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Căpățînă OO, Micluția IV, Fadgyas-Stănculete M. Current perspectives in treating negative symptoms of schizophrenia: A narrative review (Review). Exp Ther Med 2021; 21:276. [PMID: 33603883 PMCID: PMC7851661 DOI: 10.3892/etm.2021.9707] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 11/17/2020] [Indexed: 11/30/2022] Open
Abstract
The negative symptoms of schizophrenia are an unmet treatment target as currently approved treatments mostly control positive symptoms. The persistence of these symptoms holds back the patient's reinstatement in society, making them incapable of fulfilling their social, professional, or family roles. There is overwhelming research evidence suggesting that the negative symptoms of schizophrenia are associated with poorer functioning and lower quality of life than positive symptoms, confirming the need for developing new treatments for this particular category of symptoms. This present review aims to review clinical trials addressing novel pharmacological approaches addressing primary negative symptoms of schizophrenia. We overview both monotherapies, first-generation and second-generation antipsychotics, and add-on therapies, including psychostimulants, anti-inflammatory drugs, antidepressants, molecules targeting glutamatergic, cholinergic or serotonergic systems and hormones. Our findings suggest that the primary negative symptoms of schizophrenia may be mitigated by adjunctive therapies, and we highlight the pharmacological agents that have proven superior efficacy. Novel compounds such as cariprazine and MIN-101, to date, show promising results, but large clinical trials are needed to test their efficacy and safety.
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Affiliation(s)
- Octavia O Căpățînă
- Department of Neurosciences, 'Iuliu Haţieganu' University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Ioana V Micluția
- Department of Neurosciences, 'Iuliu Haţieganu' University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Mihaela Fadgyas-Stănculete
- Department of Neurosciences, 'Iuliu Haţieganu' University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
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Fountoulakis KN, Dragioti E, Theofilidis AT, Wikilund T, Atmatzidis X, Nimatoudis I, Thys E, Wampers M, Hranov L, Hristova T, Aptalidis D, Milev R, Iftene F, Spaniel F, Knytl P, Furstova P, From T, Karlsson H, Walta M, Salokangas RKR, Azorin JM, Bouniard J, Montant J, Juckel G, Haussleiter IS, Douzenis A, Michopoulos I, Ferentinos P, Smyrnis N, Mantonakis L, Nemes Z, Gonda X, Vajda D, Juhasz A, Shrivastava A, Waddington J, Pompili M, Comparelli A, Corigliano V, Rancans E, Navickas A, Hilbig J, Bukelskis L, Injac Stevovic L, Vodopic S, Esan O, Oladele O, Osunbote C, Rybakowski JΚ, Wojciak P, Domowicz K, Figueira ML, Linhares L, Crawford J, Panfil AL, Smirnova D, Izmailova O, Lecic-Tosevski D, Temmingh H, Howells F, Bobes J, Garcia-Portilla MP, García-Alvarez L, Erzin G, Karadağ H, De Sousa A, Bendre A, Hoschl C, Bredicean C, Papava I, Vukovic O, Pejuskovic B, Russell V, Athanasiadis L, Konsta A, Stein D, Berk M, Dean O, Tandon R, Kasper S, De Hert. M. Staging of Schizophrenia With the Use of PANSS: An International Multi-Center Study. Int J Neuropsychopharmacol 2019; 22:681-697. [PMID: 31563956 PMCID: PMC6872964 DOI: 10.1093/ijnp/pyz053] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 07/19/2019] [Accepted: 09/25/2019] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION A specific clinically relevant staging model for schizophrenia has not yet been developed. The aim of the current study was to evaluate the factor structure of the PANSS and develop such a staging method. METHODS Twenty-nine centers from 25 countries contributed 2358 patients aged 37.21 ± 11.87 years with schizophrenia. Analysis of covariance, Exploratory Factor Analysis, Discriminant Function Analysis, and inspection of resultant plots were performed. RESULTS Exploratory Factor Analysis returned 5 factors explaining 59% of the variance (positive, negative, excitement/hostility, depression/anxiety, and neurocognition). The staging model included 4 main stages with substages that were predominantly characterized by a single domain of symptoms (stage 1: positive; stages 2a and 2b: excitement/hostility; stage 3a and 3b: depression/anxiety; stage 4a and 4b: neurocognition). There were no differences between sexes. The Discriminant Function Analysis developed an algorithm that correctly classified >85% of patients. DISCUSSION This study elaborates a 5-factor solution and a clinical staging method for patients with schizophrenia. It is the largest study to address these issues among patients who are more likely to remain affiliated with mental health services for prolonged periods of time.
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Affiliation(s)
- Konstantinos N Fountoulakis
- 3rd Department of Psychiatry, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki,Greece,Correspondence to: Konstantinos N. Fountoulakis, 6, Odysseos str (1 Parodos Ampelonon str.), 55535 Pylaia Thessaloniki, Greece ()
| | - Elena Dragioti
- Department of Medical and Health Sciences (IMH), Faculty of Health Sciences, Linköping University, Linköping, Sweden,Hallunda Psychiatric Outpatient Clinic, Stockholm Psychiatric Southwest Clinic, Karolinska Huddinge University Hospital,Sweden
| | - Antonis T Theofilidis
- 3rd Department of Psychiatry, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki,Greece
| | - Tobias Wikilund
- Department of Medical and Health Sciences (IMH), Faculty of Health Sciences, Linköping University, Linköping, Sweden,Hallunda Psychiatric Outpatient Clinic, Stockholm Psychiatric Southwest Clinic, Karolinska Huddinge University Hospital,Sweden
| | - Xenofon Atmatzidis
- Department of Medical and Health Sciences (IMH), Faculty of Health Sciences, Linköping University, Linköping, Sweden,Hallunda Psychiatric Outpatient Clinic, Stockholm Psychiatric Southwest Clinic, Karolinska Huddinge University Hospital,Sweden
| | - Ioannis Nimatoudis
- 3rd Department of Psychiatry, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki,Greece
| | - Erik Thys
- University Psychiatric Centre KU Leuven, Kortenberg and Department of Neurosciences KU, Leuven, Belgium
| | - Martien Wampers
- University Psychiatric Centre KU Leuven, Kortenberg and Department of Neurosciences KU, Leuven, Belgium
| | - Luchezar Hranov
- University Multiprofile Hospital for Active Treatment in Neurology and Psychiatry “Sveti Naum”, Sofia, Bulgaria
| | - Trayana Hristova
- University Multiprofile Hospital for Active Treatment in Neurology and Psychiatry “Sveti Naum”, Sofia, Bulgaria
| | - Daniil Aptalidis
- University Multiprofile Hospital for Active Treatment in Neurology and Psychiatry “Sveti Naum”, Sofia, Bulgaria
| | - Roumen Milev
- Department of Psychiatry, Queen’s University, Providence Care Hospital, Kingston, Ontario, Canada
| | - Felicia Iftene
- Department of Psychiatry, Queen’s University, Providence Care Hospital, Kingston, Ontario, Canada
| | - Filip Spaniel
- National Institute of Mental Health, Klecany, Czech Republic
| | - Pavel Knytl
- National Institute of Mental Health, Klecany, Czech Republic
| | - Petra Furstova
- National Institute of Mental Health, Klecany, Czech Republic
| | - Tiina From
- Department of Psychiatry, University of Turku, Turku, Finland
| | - Henry Karlsson
- Department of Psychiatry, University of Turku, Turku, Finland
| | - Maija Walta
- Department of Psychiatry, University of Turku, Turku, Finland
| | | | - Jean-Michel Azorin
- Department of Psychiatry, Sainte Marguerite University Hospital, Marseille, France,Timone Institute of Neuroscience, CNRS and Aix-Marseille University, Marseille, France
| | - Justine Bouniard
- Department of Psychiatry, Sainte Marguerite University Hospital, Marseille, France,Timone Institute of Neuroscience, CNRS and Aix-Marseille University, Marseille, France
| | - Julie Montant
- Department of Psychiatry, Sainte Marguerite University Hospital, Marseille, France,Timone Institute of Neuroscience, CNRS and Aix-Marseille University, Marseille, France
| | - Georg Juckel
- Department of Psychiatry, Ruhr University Bochum, LWL-University Hospital, Bochum, Germany
| | - Ida S Haussleiter
- Department of Psychiatry, Ruhr University Bochum, LWL-University Hospital, Bochum, Germany
| | - Athanasios Douzenis
- 2nd Department of Psychiatry, National and Kapodistrian University of Athens, Athens, Greece
| | - Ioannis Michopoulos
- 2nd Department of Psychiatry, National and Kapodistrian University of Athens, Athens, Greece
| | - Panagiotis Ferentinos
- 2nd Department of Psychiatry, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos Smyrnis
- Department of Psychiatry, National and Kapodistrian University of Athens School of Medicine, Eginition Hospital, Athens, Greece
| | - Leonidas Mantonakis
- Department of Psychiatry, National and Kapodistrian University of Athens School of Medicine, Eginition Hospital, Athens, Greece
| | | | - Xenia Gonda
- Department of Psychiatry and Psychotherapy, Semmelweis University, Budapest, Hungary
| | - Dora Vajda
- Department of Psychiatry and Psychotherapy, Semmelweis University, Budapest, Hungary
| | - Anita Juhasz
- Department of Psychiatry and Psychotherapy, Semmelweis University, Budapest, Hungary
| | | | - John Waddington
- Molecular and Cellular Therapeutics, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Maurizio Pompili
- Department of Neurosciences, Mental Health and Sensory Organs, Suicide Prevention Center, Sant’Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Anna Comparelli
- Department of Neurosciences, Mental Health and Sensory Organs, Suicide Prevention Center, Sant’Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Valentina Corigliano
- Department of Neurosciences, Mental Health and Sensory Organs, Suicide Prevention Center, Sant’Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Elmars Rancans
- Department of Psychiatry and Narcology, Riga Stradins University, Riga, Latvia
| | - Alvydas Navickas
- Clinic of Psychiatric, Faculty of Medicine, Vilnius University, Vilnius, Lithuania,Psychosocial Rehabilitation Department of the Vilnius Mental Health Center, Department for Psychosis Treatment of the Vilnius Mental Health Center, Vilnius, Lithuania
| | - Jan Hilbig
- Clinic of Psychiatric, Faculty of Medicine, Vilnius University, Vilnius, Lithuania,Psychosocial Rehabilitation Department of the Vilnius Mental Health Center, Department for Psychosis Treatment of the Vilnius Mental Health Center, Vilnius, Lithuania
