initially describes some traditional tools that are commonly used to measure drug tolerability, including measures that take into considerations both clinicians' and patients' views. Subsequently, it highlights a few studies that compared the patient and clinician's perspective in the evaluation of drug tolerability, trying to understand whether health care providers and patients perceive antipsychotic tolerability in different ways, and whether these different ways may have implications in terms of treatment adherence and outcome. Finally, some clinical and research implications are suggested and discussed.

Shift from first generation antipsychotics to olanzapine may improve health-related quality of life of stable but residually symptomatic schizophrenic outpatients: a prospective, randomized study

OBJECTIVES

The aim of this study was to elucidate, whether shift from first generation antipsychotics (FGA) to olanzapine can affect health-related quality of life (HRQoL) of residually symptomatic schizophrenic outpatients.

METHODS

Patients were randomized to either olanzapine or to continuation on their FGA. The 15D-measured HRQoL at baseline and end-point (after 12 weeks) was compared.

RESULTS

Patients (n = 21) randomized to olanzapine achieved better HRQoL than those (n = 21) who continued on their FGA. This difference on the 15D (0.048 on a 0-1 scale; p = .037) was clinically important and comparable to that resulting from common surgical interventions, for example, hip or knee replacement.

CONCLUSIONS

HRQoL of stable outpatients with residual symptoms or adverse effects may improve substantially after shift from FGAs to olanzapine.

Attitudes toward taking medication among outpatients with schizophrenia: cross-national comparison between Tokyo and Beijing

OBJECTIVES

The aim of this study was to compare attitudes toward medication and associated factors for patients with schizophrenia in Japan and China.

METHODS

Age-group matched samples were drawn from outpatients in Tokyo (N = 76) and Beijing (N = 76) according to the same inclusion/exclusion criteria. Psychotropic prescription and attitudes toward medication were measured using Drug Attitude Inventory-30 (DAI-30) and an original questionnaire regarding beliefs about psychiatric medication. Stepwise regression analysis of the DAI-30 data was performed for each group.

RESULTS

Japanese subjects were prescribed significantly larger amounts of antipsychotics. Polypharmacy of antipsychotics and concurrent use of anticholinergics, anxiolytics, or hypnotics were more frequently found among subjects in Tokyo than among those in Beijing. However, subjects in Tokyo and Beijing had similar subjective responses to medication, subjective evaluation of side-effects, and complaints about overuse of psychotropics. Subjects in Tokyo complained less about physician's over-reliance on medication and were less concerned about medication cost than those in Beijing. In Tokyo, longer duration of illness and lower subjective distress caused by side effects predicted a more positive subjective response, while female gender, younger age, and lower Brief Psychiatric Rating Scale score were independently correlated with a better subjective response in Beijing.

CONCLUSIONS

Subjective acceptance of multiple medications is greater for patients in Japan than those in China. Determinants of subjective response to medication varied between Japan and China.

Predictors of subjective and objective quality of life in outpatients with schizophrenia

AIM

In recent years, greater attention has been given to quality of life (QOL) in schizophrenia and several studies reported that negative and depressive symptoms and cognitive dysfunction are related to patient QOL. But because a variety of QOL measures have been used in the previous studies, there seems to be no unanimous predictors for subjective and objective QOL. The purpose of the present study was to elucidate the relationship between clinical variables and subjective and objective QOL in outpatients with schizophrenia, using schizophrenia disease-specific QOL measures. Particular attention was paid to cognitive function as a predictor of QOL.

METHODS

Schizophrenia symptoms of the Positive and Negative Syndrome Scale (PANSS) were divided into five factors: positive factor, negative factor, cognitive factor, emotional discomfort, and hostility. The study sample consisted of 84 schizophrenia outpatients. Subjective and objective QOL were assessed with Schizophrenia Quality of Life Scale (SQLS) and the Quality of Life Scale (QLS), respectively.

RESULTS

Subjective QOL correlated significantly with emotional discomfort, positive factor, negative factor, extrapyramidal symptoms and cognitive factor, while objective QOL correlated with negative factor, cognitive factor, emotional discomfort, extrapyramidal symptoms, and dose of antipsychotics. Total score and three of four subscales in the QLS correlated significantly with cognitive factor, while cognitive factor had a significant correlation with only one of three scales of SQLS. Stepwise regression showed that subjective QOL was significantly predicted by emotional discomfort and extrapyramidal symptoms, while negative factor was the most important predictor of objective QOL.

CONCLUSION

Cognitive dysfunction had a greater influence on objective QOL than subjective QOL. Treating depressive and negative symptoms and extrapyramidal symptoms might contribute to enhanced subjective and objective QOL.

A randomized controlled trial of the cost-utility of second-generation antipsychotics in people with psychosis and eligible for clozapine

OBJECTIVE

To assess whether clozapine is likely to be more cost-effective than other second-generation antipsychotics (SGAs) in people with schizophrenia.

METHODS

An integrated clinical and economic multicenter, rater-blind, randomized controlled trial (RCT) compared clozapine to the class of other SGAs, using the perspectives of the National Health Service, social support services, and patients. The practice setting was secondary and primary care in the United Kingdom; patients were followed for 1 year. Incremental cost-effectiveness ratios (ICERs), net benefit statistics, and cost acceptability curves were estimated.

RESULTS

The ICER for clozapine was 33,240 pound per quality-adjusted life-year (QALY) (range 23,000-70,000 pound for the sensitivity analyses). The proportion of simulations when clozapine was more cost-effective than other SGAs reached 50% if decision-makers are prepared to pay 30,000 pound to 35,000 pound per QALY. This is at the top of the range of acceptable willingness-to-pay values per QALY implied by decisions taken by the National Institute for Health and Clinical Excellence (NICE).

CONCLUSIONS

This study adds to a limited body of evidence comparing clozapine to other SGAs and is the first economic and clinical RCT to compare clozapine to the class of other SGAs using the lower cost of generic clozapine and a pragmatic trial design. Policy decisions by the NICE suggest that additional reasons would be needed to accept clozapine as effective and efficient if it had a high probability of having ICERs more than 35,000 pound per QALY. The results and limitations of the analysis suggest that there is still a need for further economic evaluation of clozapine.

