The effect of clozapine on self-injurious behavior

Identifying eleven new ferroptosis inhibitors as neuroprotective agents from FDA-approved drugs

With increasing evidence that ferroptosis is associated with diverse neurological disorders, targeting ferroptosis offers a promising avenue for developing effective pharmaceutical agents for neuroprotection. In this study, we identified ferroptosis inhibitors as neuroprotective agents from US Food and Drug Administration (FDA)-approved drugs. 1176 drugs have been screened against erastin-induced ferroptosis in HT22 cells, resulting in 89 ferroptosis inhibitors. Among them, 26 drugs showed significant activity with EC50 below10 μM. The most active ferroptosis inhibitor is lumateperone tosylate at nanomolar level. 11 drugs as ferroptosis inhibitors were not reported previously. Further mechanistic studies revealed that their mechanisms of actions involve free radical scavenging, Fe2+ chelation, and 15-lipoxygenase inhibition. Notably, the active properties of some drugs were firstly revealed here. These ferroptosis inhibitors increase the chemical diversity of ferroptosis inhibitors, and offer new therapeutic possibilities for the treatments of related neurological diseases.

Pharmacological interventions for self-injurious behaviour in adults with intellectual disabilities

BACKGROUND

Self-injurious behaviour among people with intellectual disability is relatively common and often persistent. Self-injurious behaviour continues to present a challenge to clinicians. It remains poorly understood and difficult to ameliorate despite advances in neurobiology and psychological therapies. There is a strong need for a better evidence base in prescribing and monitoring of drugs in this population, especially since none of the drugs are actually licensed for self-injurious behaviour.

OBJECTIVES

To determine clinical effectiveness of pharmacological interventions in management of self-injurious behaviour in adults with intellectual disability.

SEARCH METHODS

We searched the following databases on 19 February 2012: CENTRAL, MEDLINE, EMBASE, PsycINFO, CINAHL, Science Citation Index, Social Science Citation Index, Conference Proceedings Citation Index - Science, Conference Proceedings Citation Index - Social Science and Humanities, ZETOC and WorldCat. We also searched ClinicalTrials.gov, ICTRP and the reference lists of included trials.

SELECTION CRITERIA

We included randomised controlled trials that examined drug interventions versus placebo for self-injurious behaviour (SIB) in adults with intellectual disability.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed risk of bias for each trial using a data extraction form. We present a narrative summary of the results is presented. We did not consider meta-analysis was appropriate due to differences in study designs, differences between interventions and heterogeneous outcome measures.

MAIN RESULTS

We found five double-blind placebo-controlled trials that met our inclusion criteria. These trials assessed effectiveness and safety of drugs in a total of 50 people with intellectual disability demonstrating SIB. Four trials compared the effects of naltrexone versus placebo and one trial compared clomipramine versus placebo.One of the naltrexone versus placebo trials reported that naltrexone had clinically significant effects (≥ 33% reduction) on the daily rates of three of the four participants' most severe form of SIB and modest to substantial reductions in SIB for all participants; however, this study did not report on statistical significance. Another trial reported that naltrexone attenuated SIB in all four participants, with 25 mg and 50 mg doses producing a statistically significant decrease in SIB (P value < 0.05). Another trial (eight people) indicated that naltrexone administration was associated with significantly fewer days of high frequency self injury and significantly more days with low frequency self injury. Naltrexone had different effects depending on the form and location of self injury. Another trial with only 26 participants found that neither single-dose (100 mg) nor long-term (50 and 150 mg) naltrexone treatment had any therapeutic effect on SIB.Comparison of clomipramine versus placebo found no statistically significant benefit for any outcome measure, which included SIB rate and intensity, stereotypy and adverse events. However, it showed clinically significant improvement in the rate and intensity of SIB and stereotypy.There were very few noteworthy adverse events to report in any of the four trials in which these were reported.All trials were at high risk of bias, apart from one trial (Lewis 1996), which was probably at low risk of bias. The short period of follow-up was a significant drawback in the design of all five trials, as it did not allow long-term assessment of behaviour over time.We were unable to examine the efficacy of antidepressants other than clomipramine, antipsychotics, mood stabilisers or beta-blockers as we did not identify any relevant placebo-controlled trials.