| | - Laurynas Bukelskis
- Clinic of Psychiatric, Faculty of Medicine, Vilnius University, Vilnius, Lithuania,Psychosocial Rehabilitation Department of the Vilnius Mental Health Center, Department for Psychosis Treatment of the Vilnius Mental Health Center, Vilnius, Lithuania
| | - Lidija Injac Stevovic
- Clinical Department of Psychiatry, Clinical Centre of Montenegro, Podgorica, Montenegro,Department of Psychiatry, School of Medicine, University of Montenegro, Dzona Dzeksona bb, Podgorica, Montenegro,Clinical Department of Neurology, Clinical Centre of Montenegro, Dzona Dzeksona bb, Podgorica, Montenegro
| | - Sanja Vodopic
- Clinical Department of Psychiatry, Clinical Centre of Montenegro, Podgorica, Montenegro,Department of Psychiatry, School of Medicine, University of Montenegro, Dzona Dzeksona bb, Podgorica, Montenegro,Clinical Department of Neurology, Clinical Centre of Montenegro, Dzona Dzeksona bb, Podgorica, Montenegro
| | - Oluyomi Esan
- Department of Psychiatry, College of Medicine, University of Ibadan,Nigeria
| | - Oluremi Oladele
- Department of Psychiatry, College of Medicine, University of Ibadan,Nigeria
| | | | - Janusz Κ Rybakowski
- Department of Adult Psychiatry, Poznan University of Medical Sciences, Poznan, Poland
| | - Pawel Wojciak
- Department of Adult Psychiatry, Poznan University of Medical Sciences, Poznan, Poland
| | - Klaudia Domowicz
- Department of Adult Psychiatry, Poznan University of Medical Sciences, Poznan, Poland
| | - Maria Luisa Figueira
- Department of Psychiatry and Mental Health, Santa Maria University Hospital, Lisbon, Portugal
| | - Ludgero Linhares
- Department of Psychiatry and Mental Health, Santa Maria University Hospital, Lisbon, Portugal
| | - Joana Crawford
- Department of Psychiatry and Mental Health, Santa Maria University Hospital, Lisbon, Portugal
| | | | - Daria Smirnova
- Samara State Medical University, Department of Psychiatry, Samara Psychiatric Hospital, Inpatient Unit, Russia
| | - Olga Izmailova
- Samara State Medical University, Department of Psychiatry, Samara Psychiatric Hospital, Inpatient Unit, Russia
| | - Dusica Lecic-Tosevski
- Institute of Mental Health, Belgrade, Serbia,Serbian Academy of Sciences and Arts, Belgrade, Serbia
| | - Henk Temmingh
- Department of Psychiatry and Mental Health, University of Cape Town Cape Town, Western Cape, South Africa
| | - Fleur Howells
- Department of Psychiatry and Mental Health, University of Cape Town Cape Town, Western Cape, South Africa
| | - Julio Bobes
- Department of Psychiatry, University of Oviedo and Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Oviedo, Spain
| | - Maria Paz Garcia-Portilla
- Department of Psychiatry, University of Oviedo and Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Oviedo, Spain
| | - Leticia García-Alvarez
- Department of Psychiatry, University of Oviedo and Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Oviedo, Spain
| | - Gamze Erzin
- Psychiatry Department, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Hasan Karadağ
- Psychiatry Department, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Avinash De Sousa
- Department of Psychiatry Lokmanya Tilak Municipal Medical College Mumbai, India
| | - Anuja Bendre
- Department of Psychiatry Lokmanya Tilak Municipal Medical College Mumbai, India
| | - Cyril Hoschl
- National Institute of Mental Health, Klecany, Czech Republic
| | | | - Ion Papava
- University of Medicine and Pharmacy of Timisoara, Romania
| | - Olivera Vukovic
- Institute of Mental Health, School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Bojana Pejuskovic
- Department of Psychiatry, Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin, Ireland
| | - Vincent Russell
- Department of Psychiatry, Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin, Ireland
| | - Loukas Athanasiadis
- 1st Department of Psychiatry, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Greece
| | - Anastasia Konsta
- 1st Department of Psychiatry, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Greece
| | - Dan Stein
- MRC Unit on Risk and Resilience in Mental Disorders, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Michael Berk
- Deakin University, IMPACT Strategic Research Centre, School of Medicine, Barwon Health, Geelong, Australia,Orygen, The National Centre of Excellence in Youth Mental Health and the Centre for Youth Mental Health, the Florey Institute for Neuroscience and Mental Health and the Department of Psychiatry, University of Melbourne, Parkville, Australia
| | - Olivia Dean
- Deakin University, School of Medicine, IMPACT Strategic Research Centre, Barwon Health, Geelong, Australia
| | - Rajiv Tandon
- Department of Psychiatry, University of Florida, ***, FL
| | - Siegfried Kasper
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
| | - Marc De Hert.
- University Psychiatric Centre KU Leuven, Kortenberg and Department of Neurosciences KU, Leuven, Belgium
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Abstract
BACKGROUND Schizophrenia is frequently a chronic and disabling illness with a heterogeneous range of symptoms. The positive symptoms usually respond to antipsychotics but the cognitive and negative symptoms of schizophrenia are difficult to treat with conventional antipsychotics and significantly impact on quality of life and social outcomes. Selective noradrenaline reuptake inhibitors (NRIs) increase prefrontal dopamine and noradrenaline levels without significantly affecting subcortical dopamine levels, making them an attractive candidate for treating cognitive and negative symptoms. OBJECTIVES To investigate the effects of selective noradrenaline reuptake inhibitors (NRIs), compared with a placebo or control treatment, for people with schizophrenia. SEARCH METHODS We searched the Cochrane Schizophrenia Group's Trials Register (up to 7 February 2017) which is based on regular searches of MEDLINE, Embase, CINAHL, BIOSIS, AMED, PubMed, PsycINFO, and registries of clinical trials. There are no language, date, document type, or publication status limitation for inclusion of records into the register. We inspected references of all included studies for further relevant studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing NRIs with either a control treatment or placebo for people with schizophrenia or related disorders (such as schizoaffective disorder) by any means of diagnosis. We included trials that met our selection criteria and provided useable information. DATA COLLECTION AND ANALYSIS We independently inspected all citations from searches, identified relevant abstracts, and independently extracted data from all included studies. For binary data we calculated risk ratio (RR), for continuous data we calculated mean difference (MD), and for cognitive outcomes we derived standardised mean difference (SMD) effect sizes, all with 95% confidence intervals (CI) and using a random-effects model. We assessed risk of bias for the included studies and used the GRADE approach to produce a 'Summary of findings' table which included our prespecified main outcomes of interest. MAIN RESULTS Searching identified 113 records. We obtained the full text of 48 of these records for closer inspection. Sixteen trials, randomising a total of 919 participants are included. The majority of trials included adults with schizophrenia or similar illness who were inpatients, and while they were poorly characterised, most appeared to include patients with a chronic presentation. The intervention NRI in nine of the 16 trials was reboxetine, with atomoxetine and viloxazine used in the remaining trials. 14 trials compared NRIs with placebo. Only two trials provided data to compare NRIs against an active control and both compared reboxetine to citalopram but at 4 weeks and 24 weeks respectively so they could not be combined in a meta-analysis.One trial was described as 'open' and we considered it to be at high risk of bias for randomisation and blinding, three trials were at high risk of bias for attrition, six for reporting, and two for other sources of bias. Our main outcomes of interest were significant response or improvement in positive/negative mental state, global state and cognitive functioning, average cognitive functioning scores, significant response or improvement in quality of life and incidence of nausea. All data for main outcomes were short term.NRIs versus placeboMental state results showed significantly greater rates of improvement in negative symptoms scores (1 RCT, n = 50; RR 3.17, 95% CI 1.52 to 6.58; very low quality evidence) with NRIs on the PANSS negative. No data were reported for significant response or improvement in positive symptoms, but average endpoint PANSS positive scores were available and showed no difference between NRIs and placebo (5 RCTs, n = 294; MD -0.16, 95% CI -0.96 to 0.63; low-quality evidence). Improvement in clinical global status was similar between groups (1 RCT, n = 28; RR 0.99, 95% CI 0.45 to 2.20; very low quality evidence). Significant response or improvement in cognitive functioning data were not reported. Average composite cognitive scores showed no difference between NRIs and placebo (4 RCTs, n = 180; SMD 0.04, 95% CI -0.28 to 0.36; low-quality evidence). Significant response or improvement in quality of life data were not reported, however average endpoint scores from the GQOLI-74 were reported. Those receiving NRIs had better quality of life scores compared to placebo (1 RCT, n = 114; MD 9.36, 95% CI 7.89 to 10.83; very low quality evidence). All-cause withdrawals did not differ between the treatment groups (8 RCTs, n = 401, RR 0.94 95% CI 0.63 to 1.39; moderate-quality evidence). Rates of nausea were not greater with NRIs (3 RCTs, n = 176; RR 0.49, 95% CI 0.10 to 2.41; low-quality evidence). AUTHORS' CONCLUSIONS Our results provide tentative very low quality evidence that compared to placebo, NRIs (specifically reboxetine) may have a benefit on the negative symptoms of schizophrenia. Limited evidence also suggests that NRIs have no effect on the positive symptoms of schizophrenia or cognitive functioning. NRIs appear generally well tolerated with no real differences in adverse effects such as nausea noted between NRIs and placebo. However, these results are based on short-term follow-up and are poor quality - there is need for more good-quality evidence. A large RCT of reboxetine over a longer period of time, focusing specifically on negative and cognitive symptoms as well as more detailed and comprehensive reporting of outcomes, including adverse events, is required.