Patterns of physician and patient rated quality of life during antipsychotic treatment in outpatients with schizophrenia

Quality of life (QoL) in patients with schizophrenia has been assessed both from physician and patient perspectives, but little is known about agreement between these perspectives and predictors of agreement. The aim of this study was to analyze a large sample of patients with schizophrenia to discover patterns of physician and patient-rated QoL in patients with schizophrenia and identify predictors for these patterns. This study (EASE) was designed to investigate the QoL and subjective well-being in out-patients with schizophrenia during antipsychotic treatment in a naturalistic setting. Assessments were carried out at baseline and at 3, 6, 9 and 12 months, using the quality of life scale (QLS) and the subjective well-being on neuroleptics scale (SWN-K). A hierarchical cluster analysis was used to define groups of patients based on the SWN-K and QLS total scores at all visits. 1174 patients were included in the cluster analyses that were based on SWN-K and QLS total scores over time. Four distinct clusters were identified: patients with: (1) continuously high QoL (23.2%), (2) continuously moderate QoL (45.8%), (3) continuously low QoL (11.2%), and (4) improving QoL (19.9%). Clusters 1-3 were stable in terms of QoL, whilst cluster 4 changed towards improvement. Various predictors for the four clusters were identified. In the cluster with improving QoL, the absence of treatment with an oral conventional antipsychotic pre-study and no medication change due to lack of efficacy at baseline were predictors for improvement. In the cluster with continuously high QoL, no medication change due to lack of efficacy and lowest CGI-S scores at baseline were predictors. Oral conventional antipsychotic treatment pre-study was predictive for the cluster with continuously moderate QoL. In the cluster with continuously low QoL, medication change due to lack of efficacy and highest CGI-S scores were predictors. These findings suggest that various factors may predict whether a patient with schizophrenia experiences a continuously high QoL, a continuously moderate QoL, a continuously low QoL, or improving QoL whilst on antipsychotic treatment.

Evaluation of subjective treatment satisfaction with antipsychotics in schizophrenia patients

Adherence to antipsychotic treatment is particularly important in the long-term management of schizophrenia and other related psychotic disorders since poor adherence to medication is associated with poor health outcomes. Although the patients' subjective satisfaction with the medication is crucial for adherence to medication, few studies have examined the relationship between subjective satisfaction with antipsychotics and adherence. In this study, we investigated subjective satisfaction with antipsychotics in patients with schizophrenia by using the Treatment Satisfaction Questionnaire for Medication (TSQM), a self-reporting instrument to assess the major dimensions of patients' satisfaction with their medication. The subjects included 121 clinically stabilized outpatients who met the following criteria: 1) patients between 20 and 65 years of age, diagnosed with schizophrenia or other psychotic disorders as defined by DSM-IV, 2) patients undergoing oral antipsychotic monotherapy or taking only an antiparkinsonian agent as an adjuvant remedy, and 3) patients who had received a stable dose of an antipsychotic for more than four weeks. Patients were asked to answer the TSQM questions, and their clinical symptoms were also evaluated by the Brief Psychiatric Rating Scale (BPRS). Satisfaction with regard to side-effects (p=0.015) and global satisfaction (p=0.035) were significantly higher in patients taking second-generation antipsychotics (SGAs, n=111) than those taking first-generation antipsychotics (FGAs, n=10), whereas no significant difference was found between the two groups in clinical symptoms according to BPRS (p=0.637) or the Drug-induced Extrapyramidal Symptoms Scale (DIEPSS, p=0.209). In addition, correlations were not significant between the subjective satisfactions and clinician-rated objective measures of the symptoms. These findings suggest that SGAs have more favorable subjective satisfaction profiles than FGAs in the treatment of schizophrenia. Since it is often difficult to detect the difference by a traditional objective assessment of the patients, it is desirable that physicians pay attention to the patients' subjective satisfaction in conjunction with their own objective clinical assessment.

Adverse effects of antipsychotics as outcome measures

BACKGROUND

Antipsychotic drugs are associated with adverse effects that can lead to poor medication adherence, stigma, distress and impaired quality of life.

AIMS

To review the use of adverse effects of antipsychotic drugs as outcome measures, with a particular emphasis on methodological issues.

METHOD

Review of data on adverse effects from sources including randomised controlled trials (RCTs), post-marketing surveillance and naturalistic studies.

RESULTS

All have advantages and disadvantages and the best overview comes from considering all sources of data together. Adverse effects are inconsistently reported, hampering cross-study comparisons. Many outcome measures lack clinical meaning. In both naturalistic studies and RCTs adverse effects often account for less treatment discontinuation than lack of efficacy.

CONCLUSIONS

Standardisation in the reporting of adverse effects is needed. Patients' subjective experience of medication should be given more consideration. Total discontinuation rates provide a useful global outcome measure that incorporates tolerability and efficacy as well as patient and clinician viewpoints. Patients should be informed of common side-effects prior to treatment and monitored for their occurrence during treatment.

Correlations of attitudes toward antipsychotic drugs with insight and objective psychopathology in schizophrenia

OBJECTIVE

The aim of this cross-sectional study was to examine the relationships between attitudes toward antipsychotics, insight, and other clinical variables in stable schizophrenia.

METHODS

Fifty Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision-(DSM-IV-TR)-diagnosed schizophrenic outpatients were evaluated through a psychiatric assessment. Drug attitudes were measured using the Drug Attitude Inventory and insight using the Scale for the Assessment of Unawareness of Mental Disorder. Differences between patients taking first- or second-generation antipsychotics were investigated.

RESULTS

Lack of insight, more severe scores on the positive and general psychopathology subscales of the Positive and Negative Syndrome Scale (PANSS), and later age at onset of schizophrenia correlated with worse global medication attitude. The multiple regression analysis revealed that unawareness of the need of treatment predicted poorer drug global attitude (R(2) = 0.312). Patients taking second-generation antipsychotics showed lower negative attitudes and better global drug attitudes than patients treated with neuroleptics.

CONCLUSION

The impact of the awareness of the need for treatment on global medication attitude needs to be a main focus of interventions targeting compliance.

Experience of quality of life and attitude to care and treatment in patients with schizophrenia: Role of cross-sectional remission

Objective. The concept of cross-sectional remission was investigated in a sample of patients with schizophrenia. A total of 243 patients were tested for quality of life, burden and handicap, insight and satisfaction with the care provided in an epidemiological study. The question addressed was if remission is of importance for outcome. Methods. Cross-sectional remission was defined by applying the symptom criteria of remission, where none of eight selected PANSS items should exceed 3 points. Out of 243 patients, 38% were in met cross-sectional remission. Quality of life was assessed with the MOS SF-36 and the Rosser Index. The patients' understanding of their illness was assessed based on symptoms and disorder insight. Finally, attitudes to care and health service were assessed by the UKU/Consumer Satisfaction Questionnaire and the Drug Attitude Inventory. Results. Patients who were in cross-sectional remission reported higher quality of life and reduced burden related to the disorder, a greater level of insight into their symptoms and the illness, and a more positive attitude to treatment, including drugs. Conclusion. This study implies that remission, here expressed in terms of cross-sectional remission, is of importance for patients' well-being. Patients who had no interference from symptoms in their daily functioning found their life better, had a superior insight and were more positive to treatment.