AUTHORS' CONCLUSIONS

There was weak evidence in included trials that any active drug was more effective than placebo for people with intellectual disability demonstrating SIB. Due to sparse data, an absence of power and statistical significance, and high risk of bias for four of the included trials, we are unable to reach any definite conclusions about the relative benefits of naltrexone or clomipramine compared to placebo.

An Examination of Psychotropic Medication Side Effects: does taking a greater number of psychotropic medications from different classes affect presentation of side effects in adults with ID?

This study examined whether the number of psychotropic medications an individual is taking across classes influences side effects among adults with Intellectual Disability (ID). Participants were 80 adults diagnosed with ID. Dependent variables were the composite score and domain scores of the Matson Evaluation of Drug Side-effects (MEDS), which is an instrument used to assess side effects. There were three levels of the independent variable: Group 1--those taking zero psychotropic medications, Group 2--those taking one psychotropic medication, and Group 3--those taking two psychotropic medications across different medication classes. There was a significant main effect regarding number of psychotropic medication classes prescribed. Further analysis revealed that four of the nine MEDS domains had significantly different mean scores for number of psychotropic medication classes. For the majority of MEDS domains, such as Central Nervous System-General, Parkinsonism/Dyskinesia, and Behavioral/Akathesia domains, participants in the no psychotropic medication group had significantly lower mean scores than those in the one and two psychotropic medication groups. Only two MEDS domains, Cardiovascular and Hematologic Effects as well as Skin, Allergies, and Temperature, were significantly different between participants taking one psychotropic medication as compared with two psychotropic medications from different classes. Implications of these findings and recommendations for future research are discussed.

The use of clozapine among individuals with intellectual disability: a review

Clozapine has been approved in the United States since 1990 for refractory or treatment resistant schizophrenia in the general population. However, as with many other antipsychotic medications, it is being prescribed for reasons other than those indicated. Among individuals with intellectual disabilities, clozapine is increasingly being prescribed to treat behavioral problems, although the empirical evidence for such a practice is lacking. This review was undertaken as an attempt to summarize the available studies regarding the use of clozapine for behavioral purposes among individuals with intellectual disabilities. Findings of our review suggest that the effectiveness of clozapine in targeting challenging behaviors among individuals with intellectual disabilities is relatively inconclusive at present. We discuss reasons why these limitations exist and offer some solutions to help alleviate these limitations.

Chronic metals ingestion by prairie voles produces sex-specific deficits in social behavior: an animal model of autism

We examined the effects of chronic metals ingestion on social behavior in the normally highly social prairie vole to test the hypothesis that metals may interact with central dopamine systems to produce the social withdrawal characteristic of autism. Relative to water-treated controls, 10 weeks of chronic ingestion of either Hg(++) or Cd(++) via drinking water significantly reduced social contact by male voles when they were given a choice between isolation or contact with an unfamiliar same-sex conspecific. The effects of metals ingestion were specific to males: no effects of metals exposure were seen in females. Metals ingestion did not alter behavior of males allowed to choose between isolation or their familiar cage-mates, rather than strangers. We also examined the possibility that metals ingestion affects central dopamine functioning by testing the voles' locomotor responses to peripheral administration of amphetamine. As with the social behavior, we found a sex-specific effect of metals on amphetamine responses. Males that consumed Hg(++) did not increase their locomotor activity in response to amphetamine, whereas similarly treated females and males that ingested only water significantly increased their locomotor activities. Thus, an ecologically relevant stimulus, metals ingestion, produced two of the hallmark characteristics of autism - social avoidance and a male-oriented bias. These results suggest that metals exposure may contribute to the development of autism, possibly by interacting with central dopamine function, and support the use of prairie voles as a model organism in which to study autism.