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Affiliation(s)
- Paul R L Matthews
- Kildare West Wicklow MHSNorth Kildare Mental Health ServiceCelbridge Community Health CentreShackleton RoadCelbridgeCo. KildareIreland
| | - Jamie Horder
- King's College LondonDepartment of Forensic and Neurodevelopmental SciencesInstitute of PsychiatryDe Crespigny ParkLondonUKSE5 8AF
| | - Michael Pearce
- Oxford Health NHS Foundation TrustDepartment of General and Older Adult PsychiatryWarneford Hospital, Warneford Lane,OxfordUKOX3 7JX
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Einoch R, Weinreb O, Mandiuk N, Youdim MBH, Bilker W, Silver H. The involvement of BDNF-CREB signaling pathways in the pharmacological mechanism of combined SSRI- antipsychotic treatment in schizophrenia. Eur Neuropsychopharmacol 2017; 27:470-483. [PMID: 28410959 DOI: 10.1016/j.euroneuro.2017.03.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 02/08/2017] [Accepted: 03/18/2017] [Indexed: 01/24/2023]
Abstract
Previous studies into the mechanism of SSRI-antipsychotic synergism in our laboratory identified unique changes in the brain, particularly in the γ-aminobutyric acid (GABA)-A receptor and its modulators. This study examined the role of brain derived neurotrophic factor (BDNF)-cAMP response element binding (CREB) protein signaling pathways, including protein kinase B (AKT), glycogen synthase kinase (GSK)-3β and related molecules in the molecular response to haloperidol, fluvoxamine, combined haloperidol+fluvoxamine and clozapine treatments in rat frontal cortex, hippocampus and primary cortical neuronal cultures. The effect of fluvoxamine augmentation on BDNF-CREB pathways in peripheral mononuclear cells (PMC׳s) of medicated schizophrenia patients was also studied. Chronic haloperidol (1mg/kg) +fluvoxamine (10mg/kg) treatment increased TrkB receptor and BDNF expression levels, and the phosphorylation of AKT/CREB/GSK-3β, compared to the individual drugs in rat brain. In addition, haloperidol+fluvoxamine treatment improved cognitive functions in rats, indicating that the molecular changes may have a role in behavioral improvement. In primary neuronal cell cultures, pretreatment with a selective PI3K inhibitor abolished the haloperidol+fluvoxamine-induced phosphorylation of AKT and GSK-3β, but did not affect the upregulation of CREB phosphorylation. In the clinic, PMC׳s of treated patients showed upregulation of mRNA expression and protein levels of BDNF, CREB and AKT after addition of fluvoxamine. Analyses of PMC genes and proteins showed significant inter-correlations and some gene changes correlated with improvement in negative and cognitive symptoms. Our study provides new knowledge of the molecular mechanisms of symptom amelioration in schizophrenia and may advance development of new drugs for this disease and other neuropsychiatric disorders.
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Affiliation(s)
- Reef Einoch
- Molecular Neuropsychiatry Unit, Shaar Menashe Brain Behavior Laboratory, Shaar Menashe MHC and Technion-Faculty of Medicine, Haifa, Israel; Eve Topf and National Parkinson Foundation Centers of Excellence for Neurodegenerative Diseases Research, Department of Pharmacology, Technion-Faculty of Medicine, Haifa, Israel
| | - Orly Weinreb
- Eve Topf and National Parkinson Foundation Centers of Excellence for Neurodegenerative Diseases Research, Department of Pharmacology, Technion-Faculty of Medicine, Haifa, Israel
| | - Nina Mandiuk
- Molecular Neuropsychiatry Unit, Shaar Menashe Brain Behavior Laboratory, Shaar Menashe MHC and Technion-Faculty of Medicine, Haifa, Israel
| | - Moussa B H Youdim
- Eve Topf and National Parkinson Foundation Centers of Excellence for Neurodegenerative Diseases Research, Department of Pharmacology, Technion-Faculty of Medicine, Haifa, Israel
| | - Warren Bilker
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Henry Silver
- Molecular Neuropsychiatry Unit, Shaar Menashe Brain Behavior Laboratory, Shaar Menashe MHC and Technion-Faculty of Medicine, Haifa, Israel; Eve Topf and National Parkinson Foundation Centers of Excellence for Neurodegenerative Diseases Research, Department of Pharmacology, Technion-Faculty of Medicine, Haifa, Israel.
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Abstract
BACKGROUND The World Health Organization (WHO) Model Lists of Essential Medicines lists chlorpromazine as one of its five medicines used in psychotic disorders. OBJECTIVES To determine chlorpromazine dose response and dose side-effect relationships for schizophrenia and schizophrenia-like psychoses. SEARCH METHODS We searched the Cochrane Schizophrenia Group's Study-Based Register of Trials (December 2008; 2 October 2014; 19 December 2016). SELECTION CRITERIA All relevant randomised controlled trials (RCTs) comparing low doses of chlorpromazine (≤ 400 mg/day), medium dose (401 mg/day to 800 mg/day) or higher doses (> 800 mg/day) for people with schizophrenia, and which reported clinical outcomes. DATA COLLECTION AND ANALYSIS We included studies meeting review criteria and providing useable data. Review authors extracted data independently. For dichotomous data, we calculated fixed-effect risk ratios (RR) and their 95% confidence intervals (CIs). For continuous data, we calculated mean differences (MD) and their 95% CIs based on a fixed-effect model. We assessed risk of bias for included studies and graded trial quality using GRADE (Grading of Recommendations Assessment, Development and Evaluation). MAIN RESULTS As a result of searches undertaken in 2014, we found one new study and in 2016 more data for already included studies. Five relevant studies with 1132 participants (585 are relevant to this review) are now included. All are hospital-based trials and, despite over 60 years of chlorpromazine use, have durations of less than six months and all are at least at moderate risk of bias. We found only data on low-dose (≤ 400 mg/day) versus medium-dose chlorpromazine (401 mg/day to 800 mg/day) and low-dose versus high-dose chlorpromazine (> 800 mg/day).When low-dose chlorpromazine (≤ 400 mg/day) was compared to medium-dose chlorpromazine (401 mg/day to 800 mg/day), there was no clear benefit of one dose over the other for both global and mental state outcomes (low-quality and very low-quality evidence). There was also no clear evidence for people in one dosage group being more likely to leave the study early, over the other dosage group (moderate-quality evidence). Similar numbers of participants from each group experienced agitation and restlessness (very low-quality evidence). However, significantly more people in the medium-dose group (401 mg/day to 800 mg/day) experienced extrapyramidal symptoms in the short term (2 RCTS, n = 108, RR 0.47, 95% CI 0.30 to 0.74, moderate-quality evidence). No data for death were available.When low-dose chlorpromazine (≤ 400 mg/day) was compared to high-dose chlorpromazine (> 800 mg/day), data from one study with 416 patients were available. Clear evidence of a benefit of the high dose was found with regards to global state. The low-dose group had significantly fewer people improving (RR 1.13, 95% CI 1.01 to 1.25, moderate-quality evidence). There was also a marked difference between the number of people leaving the study from each group for any reason, with significantly more people leaving from the high-dose group (RR 0.60, 95% CI 0.40 to 0.89, moderate-quality evidence). More people in the low-dose group had to leave the study due to deterioration in behaviour (RR 2.70, 95% CI 1.34 to 5.44, low-quality evidence). There was clear evidence of a greater risk of people experiencing extrapyramidal symptoms in general in the high-dose group (RR 0.43, 95% CI 0.32 to 0.59, moderate-quality evidence). One death was reported in the high-dose group yet no effect was shown between the two dosage groups (RR 0.33, 95% CI 0.01 to 8.14, moderate-quality evidence). No data for mental state were available. AUTHORS' CONCLUSIONS The dosage of chlorpromazine has changed drastically over the past 50 years with lower doses now being the preferred of choice. However, this change was gradual and arose not due to trial-based evidence, but due to clinical experience and consensus. Chlorpromazine is one of the most widely used antipsychotic drugs yet appropriate use of lower levels has come about after many years of trial and error with much higher doses. In the absence of high-grade evaluative studies, clinicians have had no alternative but to learn from experience. However, such an approach can lack scientific rigor and does not allow for proper dissemination of information that would assist clinicians find the optimum treatment dosage for their patients. In the future, data for recently released medication should be available from high-quality trials and studies to provide optimum treatment to patients in the shortest amount of time.