Subjective response and attitudes toward antipsychotic drug therapy during the initial treatment period: a prospective follow-up study in patients with schizophrenia

OBJECTIVE

In this prospective study, patients with schizophrenia were followed up for 3 months to investigate the impact of sociodemographic factors, psychopathology, change in psychopathology and side effects on subjective response and attitudes toward antipsychotics during the initial treatment period.

METHOD

We investigated 42 patients starting treatment with a new-generation antipsychotic. Next to the registration of demographic data various rating scales were used: the Positive and Negative Syndrome Scale (PANSS), the Udvalg for Kliniske Undersogelser (UKU) Side Effect Rating Scale and the Drug Attitude Inventory (DAI).

RESULTS

Two patients experienced a first episode of the illness and were neuroleptic naïve, and 40 had suffered from at least one prior episode of schizophrenia. Longer duration of illness as well as the amelioration of psychopathological symptoms had a positive impact on subjective response to treatment. Correlations between antipsychotic-induced side effects and drug attitude tended to be weak.

CONCLUSION

Our results emphasize the necessity of improving psychopathological symptoms during the initial treatment period to improve attitudes toward and compliance with treatment.

Quality of life and subjective well-being during treatment with antipsychotics in out-patients with schizophrenia

OBJECTIVE

To assess the Quality of Life (QOL) in outpatients with schizophrenia under antipsychotics from two perspectives: a "subjective" perspective as rated by the patient and an "objective" perspective as rated by the physician.

METHOD

EASE (External Assessment of Quality of Life in Out-patients with Schizophrenia) is a 12-month, prospective, naturalistic study of the QOL in patients on antipsychotic treatment for schizophrenia in an out-patient setting in Germany. The study included 1462 patients who were initiated on a new antipsychotic or switched to another antipsychotic. The Subjective Well-being under Neuroleptics scale (SWN) and the Quality of Life Scale (QLS) were used to assess the QOL in these patients. The Clinical Global Impression (CGI) scale was used to assess overall symptom severity. Four cohorts were identified and evaluated: (a) patients treated with olanzapine monotherapy (N=1007), (b) another atypical antipsychotic as monotherapy (N=335), (c) a typical antipsychotic as monotherapy (N=32) and (d) combination therapy with more than one antipsychotic (N=88).

RESULTS

QOL as assessed by both SWN and QLS improved in all treatment cohorts. SWN responses in the respective cohorts were (a) 52.3%, (b) 38.8%, (c) 31.3% and (d) 44.3%, whilst the QLS responses were (a) 58.2%, (b) 45.1%, (c) 59.4% and (c) 40.9%. Symptom severity as assessed by the CGI also improved over time regardless of the type of antipsychotic. An increase of one point on the CGI corresponded to a change in SWN total score of -9.67 points and a change in QLS total score of -13.36 points.

CONCLUSIONS

Both QOL and symptom severity improved over the 12-month study period, regardless of the type of antipsychotic taken. QOL improvement as perceived both from a "subjective" and an "objective" perspective was greatest in the cohort on olanzapine monotherapy.

Lack of insight in schizophrenia: impact on treatment adherence

People with schizophrenia commonly lack insight, that is, they are unaware of their illness and the consequences thereof. One of the most important consequences of lack of insight is a failure to recognise the need for treatment, leading to treatment nonadherence. With several scales that now enable objective measurement of insight, it is possible to examine correlates of insight change, including course of illness and treatment adherence. Specific interventions, both pharmacological and psychotherapeutic, have been developed to enhance illness insight and treatment adherence. The extent to which second-generation antipsychotic medications, including a recently released long-acting formulation, improve insight and/or enhance treatment adherence remains to be determined.

Efficacy and tolerability of quetiapine in the treatment of behavioral and psychological symptoms of dementia

Behavioral symptoms start to appear in mild and moderate dementia and become increasingly severe with the progression of the disease. Agitation, aggressiveness, and psychosis can be seen in Alzheimer's disease, and in particular are common manifestations in Lewy body dementia. It is the behavioral disturbances rather than the cognitive disorders that are more often the cause of the institutionalization of these patients because of the heavy assistance and emotional burden they represent for caregivers. Traditionally, these kinds of symptoms were controlled by classical antipsychotic agents, which after long-term use cause severe extrapyramidal effects, late dyskinesia, sedation, orthostatic hypotension, and cognitive function impairment. More recently, atypical antipsychotic agents have shown a better tolerability profile, with a reduced incidence of extrapyramidal effects, orthostatic hypotension, sedation, and a reduced impact on cognitive function. The aim of this study is to evaluate the efficacy and tolerability of quetiapine in a group of patients with a diagnosis of dementia and concomitant psychotic disorders. The response to treatment was evaluated by the Neuropsychiatric Inventory (NPI) and the Behavioral Pathology in Alzheimer's Disease Rating Scale (BEHAVE-AD). The NPI and BEHAVE-AD were administered at baseline and after 4 weeks and 12 weeks of therapy. Tolerability was assessed by the incidence of clinically evident side effects. The results show that quetiapine is effective in reducing behavioral symptoms, deliria and hallucinations, aggressiveness, and sleep disturbances. Quetiapine tolerability proved to be satisfactory. The only side effect of clinical significance was orthostatic hypotension, which was, however, partially preventable by a slower drug titration.

Correlation of physician and patient rated quality of life during antipsychotic treatment in outpatients with schizophrenia

Perception of quality of life (QOL) may differ depending on the perspective. This 12-month, prospective, naturalistic study compared QOL ratings in outpatients on antipsychotic treatment for schizophrenia both from a "subjective" patient rated and an "objective" physician rated perspective. Included were 1462 patients. Two scales were used to assess patient and physician perspectives: the Subjective Well-being on Neuroleptics (SWN) scale and the Quality of Life Scale (QLS). Linear correlation was found between both ratings: 10 points on the SWN corresponded to 9.35 points on the QLS. Spearman's correlation coefficients increased over time up to r=0.71 at Month 12. Patients were grouped into four cohorts depending on the degree of concordance between SWN and QLS ratings. Several factors affecting the concordance of both ratings were identified. Compared to the cohort with QLS=SWN, higher QOL ratings by the physician (QLS>>SWN) were more likely in females than in males (OR=1.36; 95% CI 1.00 - 1.85) and in older than in younger patients (<or=30 years vs. >50 years: OR=0.58, 95% CI 0.34 - 0.998), but less likely in patients with high baseline CGI-severity (CGI >4; OR=0.63; 95% CI 0.47 - 0.86) or treatment with oral typicals before baseline (OR=0.53; 95% CI 0.31 - 0.91). Higher QOL ratings by the patient (SWN>>QLS) were less likely in patients with psychotherapy before baseline (OR=0.54; 95% CI 0.36 - 0.81), medication intolerability before baseline (OR=0.53; 95% CI 0.36 - 0.78) or patient request of treatment change at baseline (OR=0.64; 95% CI 0.42 - 0.96). The combination of several factors predicted concordant ratings, including male sex, young age, high CGI at baseline, and psychotherapy prior to the study.