Psychotropic medication use for challenging behaviors in persons with intellectual disabilities: an overview

Challenging behaviors in persons with intellectual disabilities are primary target for treatment in mental health clinics and institutions. Furthermore, an increasing number of people are receiving psychotropic medications for the management of their challenging behaviors. Many people are often treated with high doses of multiple psychotropic medications for extended periods of time with little or no data collected to determine treatment efficacy. Similarly, data demonstrating treatment effectiveness is at best questionable at this time. It is for these reasons that controversy exists regarding the use of psychotropic medication for challenging behaviors. The purpose of this paper was to summarize past and current studies of drug related interventions for challenging behaviors for persons with intellectual disabilities. Based on the results of this review, the effectiveness of psychotropic medications in managing challenging behaviors is best described as minimal and a need exists for controlled studies of higher scientific quality in this area. Considering alternative psychologically based interventions and careful functional assessments appear to be advisable.

Clozapine versus typical neuroleptic medication for schizophrenia

BACKGROUND

Long-term drug treatment of schizophrenia with typical antipsychotics has limitations: 25 to 33% of patients have illnesses that are treatment-resistant. Clozapine is an antipsychotic drug, which is claimed to have superior efficacy and to cause fewer motor adverse effects than typical drugs for people with treatment-resistant illnesses. Clozapine carries a significant risk of serious blood disorders, which necessitates mandatory weekly blood monitoring at least during the first months of treatment.

OBJECTIVES

To evaluate the effects of clozapine compared with typical antipsychotic drugs in people with schizophrenia.

SEARCH STRATEGY

For the current update of this review (March 2006) we searched the Cochrane Schizophrenia Group Trials Register.

SELECTION CRITERIA

All relevant randomised clinical trials (RCTs).

DATA COLLECTION AND ANALYSIS

We extracted data independently. For dichotomous data we calculated relative risks (RR) and their 95% confidence intervals (CI) on an intention-to-treat basis, based on a fixed-effect model. We calculated numbers needed to treat/harm (NNT/NNH) where appropriate. For continuous data, we calculated weighted mean differences (WMD) again based on a fixed-effect model.

MAIN RESULTS

We have included 42 trials (3950 participants) in this review. Twenty-eight of the included studies are less than 13 weeks in duration, and, overall, trials were at significant risk of bias. We found no significant difference in the effects of clozapine and typical neuroleptic drugs for broad outcomes such as mortality, ability to work or suitability for discharge at the end of the study. Clinical improvements were seen more frequently in those taking clozapine (n=1119, 14 RCTs, RR 0.72 CI 0.7 to 0.8, NNT 6 CI 5 to 8). Also, participants given clozapine had fewer relapses than those on typical antipsychotic drugs (n=1303, RR 0.62 CI 0.5 to 0.8, NNT 21 CI 15 to 49). BPRS scores showed a greater reduction of symptoms in clozapine-treated patients, (n=1145, 16 RCTs, WMD -4.22 CI -5.4 to -3.1), although the data were heterogeneous (Chi(2) 0.0001, I(2) 66%). Short-term data from the SANS negative symptom scores favoured clozapine (n=196, 5 RCTs, WMD -5.92 CI -7.8 to -4.1). We found clozapine to be more acceptable in long-term treatment than conventional antipsychotic drugs (n=982, 16 RCTs, RR 0.60 CI 0.5 to 0.7, NNT 15 CI 12 to 20). Blood problems occurred more frequently in participants receiving clozapine (3.2%) compared with those given typical antipsychotics (0%) (n=1031, 13 RCTs, RR 7.09 CI 2.0 to 25.6). Clozapine participants experienced more drowsiness, hypersalivation, or temperature increase, than those given conventional neuroleptics. However, clozapine patients experienced fewer motor adverse effects (n=1433, 18 RCTs, RR 0.58 CI 0.5 to 0.7, NNT 5 CI 4 to 6).The clinical effects of clozapine were more pronounced in participants resistant to typical neuroleptics in terms of clinical improvement (n=370, 4 RCTs, RR 0.71 CI 0.6 to 0.8, NNT 4 CI 3 to 6) and symptom reduction. Thirty-four per cent of treatment-resistant participants had a clinical improvement with clozapine treatment.