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Affiliation(s)
| | - Xiaomeng Liu
- Utrecht UniversityPostbus 85500UtrechtNetherlands3508 GA
| | - Saskia De Haan
- GGZ Noord Holland NoordOude Hoeverweg 10AlkmaarNetherlands1816 BT
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Thompson JV, Clark JM, Legge SE, Kadra G, Downs J, Walters JT, Hamshere ML, Hayes RD, Taylor D, MacCabe JH. Antipsychotic polypharmacy and augmentation strategies prior to clozapine initiation: a historical cohort study of 310 adults with treatment-resistant schizophrenic disorders. J Psychopharmacol 2016; 30:436-43. [PMID: 26905920 DOI: 10.1177/0269881116632376] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
RATIONALE Antipsychotic polypharmacy (APP) is commonly used in schizophrenia despite a lack of robust evidence for efficacy, as well as evidence of increased rates of adverse drug reactions and mortality. OBJECTIVES We sought to examine APP and the use of other adjunctive medications in patients with treatment-resistant schizophrenic disorders (ICD-10 diagnoses F20-F29) immediately prior to clozapine initiation, and to investigate clinical and sociodemographic factors associated with APP use in this setting. METHODS Analysis of case notes from 310 patients receiving their first course of clozapine at the South London and Maudsley NHS Trust (SLaM) was undertaken using the Clinical Record Interactive Search (CRIS) case register. Medication taken immediately prior to clozapine initiation was recorded, and global clinical severity was assessed at time points throughout the year prior to medication assessment using the Clinical Global Impression - Severity scale (CGI-S). Logistic regression was used to investigate factors associated with APP. RESULTS The point prevalence of APP prior to clozapine initiation was 13.6% (n=42), with 32.6% of subjects prescribed adjuvant psychotropic medications. APP was associated with increasing number of adjuvant medications (odds ratio (OR) 1.97, 95% confidence interval (CI) 1.27-3.06), concurrent depot antipsychotic prescription (OR 2.64, CI 1.24-5.62), concurrent antidepressant prescription (OR 4.40, CI 1.82-10.63) and a CGI-S over the previous year within the two middle quartiles (Quartile 2 vs 1 OR 6.19, CI 1.81-21.10; Quartile 3 vs 1 OR 4.45, CI 1.29-15.37; Quartile 4 vs 1 OR 1.88, CI 0.45-7.13). CONCLUSIONS APP and augmentation of antipsychotics with antidepressants, mood stabilizers and benzodiazepines are being employed in treatment-resistant schizophrenia prior to clozapine. The conservative APP rate observed may have been influenced by an initiative within SLaM that reduced APP rates during the study window. Efforts to reduce the use of poorly evidenced prescribing should focus on adjuvant medications as well as APP.
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Affiliation(s)
| | - Joanne M Clark
- GKT School of Medical Education, King's College London, London, UK
| | - Sophie E Legge
- Institute of Psychological Medicine and Clinical Neurosciences, MRC Centre for Neuropsychiatric Genetics and Genomics, Cardiff University, Cardiff, UK
| | - Giouliana Kadra
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Johnny Downs
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - James Tr Walters
- Institute of Psychological Medicine and Clinical Neurosciences, MRC Centre for Neuropsychiatric Genetics and Genomics, Cardiff University, Cardiff, UK
| | - Marian L Hamshere
- Institute of Psychological Medicine and Clinical Neurosciences, MRC Centre for Neuropsychiatric Genetics and Genomics, Cardiff University, Cardiff, UK
| | - Richard D Hayes
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - David Taylor
- South London and Maudsley NHS Foundation Trust, London, UK
| | - James H MacCabe
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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7
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Abstract
Interest in the negative symptoms of schizophrenia has increased rapidly over the last several decades, paralleling a growing interest in functional, in addition to clinical, recovery, and evidence underscoring the importance negative symptoms play in the former. Efforts continue to better define and measure negative symptoms, distinguish their impact from that of other symptom domains, and establish effective treatments as well as trials to assess these. Multiple interventions have been the subject of investigation, to date, including numerous pharmacological strategies, brain stimulation, and non-somatic approaches. Level and quality of evidence vary considerably, but to this point, no specific treatment can be recommended. This is particularly problematic for individuals burdened with negative symptoms in the face of mild or absent positive symptoms. Presently, clinicians will sometimes turn to interventions that are seen as more “benign” and in line with routine clinical practice. Strategies include use of atypical antipsychotics, ensuring the lowest possible antipsychotic dose that maintains control of positive symptoms (this can involve a shift from antipsychotic polypharmacy to monotherapy), possibly an antidepressant trial (given diagnostic uncertainty and the frequent use of these drugs in schizophrenia), and non-somatic interventions (e.g., cognitive behavioral therapy, CBT). The array and diversity of strategies currently under investigation highlight the lack of evidence-based treatments and our limited understanding regarding negative symptoms underlying etiology and pathophysiology. Their onset, which can precede the first psychotic break, also means that treatments are delayed. From this perspective, identification of biomarkers and/or endophenotypes permitting earlier diagnosis and intervention may serve to improve treatment efficacy as well as outcomes.
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Trends in the access to and the use of antipsychotic medications and psychotropic co-treatments in Asian patients with schizophrenia. Epidemiol Psychiatr Sci 2016; 25:9-17. [PMID: 26289066 PMCID: PMC6998674 DOI: 10.1017/s2045796015000694] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
To date, antipsychotics remain the mainstay of treatment for schizophrenia and related disorders although other psychotropic medications and non-pharmaceutical interventions have been used adjunctively in some patients and settings. Regular surveys on access to and prescription patterns of psychotropic medications in clinical practice are an important and efficient way of examining the use and time trends of treatments in a given population and region. Unlike developed Western countries, Asian countries have not fully undergone deinstitutionalisation of the severely and chronically mentally ill, and community-based mental health services are still under-developed. As a result, a large number of psychiatric patients still receive treatments in psychiatric hospitals. Moreover, there have been very limited studies examining access to and prescription patterns of psychotropic medications for schizophrenia patients in Asian countries. In this paper, we focus on the only international project on the use of psychotropic medications in schizophrenia patients in selected East and Southeast Asian countries/territories summarising its major findings. Most of the first- and second-generation antipsychotics (FGAs and SGAs) are available in Asian countries, but the access to psychotropic medications is largely affected by socio-cultural and historical contexts, health insurance schemes, health care policy, medication cost and consumers' preference across different countries/territories. Overall, the proportional use of FGAs, high dose antipsychotic treatment and antipsychotic polypharmacy have decreased, while the use of SGAs and antidepressants have increased and the utilisation of benzodiazepines and mood stabilisers has remained relatively stable over time. However, within these general trends, there is great inter-country variation regarding the psychotropic prescribing patterns and trends in Asian schizophrenia patients that also seems to differ from data in many Western countries.
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9
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Sarkar S, Hillner K, Velligan DI. Conceptualization and treatment of negative symptoms in schizophrenia. World J Psychiatry 2015; 5:352-361. [PMID: 26740926 PMCID: PMC4694548 DOI: 10.5498/wjp.v5.i4.352] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Revised: 07/07/2015] [Accepted: 10/13/2015] [Indexed: 02/05/2023] Open
Abstract
Negative symptoms of schizophrenia including social withdrawal, diminished affective response, lack of interest, poor social drive, and decreased sense of purpose or goal directed activity predict poor functional outcomes for patients with schizophrenia. They may develop and be maintained as a result of structural and functional brain abnormalities, particularly associated with dopamine reward pathways and by environmental and psychosocial factors such as self-defeating cognitions and the relief from overstimulation that accompanies withdrawal from social and role functioning. Negative symptoms are more difficult to treat than the positive symptoms of schizophrenia and represent an unmet therapeutic need for large numbers of patients with schizophrenia. While antipsychotic medications to treat the symptoms of schizophrenia have been around for decades, they have done little to address the significant functional impairments in the disorder that are associated with negative symptoms. Negative symptoms and the resulting loss in productivity are responsible for much of the world-wide personal and economic burden of schizophrenia. Pharmacologic treatments may be somewhat successful in treating secondary causes of negative symptoms, such as antipsychotic side effects and depression. However, in the United States there are no currently approved treatments for severe and persistent negative symptoms (PNS) that are not responsive to treatments for secondary causes. Pharmacotherapy and psychosocial treatments are currently being developed and tested with severe and PNS as their primary targets. Academia, clinicians, the pharmaceutical industry, research funders, payers and regulators will need to work together to pursue novel treatments to address this major public health issue.