Quality of life in schizophrenia on conventional versus atypical antipsychotic medication: a comparative cross-sectional study

INTRODUCTION

Atypical antipsychotic drugs, with superior tolerability and possibly superior efficacy, were expected to give schizophrenia patients better quality of life (QOL) than conventional treatment. Research findings are equivocal.

METHOD

We evaluated QOL using three subjective measures--Drug Attitude Inventory (DAI); Sickness Impact Profile (SIP); Schizophrenia Quality of Life Scale (SQLS)--in 126 routinely seen patients whose treatment was stable for six months, regardless of co-morbidity, current clinical status and concomitant medications. Severity of disorder was assessed with the Global Assessment Schedule (GAS).

RESULTS

Fifty patients were on conventional treatment and 76 on atypical treatment. Atypical patients were more likely to be abusing substances (p = 0.02) and living independently (p = 0.00). Conventionally treated patients were older than atypically treated patients. Conventionally treated patients suffered schizophrenia almost twice as long as atypically treated patients. Atypically treated patients enjoyed substantially better quality of life than conventionally treated patients on all measures. The effects of confounding variables, i.e. age, duration, accommodation, co-morbid substance misuse and time spent in hospital, were evaluated with the General Linear Model. This confirmed the status of drug treatment as the primary predictor of all aspects of QOL.

CONCLUSION

We conclude that quality of life is genuinely superior on atypical treatment even allowing for the confounding effects of differential prescribing habits: atypical treatment tends to be reserved for younger, less seriously ill patients. There is no scientific or clinical rationale to support this practice.

Management of acutely ill patients in the hospital setting: focus on quetiapine

We have considered published work and clinical experience focusing on the atypical antipsychotic quetiapine in order to form a consensus on the most appropriate treatment strategies for hospitalised patients with acute schizophrenia or bipolar disorder. It is important to consider the specific treatment needs of these patients and these are discussed in the context of current treatment guidelines. We will review the efficacy and tolerability of atypical antipsychotics versus conventional antipsychotics and/or benzodiazepines as a first-line treatment, and examine the suitability of oral versus intramuscular formulations in the acute setting. The potentially beneficial properties of specific atypical agents are also considered. Appropriate dosing is particularly important in acutely ill patients as it can help achieve rapid improvement. We will discuss emerging data which show that rapid initiation of quetiapine in patients with acute psychosis or mania is not only as effective as standard initiation, but is also well tolerated. This may be important for treatment in the long term as a positive initial treatment experience can determine patient compliance and treatment adherence. In conclusion, this review recommends that oral atypical antipsychotics should be a first-choice medication for acutely ill cooperative patients in the hospital setting.

The effectiveness and predictors of response to antipsychotic agents to treat impaired quality of life in schizophrenia: A 12-month naturalistic follow-up study with implications for confounding factors, antidepressants, anxiolytics, and mood stabilizers

OBJECTIVE

This study examined specific predictors of the efficacy of risperidone (RP), olanzapine (OL) and first-generation antipsychotic agents (FGAs), the role of confounding factors, and concomitant agents such as antidepressants, anxiolytics, and mood stabilizers in the treatment of health related quality of life (HRQL) impairment of schizophrenia patients.

METHOD

This was a community-based, open label, parallel group naturalistic study of 124 schizophrenia outpatients who received either RP, OL, FGA, or combined agents (CA). Evaluations were performed at baseline and 12 months later. They included the Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q), the Positive and Negative Syndrome Scale (PANSS), the Distress Scale for Adverse Symptoms, and inventories for the assessment of distress severity, subjective tolerability, and self-efficacy.

RESULTS

OL was found to be superior to RP, FGAs and CA in terms of quality of life. FGAs revealed greater therapeutic benefit than RP, which was more beneficial than combined therapy. Improvement in Q-LES-Q was revealed in patients who received antidepressants and anxiolytics, but not mood stabilizers, or anti-Parkinson drugs. This effect was independent of treatment groups and gender. Regression models revealed that changes in emotional distress and side effects were common predictors for HRQL changes across treatment groups. Specific predictors of HRQL efficacy included self-efficacy for OL, negative and positive symptoms for RP, dysphoric mood and positive symptoms, daily doses and self-efficacy for FGA treated patients.

CONCLUSION

These findings suggest that OL is beneficial in the treatment of HRQL impairment in schizophrenia compared with RP, FGAs and CA. Special attention should be paid to specific predictors of HRQL efficacy for each antipsychotic agent, and to concomitant treatment with antidepressants and anxiolytics.

Subjective and behavioural consequences of striatal dopamine depletion in schizophrenia--findings from an in vivo SPECT study

Dysphoria is an integral part of the symptomatology of a variety of clinical states, though there is little empirical data available on the qualitative and quantitative aspects of this phenomenon. The purpose of the study was to administer alphamethyl paratyrosine (AMPT), a catecholamine depleting agent as a chemical probe to induce dysphoria, and document the ensuing changes in mental status. AMPT (4-5 g/day) was administered to a group of medication-free schizophrenic patients (n=13) over a 48 hour period, and changes in their mental status were monitored at 12 hour intervals with the Profile of Mood States (POMS), Addiction Research Center Inventory (ARCI), Drug Attitude Inventory (DAI) and other standardized rating scales. All of the subjects experienced dysphoric responses of variable severity. The profile of changes included blunted pleasure responsivity, clouded thinking, loss of motivation and lowered vigilance. Subtle subjective changes were experienced soon after the first dose of AMPT and the dysphoria steadily worsened, resulting in social withdrawal and personal distress. Subjective responses were the earliest to manifest, followed by akathisia, akinesia and rigidity. We conclude that AMPT induced dopamine depletion is a safe, rapid, reliable and reversible method of studying dysphoric states in humans. The technique is helpful in examining the phenomenology of dysphoria, the temporal relationship between subjective and behavioural consequences of dopamine depletion, and the role of dopamine in mediating subtle aspects of pleasure responsivity, which is in turn crucial to the understanding of treatment non-adherence in schizophrenia and the origins of comorbid substance abuse.