AUTHORS' CONCLUSIONS

Clozapine may be more effective in reducing symptoms of schizophrenia, producing clinically meaningful improvements and postponing relapse, than typical antipsychotic drugs - but data are weak and prone to bias. Participants were more satisfied with clozapine treatment than with typical neuroleptic treatment. The clinical effect of clozapine, however, is, at least in the short term, not reflected in measures of global functioning such as ability to leave the hospital and maintain an occupation. The short-term benefits of clozapine have to be weighed against the risk of adverse effects. Within the context of trials, the potentially dangerous white blood cell decline seems to be more frequent in children and adolescents and in the elderly than in young adults or people of middle-age.The existing trials have largely neglected to assess the views of participants and their families on clozapine. More community-based long-term randomised trials are needed to evaluate the efficacy of clozapine on global and social functioning as trials in special groups such as people with learning disabilities.

Guidelines for the use of clozapine in individuals with developmental disabilities

Clozapine is the most effective antipsychotic medication currently in use, but there has been a paucity of well-controlled research on its efficacy with people with developmental disabilities. We present a set of guidelines to ensure proper utilization of clozapine in individuals with developmental disabilities, because it can offer them therapeutic advantages similar to those observed in people with schizophrenia. We provide recommendations regarding the use of clozapine that are based on three main sources: literature and published professional practice guidelines regarding the use of clozapine in individuals who do not have developmental disabilities, the limited literature on the use of clozapine in individuals who have developmental disabilities, and our own clinical experience. The first part of the guidelines contains an overview of necessary practical knowledge regarding side effects, dose and blood level considerations, and interactions with other medications, diet and tobacco smoking. In the second part, we offer procedures for selecting individuals for clozapine therapy based on proper indications and contraindications for treatment. We also include requirements regarding informed consent, dosage and special laboratory and clinical monitoring.

Self-injurious behavior to the lower extremities among children with atypical development: a diagnostic and treatment algorithm

Self-injurious behavior is a devastating and persistent condition that results in severe tissue damage, permanent impairment, or, occasionally, death. This aberrant behavior seen in specific childhood syndromes is compounded when the lower limbs are injured. Secondary complications are more frequent, depending on the site of the injury, resulting in significant morbidity and depletion of hospital resources. A substantial body of empirical evidence indicates that this deviant behavior is partly learned and partly of biologic origin. Therefore, this article presents a case study and reviews the components of a biopsychosocial paradigm of treatment for self-inflicted wounds to the lower extremity and formulates a prototypical algorithm for its diagnosis and management.

The neonate-6-hydroxydopamine-lesioned rat: a model for clinical neuroscience and neurobiological principles

In 1973, a technique of administering 6-hydroxydopamine (2,4,5-trihydroxyphenylethylamine) intracisternally to neonate rats was introduced to selectively reduce brain dopamine (neonate-lesioned rat). This neonate treatment proved unique when compared to rats lesioned as adults with 6-hydroxydopamine--prompting the discovery of differing functional characteristics resulting from the age at which brain dopamine is reduced. A realization was that neonate-lesioned rats modeled the loss of central dopamine and the increased susceptibility for self-injury in Lesch-Nyhan disease, which allowed identification of drugs useful in treating self-injury in mentally retarded patients. The neonate-lesioned rat has also been proposed to model the hyperactivity observed in attention-deficit hyperactivity disorder. Because the neonate-lesioned rat exhibits enhanced sensitization to repeated NMDA receptor antagonist administration and has functional changes characteristic of schizophrenia, the neonate lesioning is believed to emulate the hypothesized NMDA hypofunction in this psychiatric disorder. Besides modeling features of neurological and psychiatric disorders, important neurobiological concepts emerged from pharmacological studies in the neonate-lesioned rats. One was the discovery of coupling of D1/D2-dopamine receptor function. Another was the progressive increase in responsiveness to repeated D1-dopamine agonist administration referred to as "priming" of D1-dopamine receptor function. Additionally, a unique profile of signaling protein expression related to neonate reduction of dopamine has been identified. Thus, from modeling characteristics of disease to defining adaptive mechanisms related to neonatal loss of dopamine, the neonate-lesioned rat has had a persisting influence on neuroscience. Despite an extraordinary legacy from studies of the neurobiology of this treatment, a host of unknowns remain that will inspire future investigations.