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10
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Chee KY, Tripathi A, Avasthi A, Chong MY, Sim K, Yang SY, Glover S, Xiang YT, Si TM, Kanba S, He YL, Lee MS, Chiu HFK, Kuga H, Mahendran R, Udormatn P, Kallivayalil RA, Tanra AJ, Maramis M, Shinfuku N, Shen WW, Tan CH, Sartorius N. International study on antidepressant prescription pattern at 40 major psychiatric institutions and hospitals in Asia: A 10-year comparison study. Asia Pac Psychiatry 2015; 7:366-74. [PMID: 25706498 DOI: 10.1111/appy.12176] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2014] [Accepted: 01/14/2015] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Research in prescription pattern of antidepressants in Asia is lacking. This study aims to compare the antidepressants prescription pattern in Asia in 2003-2004 and 2013. METHODS The Research in East Asia Psychotropic Prescription Pattern on Antidepressants (REAP-AD) had worked collaboratively in 2003-2004 (REAP-AD 2003/2004) and 2013 (REAP-AD 2013) to study the prescription pattern of antidepressants in Asia. The REAP-AD 2013 study was conducted in China, Hong Kong, India, Indonesia, Japan, Korea, Malaysia, Singapore, Taiwan, and Thailand using a unified research protocol and questionnaire. RESULTS Forty psychiatric centers participated in REAP-AD 2013 and a total of 2,319 patients receive antidepressants were analyzed. In 2013, 39.6% of the antidepressant prescriptions were for diagnoses other thandepressive disorder compared with 38.4% in REAP-AD 2003/2004. Out of all the antidepressants listed in the Anatomical Therapeutic Chemical Classification index by the World Health Organization Collaborating Center for Drug Statistics Methodology (Oslo), only 38% antidepressants were prescribed in participating centers in 2013 compared with 46% in REAP-AD 2003/2004. The selective serotonin reuptake inhibitors were the most common antidepressant prescribed in the participating centers, which was similar to the 2003-2004 survey. Prescription of newer generation antidepressants had increased in 2013 survey; on the contrary, prescription of tricyclic antidepressants had reduced. DISCUSSION This study has contributed significantly in relation to the changing patterns of antidepressant use in all the participating Asian centers in the last 10 years. The findings are important in shaping optimal antidepressant prescription and future policy making.
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Affiliation(s)
- Kok-Yoon Chee
- Department of Psychiatry & Mental Health, Kuala Lumpur Hospital, Kuala Lumpur, Malaysia
| | - Adarsh Tripathi
- Department of Psychiatry, King George's Medical University, Chowk, Lucknow, India
| | - Ajit Avasthi
- Department of Psychiatry, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Mian-Yoon Chong
- Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital-Kaohsiung Medical Center and School of Medicine, Chang Gung University, Taiwan, China
| | - Kang Sim
- Institute of Mental Health, Buangkok View, Buangkok Green Medical Park Singapore, Taipei, Taiwan, China
| | - Shu-Yu Yang
- Department of Pharmacy, Taipei City Hospital, Taipei, Taiwan, China
| | - Sandeep Glover
- Department of Psychiatry, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Yu-Tao Xiang
- Faculty of Health Sciences, University of Macau, Macao SAR, China
| | - Tian-Mei Si
- Department of Psychiatry, Peking University Institute of Mental Health, Beijing, China
| | - Shigenobu Kanba
- Department of Neuropsychiatry, Kyushu University, Fukuoka, Japan
| | - Yan-Ling He
- Department of Psychiatric Epidemiology, Shanghai Mental Health Center, Shanghai, China
| | - Min-Soo Lee
- Department of Psychiatry, College of Medicine, Korea University, Seoul, Korea
| | | | - Hironori Kuga
- Department of Neuropsychiatry, Kyushu University, Fukuoka, Japan
| | - Rathi Mahendran
- Department of Psychological Medicine, National University Hospital, Singapore
| | - Pichet Udormatn
- Department of Psychiatry, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | | | - Andi J Tanra
- Department of Psychiatry, Hasanuddin University Faculty of Medicine, Makassar, Sulawesi Selatan, Indonesia
| | - Margarita Maramis
- Dr. Soetomo Hospital - Faculty of Medicine, Airlangga University, Jawa Timur, Indonesia
| | | | - Winston W Shen
- Department of Psychiatry, TMU-Wan Fang Medical Center, Taipei Medical University, Taipei, Taiwan
| | - Chay-Hoon Tan
- Department of Pharmacology, National University of Singapore, Singapore
| | - Norman Sartorius
- Association for the Improvement of Mental Health Programmes, Geneva, Switzerland
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11
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Pharmacological treatment of negative symptoms in schizophrenia. Eur Arch Psychiatry Clin Neurosci 2015; 265:567-78. [PMID: 25895634 DOI: 10.1007/s00406-015-0596-y] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Accepted: 03/23/2015] [Indexed: 12/15/2022]
Abstract
Effective treatment of negative symptoms is one of the most important unmet needs in schizophrenic disorders. Because the evidence on current psychopharmacological treatments is unclear, the authors reviewed the findings published to date by searching PubMed with the keywords negative symptoms, antipsychotics, antidepressants, glutamatergic compounds, monotherapy and add-on therapy and identifying additional articles in the reference lists of the resulting publications. The findings presented here predominantly focus on results of meta-analyses. Evidence for efficacy of current psychopharmacological medications is difficult to assess because of methodological problems and inconsistent results. In general, the second-generation antipsychotics (SGAs) do not appear to have good efficacy in negative symptoms, although some show better efficacy than first-generation antipsychotics, some of which also demonstrated efficacy in negative symptoms. Specific trials on predominant persistent negative symptoms are rare and have been performed with only a few SGAs. More often, trials on somewhat persistent negative symptoms evaluate add-on strategies to ongoing antipsychotic treatment. Such trials, mostly on modern antidepressants, have demonstrated some efficacy. Several trials with small samples have evaluated add-on treatment with glutamatergic compounds, such as the naturally occurring amino acids glycine and D-serine and new pharmacological compounds. The results are highly inconsistent, although overall efficacy results appear to be positive. The unsatisfactory and inconsistent results can be partially explained by methodological problems. These problems need to be solved in the future, and the authors propose some possible solutions. Further research is required to identify effective treatment for the negative symptoms of schizophrenia.
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12
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Terevnikov V, Joffe G, Stenberg JH. Randomized Controlled Trials of Add-On Antidepressants in Schizophrenia. Int J Neuropsychopharmacol 2015; 18:pyv049. [PMID: 25991654 PMCID: PMC4576515 DOI: 10.1093/ijnp/pyv049] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Accepted: 04/27/2015] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Despite adequate treatment with antipsychotics, a substantial number of patients with schizophrenia demonstrate only suboptimal clinical outcome. To overcome this challenge, various psychopharmacological combination strategies have been used, including antidepressants added to antipsychotics. METHODS To analyze the efficacy of add-on antidepressants for the treatment of negative, positive, cognitive, depressive, and antipsychotic-induced extrapyramidal symptoms in schizophrenia, published randomized controlled trials assessing the efficacy of adjunctive antidepressants in schizophrenia were reviewed using the following parameters: baseline clinical characteristics and number of patients, their on-going antipsychotic treatment, dosage of the add-on antidepressants, duration of the trial, efficacy measures, and outcomes. RESULTS There were 36 randomized controlled trials reported in 41 journal publications (n=1582). The antidepressants used were the selective serotonin reuptake inhibitors, duloxetine, imipramine, mianserin, mirtazapine, nefazodone, reboxetin, trazodone, and bupropion. Mirtazapine and mianserin showed somewhat consistent efficacy for negative symptoms and both seemed to enhance neurocognition. Trazodone and nefazodone appeared to improve the antipsychotics-induced extrapyramidal symptoms. Imipramine and duloxetine tended to improve depressive symptoms. No clear evidence supporting selective serotonin reuptake inhibitors' efficacy on any clinical domain of schizophrenia was found. Add-on antidepressants did not worsen psychosis. CONCLUSIONS Despite a substantial number of randomized controlled trials, the overall efficacy of add-on antidepressants in schizophrenia remains uncertain mainly due to methodological issues. Some differences in efficacy on several schizophrenia domains seem, however, to exist and to vary by the antidepressant subgroups--plausibly due to differences in the mechanisms of action. Antidepressants may not worsen the course of psychosis. Better designed, larger, and longer randomized controlled trials are needed.
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Affiliation(s)
- Viacheslav Terevnikov
- Kellokoski Hospital, Kellokoski, Finland (Dr Terevnikov); Department of Psychiatry, Helsinki University Central Hospital, Hospital District of Helsinki and Uusimaa, Helsinki, Finland (Drs Joffe and Stenberg).