[Comparative evaluation of quality of life in patients with schizophrenia treated with conventional versus atypical neuroleptics: results of a transversal study]

AIM

The World Health Organization has defined quality of life as "the perception of an individual, his/her place in life, in the context of the culture and the system of values in which he/she lives and in relation to his/her objectives, expectations, standards and concerns". The quality of life of the schizophrenic patients has been largely studied for the evaluation of their medical, social and therapeutic needs. The impact of neuroleptics, in particular atypical neuroleptics, on the subjective quality of life of these patients remains to be specified. The aim of this study was to compare the subjective quality of life of schizophrenic patients treated with classical neuroleptics (CN) or atypical neuroleptics (AN).

METHODS

One hundred patients meeting DSM IV criteria for the diagnosis of schizophrenia (American Psychiatric Association, 1994) were included in the study. Sixty-four schizophrenic patients were treated with CN and thirty-six with AN. The symptomatology of the patients was assessed using the Positive And Negative Syndrome Scale, (PANSS, Kay et al., 1987) and the Schedule for the Deficit Syndrome (SDS, Kirkpatrick et al., 1989). The extra-pyramidal symptoms were assessed using the Extrapyramidal Symptom Rating Scale (Chouinard et al., 1980). The Subjective quality of life was studied using the Lehman Quality of Life Interview (QOLI, Lehman, 1988) translated and validated in France.

RESULTS

The patients treated by CN did not differ from the patients treated by AN in terms of severity of the positive and negative symptoms. The patients treated with AN presented significantly less extrapyramidal side effects than the patients treated with CN. No significant difference in terms of quality of life was found between both groups of patients.

CONCLUSION

The kind of neuroleptic (CN vs AC) does not seem to influence the quality of subjective life of schizophrenic patients.

The relationship between patient satisfaction and treatment outcomes in schizophrenia

In recent years, the goals of treatment in schizophrenia have evolved from objective improvements in psychotic symptoms to encompass patient-related factors such as subjective response and quality of life. In order to examine factors that influence patient satisfaction with treatment, subjective quality of life and subjective response to treatment, two literature searches were performed using PubMed. The first searched for articles of any kind with no time limits using the search parameters 'schizophrenia AND satisfaction', 'antipsychotic AND satisfaction', 'schizophrenia AND subjective response', 'schizophrenia AND therapeutic alliance', 'schizophrenia AND psychosocial OR psychoeducation'. Secondly, PubMed was searched between January 1990 and December 2005 using the key words 'satisfaction', 'subjective response' and 'quality of life' in combination with an array of atypical agents. Results demonstrated that patient satisfaction with antipsychotic therapy is influenced by multiple factors. The most frequently reported reasons for dissatisfaction include drug side effects, lack of involvement in treatment planning or decision-making and lack of involvement of family members in the care plan. The majority of studies have demonstrated that the atypical antipsychotics are associated with significant improvements in quality of life, functional status and patient satisfaction compared with conventional agents. The therapeutic alliance is key to achieving optimal outcomes, by providing information and education to meet patients' needs, while facilitating compliance with drug therapy to ensure better clinical outcomes. A long-acting atypical antipsychotic that can ensure medication delivery will provide a platform for psychosocial interventions, and thus may further increase patient satisfaction and, ultimately, improve long-term outcomes in schizophrenia.

Symptom domains of schizophrenia: the role of atypical antipsychotic agents

Given their more obvious presentation, the reduction of positive symptoms and their associated behavioural problems have been considered the most important treatment outcome parameter in patients with schizophrenia. However, the development of the atypical antipsychotic agents in the early 1990s resulted in the adoption of more wide-reaching measures of therapeutic outcome. The aim of this review was to evaluate the efficacy of currently available atypical agents across multiple symptom domains of schizophrenia with a specific focus on negative symptoms, neurocognition, social functioning, quality of life and insight. As such, studies published between January 1990 and December 2005 that evaluated the clinical efficacy and tolerability of atypical antipsychotics in different symptom domains of schizophrenia were reviewed as identified from literature researches using MEDLINE and Embase. Abstracts and posters presented at key psychiatry and schizophrenia congresses during this period were also reviewed where available in the public domain. Results from the studies identified have consistently demonstrated that atypical antipsychotics have substantial advantages over conventional antipsychotics with a broader spectrum of efficacy across symptomatic domains of schizophrenia as proven by greater improvements in negative symptoms and cognitive function and a beneficial effect on affective symptoms and quality of life. However, their clinical advantages have often been limited by patients' partial compliance with therapy. As such, the development of a long-acting atypical antipsychotic agent may provide a new and valuable treatment option for patients with schizophrenia.

Predicting medication-free treatment response in acute psychosis: cross-validation from the Finnish Need-Adapted Project

This study tested predictors of 2-year antipsychotic-free response from the Soteria study (older, better social functioning, fewer cardinal symptoms) using data from the Finnish Acute Psychosis Integrated treatment study. The quasi-experimental study compared need-adapted family-oriented psychosocial intervention within a 3-week antipsychotic-free trial to psychosocial intervention plus antipsychotic medications. Forty-six percent of experimental completers (37% of intent-to-treat subjects) were successfully treated without antipsychotic medications for the entire 2-year study. The DSM-III-R diagnoses of schizophrenia and schizophreniform disorder and Soteria-suggested predictors were not related to antipsychotic-free response. Different variables within the same domains of good prognosis and fewer schizophrenia symptoms predicted antipsychotic-free response or nonresponse with 74% accuracy. The 6-month duration of symptom criterion distinguishing schizophrenia from schizophreniform disorder does not separate medication-free treatment responders from those requiring medications. Prognosis appears related to antipsychotic-free response and may be helpful in distinguishing schizophrenia from schizophreniform disorder in early episodes.

Effect of antipsychotic replacement with quetiapine on the symptoms and quality of life of schizophrenic patients with extrapyramidal symptoms

Replacement of antipsychotic drugs with quetiapine (QTP) was tried in a naturalistic setting in chronic schizophrenic patients who still showed moderate psychiatric symptoms and either showed extrapyramidal symptoms (EPS) or took anti-parkinson drugs for the EPS. QTP was added on and gradually increased while the previous drugs were tapered and discontinued whenever possible. Clinical symptoms, objective and subjective QOL, and EPS were measured before and 6 months after QTP addition, using Brief Psychiatric Rating Scale (BPRS), Quality of Life Scale (QLS), Schizophrenia Quality of Life Scale (SQLS) and Drug-Induced Extrapyramidal Symptom Scale (DIEPSS), respectively. Twenty-one patients completed the trial and received the assessment. It was found that replacement with QTP-improved clinical symptoms, objective and subjective QOL and EPS. This improvement was equally observed in not only patients who switched to QTP monotherapy (n = 11) but also patients who took QTP together with reduced small doses (4.4 +/- 4.3 mg/day) of previous drugs (n = 11). The results suggest that replacement with QTP improves symptoms as well as objective and subjective QOL in a subgroup of schizophrenia.