The use of clozapine in adults with intellectual disability

BACKGROUND

There are not many studies on the use of clozapine in patients with intellectual disability (ID). The authors describe a case series of patients treated with clozapine, drawn from a medium secure unit, a low secure assessment and treatment service and a community team in the London region.

METHOD

A retrospective file-review of patients treated in these three settings during the time period March-June 2002 was performed (n = 24). Information was collected using a semistructured proforma.

RESULTS

Of the 24 patients, 67% had schizophrenia, 17% had schizoaffective disorder and 8% had bipolar disorder. Patients had been unwell for a mean of 6 years and had been tried on a mean of four antipsychotics. The mean maximum dose of clozapine was 488 mg. The outcomes on the clinical global impression (CGI) scale showed 29% very much improved, 42% much improved, 21% minimally improved and 8% no change. 54% of the whole sample and 53% of those from the medium secure unit were discharged to homes in the community. The drug had to be stopped in four patients, of which three were because of neutropaenia.

CONCLUSION

Clozapine appears to be safe and efficacious in many people with ID. Careful monitoring of side-effects is needed during therapy.

Antipsychotic medication for challenging behaviour in people with learning disability

BACKGROUND

The term 'challenging behaviour', in the absence of psychiatric disorder, encompasses a wide range of behaviours that may be harmful to people or property, may be difficult to manage and may limit access to community facilities. Antipsychotic medications have been used to modify such behaviours in people with learning disability, but there is little evidence to suggest that the benefits outweigh the risks.

OBJECTIVES

To determine the effectiveness of antipsychotic medication for people with learning disability and challenging behaviour without additional mental illness.

SEARCH STRATEGY

Biological Abstracts, the Cochrane Library, EMBASE, MEDLINE, PsycINFO and BIOSIS were searched. Further references were sought from published trials and pharmaceutical companies. Trials were reliably identified and data extracted.

SELECTION CRITERIA

All randomised controlled trials of antipsychotic medication versus placebo.

DATA COLLECTION AND ANALYSIS

Reviewers independently evaluated and analysed data on an intention to treat basis. Data were evaluated at 4, 8 and 12 weeks as longer follow-up data were not available. Reviewers assumed that those subjects lost to follow-up had a bad outcome.

MAIN RESULTS

Only nine randomised controlled trials could be included in the analyses. These provided no evidence of whether antipsychotic medication helps or harms adults with learning disability and challenging behaviour.

REVIEWERS' CONCLUSIONS

There are limited data on this important issue and more research is urgently needed.

Brief report: effects of clozapine on self-injurious behavior of two risperidone nonresponders with mental retardation

Atypical antipsychotic medications for self-injurious behavior (SIB), aggression, and destruction among people with mental retardation and development disabilities are becoming increasingly accepted. Most studies are on risperidone and fewer have been conducted on clozapine. The present single-blind study reports marked reductions in SIB and aggression of two persons with profound mental retardation who were nonresponsive to all other behavioral and psychopharmacological interventions, including risperidone. The most effective dose was 200 mg/day. Side effects were mild and the drug was tolerated well.