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13
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Antidepressants for cognitive impairment in schizophrenia--a systematic review and meta-analysis. Schizophr Res 2014; 159:385-94. [PMID: 25240772 PMCID: PMC4252251 DOI: 10.1016/j.schres.2014.08.015] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2014] [Revised: 08/15/2014] [Accepted: 08/19/2014] [Indexed: 11/23/2022]
Abstract
BACKGROUND Cognitive impairment in schizophrenia is disabling, but current treatment options remain limited. OBJECTIVE To meta-analyze the efficacy and safety of adjunctive antidepressants for cognitive impairment in schizophrenia. DATA SOURCES AND STUDY SELECTION PubMed, MEDLINE, PsycINFO, and Cochrane Library databases were searched until 12/2013 for randomized controlled trials comparing antidepressant augmentation of antipsychotics with placebo regarding effects on cognitive functioning in schizophrenia. DATA EXTRACTION Two authors independently extracted data. Standardized mean differences (SMDs) were calculated for continuous outcomes and risk ratios for categorical outcomes. SMDs of individual cognitive tests were pooled on a study level within domains (primary outcome) and across domains. When results were heterogeneous, random instead of fixed effects models were used. RESULTS We meta-analyzed 11 studies (duration = 8.7 ± 3.7 weeks) including 568 patients (mean age = 39.5 ± 6.9 years, males = 67.2%, illness duration = 12.5 ± 8.0 years). Antidepressants included mirtazapine (4 studies; n = 126), citalopram (2 studies; n = 231), fluvoxamine (1 study; n = 47), duloxetine (1 study; n = 40), mianserin (1 study; n = 30), bupropion (1 study; n = 61), and reboxetine (1 study; n = 33). Statistically significant, but clinically negligible, advantages were found for pooled antidepressants compared to placebo in executive function (Hedges' g = 0.17, p = 0.02) and a composite cognition score (Hedges' g = 0.095, p = 0.012). Depression improved with serotonergic antidepressants (p = 0.0009) and selective serotonin reuptake inhibitors (p = 0.009), but not with pooled antidepressants (p = 0.39). Sedation was more common with pooled antidepressants (p = 0.04). CONCLUSION Adjunctive antidepressants do not demonstrate clinically significant effects on cognition in schizophrenia patients, however, larger studies, preferably in euthymic schizophrenia patients and using full neurocognitive batteries, are needed to confirm this finding.
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Azorin JM, Belzeaux R, Adida M. Negative Symptoms in Schizophrenia: Where We have been and Where We are Heading. CNS Neurosci Ther 2014; 20:801-8. [PMID: 24931186 DOI: 10.1111/cns.12292] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Revised: 05/06/2014] [Accepted: 05/06/2014] [Indexed: 01/31/2023] Open
Abstract
This review traces the history of negative symptom profiles in neuropsychiatry from their earliest emergence in the 19th century to the current psychiatric concepts and therapeutic approaches. Recent investigations performing exploratory and confirmatory factor analysis have suggested that negative symptoms are multidimensional, including evidence for at least two distinct negative symptom subdomains: diminished expression and amotivation. Preliminary studies have demonstrated the clinical validity of this distinction. Several potential pathophysiological validating factors based on brain imaging analysis of emotional experiences and expressions in individuals with schizophrenia are examined. Finally, the potential of different treatment strategies, including medications and various psychotherapeutic techniques, to most favorably treat each of these subdomains is discussed.
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15
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Barnes SA, Der-Avakian A, Markou A. Anhedonia, avolition, and anticipatory deficits: assessments in animals with relevance to the negative symptoms of schizophrenia. Eur Neuropsychopharmacol 2014; 24:744-58. [PMID: 24183826 PMCID: PMC3986268 DOI: 10.1016/j.euroneuro.2013.10.001] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2013] [Revised: 07/30/2013] [Accepted: 10/05/2013] [Indexed: 12/11/2022]
Abstract
Schizophrenia represents a complex, heterogeneous disorder characterized by several symptomatic domains that include positive and negative symptoms and cognitive deficits. Negative symptoms reflect a cluster of symptoms that remains therapeutically unresponsive to currently available medications. Therefore, the development of animal models that may contribute to the discovery of novel and efficacious treatment strategies is essential. An animal model consists of both an inducing condition or manipulation (i.e., independent variable) and an observable measure(s) (i.e., dependent variables) that are used to assess the construct(s) under investigation. The objective of this review is to describe currently available experimental procedures that can be used to characterize constructs relevant to the negative symptoms of schizophrenia in experimental animals. While negative symptoms can encompass aspects of social withdrawal and emotional blunting, this review focuses on the assessment of reward deficits that result in anhedonia, avolition, and abnormal reward anticipation. The development and utilization of animal procedures that accurately assess reward-based constructs related to negative symptomatology in schizophrenia will provide an improved understanding of the neural substrates involved in these processes.
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Affiliation(s)
- Samuel A Barnes
- Department of Psychiatry, School of Medicine, University of California San Diego, La Jolla, CA 92093-0603, USA
| | - Andre Der-Avakian
- Department of Psychiatry, School of Medicine, University of California San Diego, La Jolla, CA 92093-0603, USA
| | - Athina Markou
- Department of Psychiatry, School of Medicine, University of California San Diego, La Jolla, CA 92093-0603, USA.
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16
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Chue P, Lalonde JK. Addressing the unmet needs of patients with persistent negative symptoms of schizophrenia: emerging pharmacological treatment options. Neuropsychiatr Dis Treat 2014; 10:777-89. [PMID: 24855363 PMCID: PMC4020880 DOI: 10.2147/ndt.s43404] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
The negative symptoms of schizophrenia represent an impairment of normal emotional responses, thought processes and behaviors, and include blunting or flattening of affect, alogia/aprosody, avolition/apathy, anhedonia, and asociality. Negative symptoms contribute to a reduced quality of life, increased functional disability, increased burden of illness, and poorer long-term outcomes, to a greater degree than positive symptoms. Primary negative symptoms are prominent and persistent in up to 26% of patients with schizophrenia, and they are estimated to occur in up to 58% of outpatients at any given time. Negative symptoms respond less well to medications than positive symptoms, and to date treatment options for negative symptoms have been limited, with no accepted standard treatment. Modest benefits have been reported with a variety of different agents, including second-generation antipsychotics and add-on therapy with antidepressants and other pharmacological classes. Recent clinical research focusing on negative symptoms target novel biological systems, such as glutamatergic neurotransmission. Different approaches include: enhancing N-methyl-D-aspartate receptor function with agents that bind directly to the glycine ligand site or with glycine reuptake inhibitors; influencing the metabotropic glutamate receptor (mGluR2/3) with positive allosteric modulators; and stimulating nicotinic acetylcholine receptors. In conclusion, the lack of clearly efficacious pharmacological treatments for the management of negative symptoms represents a significant unmet need, especially considering the importance of these symptoms on patient outcomes. Hence, further research to identify and characterize novel pharmacological treatments for negative symptoms is greatly needed.
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Affiliation(s)
- Pierre Chue
- Department of Psychiatry, University of Alberta, Edmonton, AB, Canada
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Nitta M, Kishimoto T, Müller N, Weiser M, Davidson M, Kane JM, Correll CU. Adjunctive use of nonsteroidal anti-inflammatory drugs for schizophrenia: a meta-analytic investigation of randomized controlled trials. Schizophr Bull 2013; 39:1230-41. [PMID: 23720576 PMCID: PMC3796088 DOI: 10.1093/schbul/sbt070] [Citation(s) in RCA: 137] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To meta-analytically assess the efficacy and tolerability of nonsteroidal anti-inflammatory drugs (NSAIDs) vs placebo in schizophrenia. METHOD Searching PubMed, PsycINFO, ISI Web of Science, and the US National Institute of Mental Health clinical trials registry from database inception to December 31, 2012, we conducted a systematic review/meta-analysis of randomized placebo-controlled studies assessing the efficacy of adjunctive NSAIDs. Primary outcome was the change in Positive and Negative Syndrome Scale (PANSS) total score. Secondary outcomes included change in PANSS positive and negative subscores, all-cause discontinuation, and tolerability outcomes. Random effects, pooled, standardized mean changes (Hedges' g) and risk ratios were calculated. RESULTS Across 8 studies, including 3 unpublished reports (n = 774), the mean effect size for PANSS total score was -0.236 (95% CI: -0.484 to 0.012, P = .063, I(2) = 60.6%), showing only trend-level superiority for NSAIDs over placebo. The mean effect sizes for the PANSS positive and negative scores were -0.189 (95% CI: -0.373 to -0.005, P = .044) and -0.026 (95% CI: -0.169 to 0.117, P = .72), respectively. The relative risk for all-cause discontinuation was 1.13 (95% CI: 0.794 to 1.599, P = .503). Significant superiority of NSAIDs over placebo regarding PANSS total scores was moderated by aspirin treatment (N = 2, P = .017), inpatient status (N = 4, P = .029), first-episode status (N = 2, P = .048), and (in meta-regression analyses) lower PANSS negative subscores (N = 6, P = .026). INTERPRETATION These results indicate that adjunctive NSAIDs for schizophrenia may not benefit patients treated with first-line antipsychotics judged by PANSS total score change. NSAIDs may have benefits for positive symptoms, but the effect was minimal/small. However, due to a limited database, further controlled studies are needed, especially in first-episode patients.