Effects of Sun Ginseng on subjective quality of life in cancer patients: a double-blind, placebo-controlled pilot trial

OBJECTIVE

Ginseng has been reported to increase mental and physical abilities, improve mood and promote general health and well-being. The purpose of this study was to examine the effects of sun ginseng (SG) on quality of life in cancer patients.

METHODS

A randomized, double-blind, placebo-controlled pilot trial was performed for 12 weeks. Fifty-three patients were randomly assigned to SG 3000 mg a day (n = 32) or placebo (n = 21) in a 3 : 2 ratio. Patients' diagnoses were gynecologic cancer (n = 28), hepatobiliary cancer (n = 13) and other cancers (n = 12). Quality of life was assessed using the World Health Organization Quality of Life Assessment-Bref (WHOQOL-BREF) and the General Health Questionnaire-12 (GHQ-12).

RESULTS

After 12 weeks of therapy, the 'psychological domain' score of the WHOQOL-BREF was significantly improved in patients randomized to SG, compared with those randomized to placebo (P = 0.02). There was a tendency for SG to improve the 'physical health' (P = 0.06) and 'environment' (P = 0.07) domain scores of the WHOQOL-BREF, compared with placebo. The GHQ-12 total score was significantly improved in patients treated with SG than in those with placebo (P < 0.01). No significant adverse events were observed in both groups of patients.

CONCLUSIONS

Sun ginseng was found to be beneficial in improving some aspects of mental and physical functioning after 12 weeks of therapy in cancer patients, who were mainly diagnosed with gynaecologic cancer or hepatobiliary cancer. Further studies are required to evaluate the long-term effects of SG on multiple facets of quality of life in various cancer patients.

The impact of subjective well-being under neuroleptic treatment on compliance and remission

The patients' perspective of antipsychotic treatment was largely neglected for a long period. It has only been during the last 10 years, with the development of atypical antipsychotics, that scientific interest in this issue has markedly increased. Numerous studies have shown that the majority of schizophrenic patients are able to fill out a self-rating scale in a meaningful way, and several self-report scales with sufficient internal consistency and good construct validity have been developed. The effects of antipsychotic treatment on psychopathology and on subjective well-being (SW) are not strongly related; the perspectives of the patient and his/her psychiatrist markedly differ. Recent research indicates that SW/quality of life, much more improved by atypical than by typical antipsychotics, has a strong impact on compliance, as well as on the chance of achieving remission. The data strongly suggest that a systematic evaluation of the patient's perspective of antipsychotic treatment is meaningful and necessary to increase compliance, functional outcome, and long-term prognosis.

Classical as well as novel antipsychotic drugs increase self-stimulation threshold in the rat--similar mechanism of action?

Antipsychotic drugs given acutely increase the threshold for intracranial self-stimulation elicited from the ventral tegmental area. As all the antipsychotic drugs share the dopamine D2-receptor antagonism it is reasonable to believe that this is the cause for suppression of intracranial self-stimulation behaviour. The objective of this investigation was to examine the effect of classical (haloperidol) as well as novel antipsychotic drugs (clozapine, olanzapine and sertindole) on intracranial self-stimulation behaviour. Furthermore, the effects of different specific receptor antagonists on intracranial self-stimulation behaviour were examined. Our results showed that both the classical (haloperidol) and the three novel antipsychotic drugs increase the threshold for intracranial self-stimulation. The results obtained with the receptor specific antagonists showed that dopamine D2, alpha1-adrenoceptor and serotonin 5-HT2A receptor antagonisms inhibit intracranial self-stimulation behaviour and that muscarinic receptor antagonism is without effect. Even though all the tested antipsychotic drugs inhibited intracranial self-stimulation behaviour, there seems to be a difference in their ratio between doses that inhibits intracranial self-stimulation behaviour and those that produce antipsychotic effect in a preclinical model (amphetamine hyperactivity). Sertindole was the only antipsychotic drug able to produce antipsychotic effect without significant inhibition of intracranial self-stimulation behaviour at a narrow dose interval. The remaining antipsychotic drugs all inhibited intracranial self-stimulation behaviour at equal or lower doses than those producing antipsychotic effect.

World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of schizophrenia, part 2: long-term treatment of schizophrenia

These guidelines for the biological treatment of schizophrenia were developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBP). The goal during the development of these guidelines was to review systematically all available evidence pertaining to the treatment of schizophrenia, and to reach a consensus on a series of practice recommendations that are clinically and scientifically meaningful based on the available evidence. These guidelines are intended for use by all physicians seeing and treating people with schizophrenia. The data used for developing these guidelines have been extracted primarily from various national treatment guidelines and panels for schizophrenia, as well as from meta-analyses, reviews and randomised clinical trials on the efficacy of pharmacological and other biological treatment interventions identified by a search of the MEDLINE database and Cochrane Library. The identified literature was evaluated with respect to the strength of evidence for its efficacy and then categorised into four levels of evidence (A-D). This second part of the guidelines covers the long-term treatment as well as the management of relevant side effects. These guidelines are primarily concerned with the biological treatment (including antipsychotic medication, other pharmacological treatment options, electroconvulsive therapy, adjunctive and novel therapeutic strategies) of adults suffering from schizophrenia.

Outcome on quality of life in a Canadian national sample of patients with schizophrenia and related psychotic disorders

OBJECTIVE

To examine changes in subjective and objective dimensions of quality of life (QoL) in a large Canadian sample of patients with diagnosis of schizophrenia or schizoaffective disorder treated in academic and non-academic settings over a 2-year period.

METHOD

Patients recruited in the study across the country were assessed for QoL and functioning using the Client and Provider versions of the Wisconsin Quality of Life Questionnaire (WQoL) and the Short Form-36 (SF-36) at baseline (n = 448), 1 year (n = 308-353) and 2 years (188-297). Data were analyzed to examine change across time using multivariate analyses controlling for potential influence of variables such as age, regional variation, gender, duration of illness, type of treatment taken and baseline measures of symptoms and QoL.