Psychopharmacology and mental retardation: a 10 year review (1990-1999)

We conducted a 10 year review of the literature pertaining to psychopharmacology and mental retardation. Studies were included or excluded from the review based on meeting one or more of the methodological criteria normally considered fundamental for sound scientific research. The vast majority of studies conducted in the last 10 years in this area had major methodological flaws. While a large number of medications were prescribed for various psychological disorders and behavior problems, most drug administrations were not based in science, were not evaluated appropriately, and generally did not follow best practices for treatment of persons with mental retardation. Very few medications prescribed were behavior or psychiatric symptom specific; that is, most medications were given to suppress a myriad of aberrant behaviors thus chemically restraining the individual in question. Practices such as these present serious problems for service providers due to the deleterious side effects of many psychotropic medications and the federal government's intervention into the care-provision practices of developmental centers, community homes, and other living arrangements for persons with mental retardation. Implications of our review are discussed.

Antipsychotic medication for challenging behaviour in people with learning disability

BACKGROUND

The term 'challenging behaviour', in the absence of psychiatric disorder, encompasses a wide range of behaviours that may be harmful to people or property, may be difficult to manage and may limit access to community facilities. Antipsychotic medications have been used to modify such behaviours in people with learning disability, but there is little evidence to suggest that the benefits outweigh the risks.

OBJECTIVES

To determine the effectiveness of antipsychotic medication for people with learning disability and challenging behaviour.

SEARCH STRATEGY

Biological abstracts, the Cochrane Library, the Cochrane Schizophrenia Group's Register, EMBASE, MEDLINE, PsycLIT were searched. Further references were sought from published trials and pharmaceutical companies. Trials were reliably identified and data extracted.

SELECTION CRITERIA

All randomised controlled trials of antipsychotic medication versus placebo.

DATA COLLECTION AND ANALYSIS

Reviewers independently evaluated and analysed data on an intention to treat basis. Data were evaluated at 4 and 8 weeks as longer follow-up data were not available. Reviewers assumed that those subjects lost to follow-up had a bad outcome.

MAIN RESULTS

Only three randomised controlled trials could be included in the analyses. These provided no evidence of whether antipsychotic medication helps or harms adults with learning disability and challenging behaviour.

REVIEWER'S CONCLUSIONS

There is limited data on this important issue and more research is urgently needed.

Clozapine versus typical neuroleptic medication for schizophrenia

BACKGROUND

Long-term drug treatment of schizophrenia with conventional antipsychotics has limitations: 25-33% of patients have illnesses that are treatment-resistant. Clozapine is an atypical antipsychotic drug, which is claimed to have superior efficacy and to cause fewer motor adverse effects than typical drugs for people with treatment-resistant illnesses. Clozapine carries a significant risk of serious blood disorders, which necessitates mandatory weekly blood monitoring at least during the first months of treatment.

OBJECTIVES

To evaluate the effects of clozapine for schizophrenia in comparison to typical antipsychotic drugs.

SEARCH STRATEGY

Publications in all languages were searched from the following databases: Biological Abstracts (1982-1999), The Cochrane Library CENTRAL (Issue 2, 1999), Cochrane Schizophrenia Group's Specialised Register (1999), EMbase (1980-1999), ISI Citation Index, LILACS (1982-1999), MEDLINE (1966-1999), and PsycLIT (1974-1999). Reference list screening of included papers was performed. Authors of recent trials and the manufacturer of clozapine contacted.

SELECTION CRITERIA

All randomised controlled trials comparing clozapine with typical antipsychotic drugs were included by independent assessment by at least two reviewers.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by at least two reviewers. Authors of trials published since 1980 were contacted for additional and missing data. Odds ratios (OR) and 95% confidence intervals (CI) of homogeneous dichotomous data were calculated with the Peto method. A random effects model was used for heterogeneous dichotomous data. Where possible the numbers needed to treat (NNT) or needed to harm (NNH) were also calculated. Weighted or standardised means were calculated for continuous data.