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Affiliation(s)
- Masahiro Nitta
- *To whom correspondence should be addressed; Psychiatry Research, The Zucker Hillside Hospital, North Shore-Long Island Jewish Health System, 75-59 263rd Street, Glen Oaks, NY 11004; tel: (718) 470-4812, fax: (718) 343-1659, e-mail:
| | - Taishiro Kishimoto
- Psychiatry Research, The Zucker Hillside Hospital, North Shore—Long Island Jewish Health System, Geln Oaks, NY
| | - Norbert Müller
- Hospital for Psychiatry and Psychotherapy, Ludwig-Maximilians-Universität, München, Germany
| | - Mark Weiser
- Department of Psychiatry, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michael Davidson
- Department of Psychiatry, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - John M. Kane
- Psychiatry Research, The Zucker Hillside Hospital, North Shore—Long Island Jewish Health System, Geln Oaks, NY; ,Department of Psychiatry and Molecular Medicine, Hofstra North Shore LIJ School of Medicine, Hempstead, NY;,The Feinstein Institute for Medical Research, Psychiatric Neuroscience Center of Excellence, Manhasset, NY;,Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, Bronx, NY
| | - Christoph U. Correll
- Psychiatry Research, The Zucker Hillside Hospital, North Shore—Long Island Jewish Health System, Geln Oaks, NY; ,Department of Psychiatry and Molecular Medicine, Hofstra North Shore LIJ School of Medicine, Hempstead, NY;,The Feinstein Institute for Medical Research, Psychiatric Neuroscience Center of Excellence, Manhasset, NY;,Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, Bronx, NY,*To whom correspondence should be addressed; Psychiatry Research, The Zucker Hillside Hospital, North Shore—Long Island Jewish Health System, 75-59 263rd Street, Glen Oaks, NY 11004; tel: (718) 470–4812, fax: (718) 343–1659, e-mail:
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Chien WT, Yip ALK. Current approaches to treatments for schizophrenia spectrum disorders, part I: an overview and medical treatments. Neuropsychiatr Dis Treat 2013; 9:1311-32. [PMID: 24049446 PMCID: PMC3775702 DOI: 10.2147/ndt.s37485] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
During the last three decades, an increasing understanding of the etiology, psychopathology, and clinical manifestations of schizophrenia spectrum disorders, in addition to the introduction of second-generation antipsychotics, has optimized the potential for recovery from the illness. Continued development of various models of psychosocial intervention promotes the goal of schizophrenia treatment from one of symptom control and social adaptation to an optimal restoration of functioning and/or recovery. However, it is still questionable whether these new treatment approaches can address the patients' needs for treatment and services and contribute to better patient outcomes. This article provides an overview of different treatment approaches currently used in schizophrenia spectrum disorders to address complex health problems and a wide range of abnormalities and impairments resulting from the illness. There are different treatment strategies and targets for patients at different stages of the illness, ranging from prophylactic antipsychotics and cognitive-behavioral therapy in the premorbid stage to various psychosocial interventions in addition to antipsychotics for relapse prevention and rehabilitation in the later stages of the illness. The use of antipsychotics alone as the main treatment modality may be limited not only in being unable to tackle the frequently occurring negative symptoms and cognitive impairments but also in producing a wide variety of adverse effects to the body or organ functioning. Because of varied pharmacokinetics and treatment responsiveness across agents, the medication regimen should be determined on an individual basis to ensure an optimal effect in its long-term use. This review also highlights that the recent practice guidelines and standards have recommended that a combination of treatment modalities be adopted to meet the complex health needs of people with schizophrenia spectrum disorders. In view of the heterogeneity of the risk factors and the illness progression of individual patients, the use of multifaceted illness management programs consisting of different combinations of physical, psychological, and social interventions might be efficient and effective in improving recovery.
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Affiliation(s)
- Wai Tong Chien
- School of Nursing, Faculty of Health and Social Sciences, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong
| | - Annie LK Yip
- School of Nursing, Faculty of Health and Social Sciences, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong
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Wyss C, Hitz K, Hengartner MP, Theodoridou A, Obermann C, Uhl I, Roser P, Grünblatt E, Seifritz E, Juckel G, Kawohl W. The loudness dependence of auditory evoked potentials (LDAEP) as an indicator of serotonergic dysfunction in patients with predominant schizophrenic negative symptoms. PLoS One 2013; 8:e68650. [PMID: 23874705 PMCID: PMC3709903 DOI: 10.1371/journal.pone.0068650] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Accepted: 05/31/2013] [Indexed: 11/18/2022] Open
Abstract
Besides the influence of dopaminergic neurotransmission on negative symptoms in schizophrenia, there is evidence that alterations of serotonin (5-HT) system functioning also play a crucial role in the pathophysiology of these disabling symptoms. From post mortem and genetic studies on patients with negative symptoms a 5-HT dysfunction is documented. In addition atypical neuroleptics and some antidepressants improve negative symptoms via serotonergic action. So far no research has been done to directly clarify the association between the serotonergic functioning and the extent of negative symptoms. Therefore, we examined the status of brain 5-HT level in negative symptoms in schizophrenia by means of the loudness dependence of auditory evoked potentials (LDAEP). The LDAEP provides a well established and non-invasive in vivo marker of the central 5-HT activity. We investigated 13 patients with schizophrenia with predominant negative symptoms treated with atypical neuroleptics and 13 healthy age and gender matched controls with a 32-channel EEG. The LDAEP of the N1/P2 component was evaluated by dipole source analysis and single electrode estimation at Cz. Psychopathological parameters, nicotine use and medication were assessed to control for additional influencing factors. Schizophrenic patients showed significantly higher LDAEP in both hemispheres than controls. Furthermore, the LDAEP in the right hemisphere in patients was related to higher scores in scales assessing negative symptoms. A relationship with positive symptoms was not found. These data might suggest a diminished central serotonergic neurotransmission in patients with predominant negative symptoms.
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Affiliation(s)
- Christine Wyss
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric University Hospital Zurich, Zurich, Switzerland
| | - Konrad Hitz
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric University Hospital Zurich, Zurich, Switzerland
| | - Michael P. Hengartner
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric University Hospital Zurich, Zurich, Switzerland
| | - Anastasia Theodoridou
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric University Hospital Zurich, Zurich, Switzerland
| | - Caitriona Obermann
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric University Hospital Zurich, Zurich, Switzerland
| | - Idun Uhl
- Department of Psychiatry, Ruhr University Bochum, LWL University Hospital, Bochum, Germany
| | - Patrik Roser
- Department of Psychiatry, Ruhr University Bochum, LWL University Hospital, Bochum, Germany
| | - Edna Grünblatt
- Department of Child and Adolescent Psychiatry, University of Zurich, Zurich, Switzerland
| | - Erich Seifritz
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric University Hospital Zurich, Zurich, Switzerland
| | - Georg Juckel
- Department of Psychiatry, Ruhr University Bochum, LWL University Hospital, Bochum, Germany
| | - Wolfram Kawohl
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric University Hospital Zurich, Zurich, Switzerland
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Vahia IV, Lanouette NM, Golshan S, Fellows I, Mohamed S, Kasckow JW, Zisook S. Adding antidepressants to antipsychotics for treatment of subsyndromal depressive symptoms in schizophrenia: Impact on positive and negative symptoms. Indian J Psychiatry 2013; 55:144-8. [PMID: 23825848 PMCID: PMC3696237 DOI: 10.4103/0019-5545.111452] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES It remains unclear how augmenting anti-psychotic medications with anti-depressants impacts primary positive and negative symptoms of schizophrenia. In this study, we used data collected from a randomized trial comparing citalopram to placebo for management of subsyndromal depression (SSD) in schizophrenia and schizoaffective disorder, to assess the effects of antidepressant augmentation on positive and negative symptoms. MATERIALS AND METHODS Participants in this study conducted at the University of California, San Diego and the University of Cincinnati, were persons with schizophrenia or schizoaffective disorder aged 40 or older and who met study criteria for SSD. Patients were randomly assigned to flexible-dose treatment with citalopram or placebo augmentation of their current anti-psychotic medication. Analysis of covariance was used to compare changes in positive and negative syndrome scale (PANSS) scores between treatment groups. We also assessed mediating effects of improvement in depression and moderating effects of multiple factors on positive and negative symptoms. RESULTS There was significant improvement in PANSS negative symptoms scores in the citalopram group, which was partially mediated by improvement in depressive symptoms. There was no effect on PANSS positive scores. CONCLUSIONS In patients with schizophrenia/schizoaffective disorder, treating depressive symptoms with citalopram appears to carry the added benefit of improving negative symptoms.