RESULTS

The weighted quality of life index (W-QoL-I) showed a significant change on both the client and the provider versions of the WQoL while the physical and mental composites of the SF-36 showed change only at 2 years. These changes were influenced significantly by baseline scores on W-QoL-I and in the case of provider version of the WQoL by baseline Brief Psychiatric Rating Scale (BPRS) scores. Regional variation or type of medication had no impact on improvement in QoL.

CONCLUSION

Within a naturalistic sample of schizophrenia patients treated and followed in routine care the overall QoL showed an improvement over time but this improvement was not influenced by the type of medication prescribed.

Subjective response to clozapine and risperidone treatment in outpatients with schizophrenia

The purpose of the present study was to compare the subjective response and attitude towards antipsychotic treatment between schizophrenic patients receiving clozapine and those receiving risperidone. Ninety-four outpatients who had been on a stable drug dosage were evaluated (clozapine group: n=57, mean dose=254.1 mg/day; risperidone group: n=37, mean dose=3.0 mg/day). Subjective response to antipsychotic treatment was assessed using the Drug Attitude Inventory (DAI). The two treatment groups had a positive total mean score, indicating that both groups had a positive subjective view of drug treatment. The proportion of subjects who had a positive total score was not different between the two groups. In subscale scores, multivariate analysis revealed that clozapine group tended to have a higher score on the subjective positive response subscale (P=0.06). The scores of subjective negative response or attitude to medication subscales were not different between groups. In conclusion, there was no marked difference between stabilized outpatients taking clozapine and risperidone in terms of subjective response and attitude towards antipsychotic treatment. Considering that subjects treated with clozapine were treatment resistant patients, equal DAI score might indicate a more favorable subjective experience of clozapine. Further prospective studies on subjective response to various atypical agents are required to obtain valuable insight into how best to use these drugs from the patient's perspective.

Patterns of prescription of four major antipsychotics: a retrospective study based on medical records of psychiatric inpatients

PURPOSE

(1) To identify factors associated with the choice among the three atypical antipsychotics available in France (amisulpride, olanzapine, risperidone) and the typical antipsychotic of reference: (haloperidol), (2) to compare psychotropic co-prescription rates according to antipsychotic.

METHODS

All antipsychotic prescriptions including at least one of the four antipsychotics (n=421) for all inpatients (n=372) hospitalized 24 hours or more in the 6 months previous to the start of the study were included (2003). Data were obtained from medical records and psychiatrist interviews. Of the prescriptions, 13.3% included amisulpride, 39.4% olanzapine, 27.3% risperidone, and 20.0% haloperidol. Mean dosages were 142 mg (amisulpride), 15 mg (olanzapine), 4.5 mg (risperidone), and 19.5 mg (haloperidol).

RESULTS

Differences between antipsychotics were observed in relation to patients' age (younger patients prescribed amisulpride and olanzapine, p=0.04), diagnoses (affective disorders more frequently prescribed olanzapine and risperidone, p=0.005), and mode of hospitalization (admissions under constraint more frequently prescribed haloperidol, p<0.001). Antidepressant and anxiolytic-hypnotic co-prescription rates were lower with haloperidol than with atypicals. Mood-stabilizer co-prescription rates were higher for olanzapine and risperidone than for haloperidol and amisulpride. Anticholinergic co-prescription was higher with haloperidol than with atypicals (p<0.001).

CONCLUSIONS

Haloperidol was prescribed to a minority and targeted male patients hospitalized under constraint, using high dosages. Type and rate of co-prescriptions varied considerably between haloperidol and atypicals.

Critical assessment of how to study addiction and its treatment: human and non-human animal models

Laboratory models, both animal and human, have made enormous contributions to our understanding of addiction. For addictive disorders, animal models have the great advantage of possessing both face validity and a significant degree of predictive validity, already demonstrated. Another important advantage to this field is the ability of reciprocal interplay between preclinical and clinical experiments. These models have made important contributions to the development of medications to treat addictive disorders and will likely result in even more advances in the future. Human laboratory models have gone beyond data obtained from patient histories and enabled investigators to make direct observations of human drug self-administration and test the effects of putative medications on this behavior. This review examines in detail some animal and human models that have led not only to important theories of addiction mechanisms but also to medications shown to be effective in the clinic.

Patient satisfaction with psychotropic drugs: sensitivity to change and relationship to clinical status, quality-of-life, compliance and effectiveness of treatment. Results from a nation-wide 6-month prospective study

OBJECTIVE

To see if patient satisfaction with psychotropics (PSP) could be used as a patient-oriented outcome variable in the evaluation of PSP drugs in clinical epidemiological studies, relationships between PSP, clinical status, QoL, compliance and the type of antipsychotic were analyzed. Elements of validation of PSP were also assessed.

METHOD

In a 6-month prospective study, 933 schizophrenic outpatients with initiation or change to their antipsychotic treatment were enrolled. Psychiatrists completed five CGI-SCH scales (positive, negative, cognitive, depressive and global), hospitalization, compliance, and prescription variables. Patients completed PSP, EuroQoL scales, sexual function and compliance variables.

RESULTS

A satisfactory structural equation model was obtained showing significant relationships PSP/compliance (coef.=0.16), QoL/PSP (coef.=0.37), clinical status/QoL (coef.=0.61), clinical status/compliance (coef.=0.09). Patients receiving olanzapine were more satisfied than patients receiving other atypicals (coef.=012) and had better clinical status than patients treated with typicals (coef.=0.08). Evolution of PSP was related to clinical status, QoL, and continuation of treatment (all P<001). Sensitivity to change of PSP was moderate (effect size=0.2).

CONCLUSION

PSP produced consistent results in relation to validated outcome variables. However, a single-item measure was not sufficiently sensitive to change. Multi-item questionnaires evaluating different dimensions are needed.

At therapeutic concentrations, olanzapine does not affect basal or insulin-stimulated glucose transport in 3T3-L1 adipocytes

The newer, atypical antipsychotic drugs have improved the treatment of schizophrenia and are widely used. A disadvantage is that they increase food intake, promote weight gain and may facilitate development of diabetes. The mechanism of the latter effect is controversial. A possible interaction of these drugs with glucose transporters has been proposed: peripheral insulin resistance may develop if these drugs inhibited glucose transport in cells which express the insulin responsive glucose transporter, GLUT4, i.e., muscle and adipocytes. To test this hypothesis, we incubated 3T3-L1 adipocytes, which express GLUT1 and GLUT4, with the atypical antipsychotic drug olanzapine for 1 or 20 h and then measured basal and insulin-stimulated glucose transport. The doses of olanzapine tested (70 nM and 350 nM) encompass and exceed maximal steady-state concentrations of the drug in plasma of patients maintained on maximal recommended doses (20 mg QD) of olanzapine. A maximally stimulating insulin concentration (100 nM) accelerated glucose transport 10- to 15-fold in 3T3-L1 adipocytes, and the half-maximally stimulating insulin dose was 0.4 nM. Olanzapine (70 or 350 nM) did not affect basal or insulin-stimulated glucose transport following 1 or 20 h drug treatment at any insulin concentration tested. The data do not support the hypothesis that olanzapine at therapeutically relevant concentrations may cause peripheral insulin resistance by direct interaction with the insulin responsive glucose transport system.