MAIN RESULTS

Currently the review includes 31 studies, 26 of which are less than 13 weeks in duration. These studies include 2589 participants, most of whom were men (74%). The average age was 38 years. There was no difference in the effects of clozapine and typical neuroleptic drugs for broad outcomes such as mortality, ability to work or suitability for discharge at end of the study. Clinical improvement was seen more frequently in those taking clozapine (random effects OR 0.4 CI 0.2-0.6, NNT 6) both in the short and the long term. Also, in the short term, participants on clozapine had fewer relapses than those on typical antipsychotic drugs (OR 0.6 CI 0.4-0.8, NNT 20 CI 17-38), and this may be true for long-term treatment as well. Symptom assessment scales showed a greater reduction of symptoms in clozapine-treated patients. Clozapine treatment was more acceptable than low-potency antipsychotics such as chlorpromazine (OR 0.6 CI 0.4-0.9) but did not differ from acceptability of high-potency neuroleptics such as haloperidol (random effects OR 0.8 CI 0.4-1.5). Clozapine was more acceptable in long-term treatment than conventional antipsychotic drugs (random effects OR 0.4 CI 0.2-0.7, NNT 6 CI 3-111). Patients were more satisfied with clozapine treatment (OR 0.5 CI 0.3-0.8, NNT 12 CI 7-37), but they experienced more hypersalivation, temperature increase, and drowsiness than those given conventional neuroleptics. However, clozapine patients experience fewer motor side effects and less dry mouth. The clinical efficacy of clozapine was more pronounced in participants resistant to typical neuroleptics in terms of clinical improvement (random effects OR 0.2 CI 0.1-0.5, NNT 5 CI 4-7) and symptom reduction. Thirty-two percent of treatment resistant people had a clinical improvement with clozapine treatment.

REVIEWER'S CONCLUSIONS

This systematic review confirms that clozapine is convincingly more effective than typical antipsychotic drugs in reducing symptoms of schizophrenia, producing clinically meaningful improvements and postponing relapse. Patients were more satisfied with clozapine treatment than with typical neuroleptic treatment. (ABSTRACT TRUNCATED

Antipsychotic medication for challenging behaviour in people with intellectual disability: a systematic review of randomized controlled trials

A study was performed to determine the effectiveness of antipsychotic medication for people with intellectual disability (ID) and challenging behaviour. Randomized controlled trials comparing antipsychotic medication to placebo in people with ID and challenging behaviour were identified by electronic searching and hand-searching. Reviewers independently evaluated and analysed data on an intention-to-treat basis. Only three randomized controlled trials could be included in the analyses. These trials provided no evidence as to whether antipsychotic medication does or does not help adults with ID and challenging behaviour. There is limited data on this important issue and good quality research is urgently needed.

The use of clozapine in the treatment of aggressive schizophrenia

The atypical antipsychotic drug clozapine was introduced to clinical practice in 1972. It is a dibenzodiazepine derivative with, among other known receptor site activities, a relatively high D1/D2 receptor affinity ratio. The serious side effects of bone marrow suppression and agranulocytosis delayed the acceptance of clozapine into common clinical practice but scrupulous application of a monitoring protocol led to adequate protection from these side effects. There is now a broad consensus about the benefits of clozapine which supports the use of clozapine as a first-line treatment of schizophrenia. There is good evidence that relapse and rehospitalization drop to 22% of the incidence in preclozapine treatment patients. The majority of responders are identified within 4 months of treatment. Clozapine has been demonstrated to be an effective treatment for neuroleptic refractory patients. Forty percent of clozapine-treated patients show significant improvement, with 11% of treated patients showing no residual psychosis. This review also describes the results of clozapine on aggressive and violent assault in a patient population characterized by severe functional deficits, typically chronic schizophrenia with severe impairment, chronic brain syndromes, and developmental handicap. Prior to the introduction of clozapine therapy, in a chronically disrupted milieu that precluded adequate psychosocial programming, seriously assaultive behaviour resulting in peer and staff injury was a common occurrence. Evidence suggests that clozapine is an effective medical treatment for the target symptoms of hostile agitation, threatening, and assaultive violence.