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Affiliation(s)
- Ipsit V Vahia
- Department of Psychiatry, University of California San Diego, California, USA ; Stein Institute for Research on Aging, University of California San Diego, California, USA
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Abstract
PURPOSE OF REVIEW Combining psychotropic medications is common for people diagnosed with schizophrenia facing a variety of clinical circumstances. This review provides an update on evidence regarding the effectiveness of polypharmacy approaches. RECENT FINDINGS Epidemiology studies have demonstrated that polypharmacy is extremely common, but evidence regarding all polypharmacy approaches for schizophrenia from randomized controlled trials remains scarce. Combinations of antipsychotic medicines are unsupported by evidence. Antidepressants are commonly used to treat depressive symptoms; this logical role for antidepressants has little support from randomized controlled trials (RCTs) but may be associated with lower suicide and all-cause mortality. Insufficient evidence supports the use of benzodiazepines for schizophrenia; possible risks of benzodiazepines, including increased mortality rates revealed in observational studies, warrant caution and further study. SUMMARY The lack of evidence regarding common treatment strategies exacerbates the tremendous challenge of providing optimal pharmacotherapy for individuals with schizophrenia. Comparative effectiveness research, using observational methods when appropriate and RCTs when possible, is needed to inform clinical practice, use resources wisely and improve outcomes.
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Affiliation(s)
- Paul Matthews
- Oxford Health NHS Foundation Trust; Marlborough House Medium Secure Unit; Milton Keynes Hospital Site Eaglestone Milton Keynes BUCKS UK MK6 5NG
| | - Jamie Horder
- Institute of Psychiatry, King's College London; Department of Forensic and Neurodevelopmental Sciences; De Crespigny Park London UK SE5 8AF
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Affiliation(s)
- Paul Howard
- Duchess of Kent House, Reading, United Kingdom
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Abstract
Despite pharmacologic advances, the treatment of schizophrenia remains a challenge, and suboptimal outcomes are still all too frequent. Although treatment goals of response, remission, and recovery have been defined more uniformly, a good “effectiveness” measure mapping onto functional outcomes is still lacking. Moreover, the field has to advance in transferring measurement-based approaches from research to clinical practice. There is an ongoing debate whether, and which, first- or second-generation antipsychotics should be used. However, an individualized treatment approach needs to consider current symptoms, comorbid conditions, past therapeutic response, and adverse effects, as well as patient choice and expectations. Moreover, acute and long-term goals and effects of medication treatment need to be balanced. While the acute response to appropriately dosed first-generation antipsychotics may not differ much from second-generation antipsychotics, advantages of lower rates of extrapyramidal side effects, tardive dyskinesia, and, possibly, relapse may favor second-generation antipsychotics. However, when considering individual adverse effect prof iles, the differentiation into first- and second-generation antipsychotics as unified classes can not be upheld, and a more differentiated view and treatment selection is required. To date, clozapine is the only evidence-based treatment for refractory patients, and the role of antipsychotic polypharmacy and other augmentation strategies remains unclear, at best. To improve the treatment outcomes in schizophrenia, research efforts are needed that elucidate biomarkers of the illness and of treatment response (both therapeutic and adverse effects). Moreover, new treatment options are needed that affect nondopaminergic targets with relevance for symptom reduction, relapse prevention, enhanced efficacy for nonresponders, and reduced key adverse effects.
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Affiliation(s)
- John M Kane
- Zucker Hillside Hospital, 75-59 263rd Street, Glen Oaks, NY 11004, USA.
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Kane JM, Correll CU. Pharmacologic treatment of schizophrenia. DIALOGUES IN CLINICAL NEUROSCIENCE 2010; 12:345-57. [PMID: 20954430 PMCID: PMC3085113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/12/2024]
Abstract
Despite pharmacologic advances, the treatment of schizophrenia remains a challenge, and suboptimal outcomes are still all too frequent. Although treatment goals of response, remission, and recovery have been defined more uniformly, a good "effectiveness" measure mapping onto functional outcomes is still lacking. Moreover, the field has to advance in transferring measurement-based approaches from research to clinical practice. There is an ongoing debate whether, and which, first- or second-generation antipsychotics should be used. However an individualized treatment approach needs to consider current symptoms, comorbid conditions, past therapeutic response, and adverse effects, as well as patient choice and expectations. Moreover acute and long-term goals and effects of medication treatment need to be balanced. While the acute response to appropriately dosed first-generation antipsychotics may not differ much from second-generation antipsychotics, advantages of lower rates of extrapyramidal side effects, tardive dyskinesia, and, possibly, relapse may favor second-generation antipsychotics. However when considering individual adverse effect profiles, the differentiation into first- and second-generation antipsychotics as unified classes can not be upheld, and a more differentiated view and treatment selection is required. To date, clozapine is the only evidence-based treatment for refractory patients, and the role of antipsychotic polypharmacy and other augmentation strategies remains unclear, at best. To improve the treatment outcomes in schizophrenia, research efforts are needed that elucidate biomarkers of the illness and of treatment response (both therapeutic and adverse effects). Moreover, new treatment options are needed that affect nondopaminergic targets with relevance for symptom reduction, relapse prevention, enhanced efficacy for nonresponders, and reduced key adverse effects.
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Affiliation(s)
- John M Kane
- Zucker Hillside Hospital, 75-59 263rd Street, Glen Oaks, NY 11004, USA.
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Correll CU, Rummel-Kluge C, Corves C, Kane JM, Leucht S. Antipsychotic combinations vs monotherapy in schizophrenia: a meta-analysis of randomized controlled trials. Schizophr Bull 2009; 35:443-57. [PMID: 18417466 PMCID: PMC2659301 DOI: 10.1093/schbul/sbn018] [Citation(s) in RCA: 242] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
CONTEXT Despite lacking evidence for its safety and efficacy, antipsychotic cotreatment is common in schizophrenia. OBJECTIVE To evaluate therapeutic and adverse effects of antipsychotic cotreatment vs monotherapy in schizophrenia. DATA SOURCES Cochrane Schizophrenia Group register and hand searches of relevant journals/conference proceedings. STUDY SELECTION Randomized controlled trials comparing antipsychotic monotherapy to cotreatment with a second antipsychotic. DATA EXTRACTION AND ANALYSIS Two authors independently extracted data. For homogenous dichotomous data, we calculated random effects, relative risk (RR), 95% confidence intervals (CIs), and numbers needed to treat (NNT). For continuous data, weighted mean differences were calculated. RESULTS In 19 studies (1229 patients) with 28 monotherapy and 19 cotreatment arms, antipsychotic cotreatment was superior to monotherapy regarding 2 a priori defined coprimary outcomes: less study-specific defined inefficacy (N = 22, n = 1202, RR = 0.76, CI = 0.63-0.90, P = .002, NNT = 7, CI = 4-17, P = .0008, I(2) = 78.9%) and all-cause discontinuation (N = 20, n = 1052, RR = 0.65, CI = 0.54-0.78, P < .00001). Results were consistent using Clinical Global Impressions thresholds of less than much (P = .006) and less than minimally (P = .01) improved. Specific psychopathology and adverse event data were insufficient to yield meaningful results. In sensitivity analyses, 5 efficacy moderators emerged: concurrent polypharmacy initiation, clozapine combinations, trial duration >10 weeks, Chinese trials, and second-generation + first-generation antipsychotics. In a meta-regression, similar dose combinations, second-generation + first-generation antipsychotics and concurrent polypharmacy initiation remained significant. CONCLUSIONS In certain clinical situations, antipsychotic cotreatment may be superior to monotherapy. However, the database is subject to possible publication bias and too heterogeneous to derive firm clinical recommendations, underscoring the need for future research.
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Affiliation(s)
- Christoph U Correll
- The Zucker Hillside Hospital, Psychiatry Research, Glen Oaks, New York, NY 11004, USA.
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Silver H, Chertkow Y, Weinreb O, Danovich L, Youdim M. Multifunctional pharmacotherapy: what can we learn from study of selective serotonin reuptake inhibitor augmentation of antipsychotics in negative-symptom schizophrenia? Neurotherapeutics 2009; 6:86-93. [PMID: 19110201 PMCID: PMC5084258 DOI: 10.1016/j.nurt.2008.10.034] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Many patients suffering from major psychiatric disorders do not respond adequately to monotherapy and require additional drugs. To date, there are no objective guidelines for deciding which combination may be effective, and the choice is based on previous clinical experience and on trial and error. Even when combination drugs are effective, the biochemical mechanisms responsible for the value-added effect are unknown. Understanding the mechanism of such synergism may provide a rational basis for choosing drug combinations and for developing more effective drugs. In schizophrenia, negative symptoms respond poorly to antipsychotics, but may improve when these are augmented with selective serotonin reuptake inhibitors (SSRI). This augmenting effect cannot be explained by summating the pharmacological effects of the individual drugs. We proposed that the study of SSRI augmentation can serve as a window to understanding the biochemical mechanisms of clinically effective drug synergism. In a series of studies we identified unique biochemical effects of the combination, different from each individual drug, and proposed that some of these are involved in mediating the clinical effect. Here we review some of the findings and propose that the mechanism of action involves regionally selective modulation of the GABA system. The evidence indicates that the SSRI antidepressant-antipsychotic combination may be a useful paradigm for studying therapeutically effective synergistic drug interactions in schizophrenia. Although as yet limited in scope, the findings of definable molecular targets for synergistic SSRI-antipsychotic interaction provide new directions to inform future research and provide novel bio-molecular targets for drug development.
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Affiliation(s)
- Henry Silver
- Molecular Neuropsychiatry Unit, Brain Behavior Laboratory, Shaar Menashe Mental Health Center, and Technion-Faculty of Medicine, Haifa 32000, Israel.
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