Effectiveness, tolerability and subjective well-being in patients receiving quetiapine: findings of a post-marketing surveillance study in schizophrenia

Objectives. Previous studies of antipsychotics have mainly focused on efficacy and tolerability. However, patient subjective well-being is increasingly being accepted as a valid and important measure of antipsychotic treatment outcomes and tolerability. Methods. In this open-label, observational trial data from 1322 outpatients with schizophrenia treated with flexibly dosed quetiapine were collected at baseline, Week 4 and Week 12. Patient well-being was assessed using Subjective Well-being under Neuroleptics (SWN-K) scale and disease severity with the Clinical Global Impressions-Severity of Illness (CGI-S) scale following quetiapine treatment. In addition, safety and tolerability were monitored throughout the study. Results. Quetiapine treatment, mean endpoint dose 337 mg/day, led to a significant reduction in disease severity, with improvements in CGI-S score of -0.7 at Week 4 and -1.3 at Week 12 (both P<0.001). In addition, patients' subjective well-being was significantly improved at Week 12, with a mean (SD) increase from baseline in SWN-K total score of 22.9 (18.7) (P<0.001). Further, an improved tolerability profile compared with previous medication was reported. Conclusions. This study emphasises the importance of patients' subjective well-being and the favourable acceptability of quetiapine among patients with schizophrenia.

Strategies for improving adherence to second-generation antipsychotics in patients with schizophrenia by increasing ease of use

Despite the advances in the treatment of patients with schizophrenia that have occurred since the introduction of the second-generation (atypical) antipsychotic agents, a leading cause of suboptimal outcome is poor patient adherence to oral medication. Partial adherence can be attributed to a number of factors, including lack of insight, cognitive dysfunction, a complicated treatment regimen, drug-related side effects, patient attitude, lack of patient education, and cultural factors. A number of strategies, including psychosocial interventions, cognitive-behavioral techniques, strategies that minimize side effects, and pharmacological approaches that increase ease of medication use, can be employed to support adherence and improve long-term outcomes. This article focuses on strategies for increasing ease of use of antipsychotics in the treatment of patients with schizophrenia. These strategies include using monotherapy rather than polypharmacy, simplifying the medication regimen, and using a long-acting antipsychotic formulation. The goal of these strategies is to improve adherence and help prevent relapse by ensuring continuous antipsychotic coverage. Strategies that optimize ease of use of medication treatment for schizophrenia and thus improve adherence to treatment are likely to promote the attainment of new treatment goals and improved patient outcomes.

Adolescence, schizophrenia and drug abuse: a window of vulnerability

OBJECTIVE

To discuss the neurobiological and psychosocial developmental factors in adolescence contributing to simultaneous onset and co-occurrence of psychosis and substance use disorders.

METHOD

A review of the literature.

RESULTS

Adolescence is a period with specific psychosocial challenges and specific changes in the brain that increase the probability of the onset of both psychosis and substance abuse, in predisposed people. In vulnerable adolescents it is proposed that an excessive pruning of dopaminergic neurones leads to mesocortical hypofrontality causing anhedonia and dysphoria. At the same time, anhedonia and dysphoria are important risk factors for the development of substance abuse. In turn, hypofrontality leads to a reduction in mesocortical feedback inhibition of the mesolimbic system resulting in aberrant salience and positive symptoms. Finally, the development of aberrant salience plays a role in both psychoses and craving.

CONCLUSION

Attention should be paid to the interaction of drug abuse and schizophrenia and an integrated treatment is needed. Dysphoria and anhedonia in schizophrenic adolescents are important factors in treatment with antipsychotic medication, both in terms of patient satisfaction and in the prevention of substance abuse.

Neuroleptic dysphoria: revisiting the concept 50 years later

OBJECTIVE

To review the concept of neuroleptic dysphoria, its historical development and the current state of the art.

METHOD

This paper is based on extensive but selective literature review and also draws on our extensive clinical and research experiences.

RESULTS

Although the construct of neuroleptic dysphoria was recognized shortly following the introduction of the first antipsychotic, chlorpromazine, it took several years for the concept to receive adequate research and clinical attention. Without having direct evidence to link neuroleptic dysphoria to dopamine, it was generally understood that dopamine played a significant role in its genesis. In recent neuroimaging studies and dopamine depletion strategies, the role of dopamine in the genesis of neuroleptic dysphoria has been directly confirmed.

CONCLUSION

Neuroleptic dysphoria is a valid construct, which has significant implications for treatment and outcome. It is now clear that it relates to dopamine activities in the nigrostriatal complex. Recent research has also raised the issue of whether neuroleptic dysphoria is a variant of extrapyramidal symptoms. Meanwhile, the role of dopamine in both the genesis of neuroleptic dysphoria and addictive behaviour has raised the issue of both conditions being different facets of the schizophrenic disease process. The recent interface of addiction and psychiatry research may have opened a new science: the science of subjective tolerability disorders.

Emergency management of agitation in schizophrenia

Schizophrenia is a common psychiatric condition, affecting approximately 1% of the population. Acute emergent presentations often include hallucinations, delusions, thought, and speech disorders. Agitation is common among emergency patients with schizophrenia. Decisional capacity should be assessed in all patients. Reversible causes of agitation should be ruled out, including infection, metabolic disorders, endocrine disorders, trauma, pain, noncompliance, toxicological disorders, and structural brain abnormalities. Agitation may be managed acutely using a combination of pharmacological agents and nonpharmacological interventions. Effective pharmacological agents include several classes of antipsychotic agents and benzodiazepines. Potential life-threatening complications of pharmacological therapy should be anticipated, which may include neuroleptic malignant syndrome (NMS), prolonged QT syndrome, and respiratory depression. Nonpharmacological interventions may include a quiet environment, physical restraints, and behavioral interventions. Disposition decisions should be made based on the etiology of agitation, effective management, decisional capacity, and presence of suicidal or homicidal intentions. Many patients who have required nonpharmacological or pharmacological management of agitation require inpatient psychiatric treatment, either voluntarily or involuntarily. Psychiatric consultation should be sought for patients with schizophrenia and uncertain disposition determinations, or those requiring other complex management decisions.