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Vita A, Nibbio G, Barlati S. Conceptualization and characterization of "primary" and "secondary" cognitive impairment in schizophrenia. Psychiatry Res 2024; 340:116126. [PMID: 39128169 DOI: 10.1016/j.psychres.2024.116126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Revised: 07/25/2024] [Accepted: 08/04/2024] [Indexed: 08/13/2024]
Abstract
Cognitive impairment represents one of the core features of schizophrenia, involves both neurocognition and social cognition domains, and has a significant negative impact on real-world functioning. The present review provides a framework for the conceptualization and characterization of "primary" and "secondary" cognitive impairment in schizophrenia. In this conceptualization, primary cognitive impairment can be defined as a consequence of the neurobiological alterations that underlie psychopathological manifestations of the disorder, while secondary cognitive impairment can be defined as the results of a source issue that has a negative impact on cognitive performance. Sources of secondary cognitive impairment are frequent in people with schizophrenia and include several different factors, such as positive and negative symptoms, depressive symptoms, autistic symptoms, pharmacotherapy, substance abuse, metabolic syndrome, social deprivation, and sleep disorders. It can be hypothesized that secondary cognitive impairment may be improved by effectively resolving the source issue, while primary cognitive impairment may benefit from dedicated treatment. Further research is required to confirm this hypothesis, to better characterize the distinction between primary and secondary cognitive impairment in a clinical and in a neurobiological perspective, and to evaluate the impact of systematically assessing and treating secondary cognitive impairment.
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Affiliation(s)
- Antonio Vita
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy; Department of Mental Health and Addiction Services, ASST Spedali Civili of Brescia, Brescia, Italy.
| | - Gabriele Nibbio
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Stefano Barlati
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy; Department of Mental Health and Addiction Services, ASST Spedali Civili of Brescia, Brescia, Italy
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Tsapakis EM, Treiber M, Mitkani C, Drakaki Z, Cholevas A, Spanaki C, Fountoulakis KN. Pharmacological Treatments of Negative Symptoms in Schizophrenia-An Update. J Clin Med 2024; 13:5637. [PMID: 39337126 PMCID: PMC11432821 DOI: 10.3390/jcm13185637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2024] [Accepted: 09/21/2024] [Indexed: 09/30/2024] Open
Abstract
Schizophrenia is a chronic psychotic disorder comprising positive symptoms, negative symptoms, and cognitive deficits. Negative symptoms are associated with stigma, worse functional outcomes, and a significant deterioration in quality of life. Clinical diagnosis is challenging despite its significance, and current treatments offer little improvement in the burden of negative symptoms. This article reviews current pharmacological strategies for treating negative symptoms. Dopaminergic, glutamatergic, serotonergic, noradrenergic, cholinergic, anti-inflammatory compounds, hormones, and psychostimulants are explored. Finally, we review pharmacological global treatment guidelines for negative symptoms. In general, switching to a second-generation antipsychotic seems to be most often recommended for patients with schizophrenia on first-generation antipsychotics, and an add-on antidepressant is considered when depression is also present. However, the treatment of negative symptoms remains an unmet need. Future, larger clinical studies and meta-analyses are needed to establish effective pharmacological agents for the effective treatment of negative symptoms.
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Affiliation(s)
- Evangelia Maria Tsapakis
- 3rd Department of Psychiatry, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece
- Department of Neurosciences, School of Medicine, University of Crete, 71003 Heraklion, Greece
| | - Michael Treiber
- 3rd Department of Psychiatry, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, 1090 Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health (C3NMH), Medical University of Vienna, 1090 Vienna, Austria
| | - Calypso Mitkani
- 3rd Department of Psychiatry, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece
- Department of Neurology, Agios Pavlos General Hospital of Thessaloniki, 55134 Thessaloniki, Greece
| | - Zoe Drakaki
- Department of Neurosciences, School of Medicine, University of Crete, 71003 Heraklion, Greece
| | - Anastasios Cholevas
- Department of Neurosciences, School of Medicine, University of Crete, 71003 Heraklion, Greece
| | - Cleanthe Spanaki
- Department of Neurosciences, School of Medicine, University of Crete, 71003 Heraklion, Greece
- Department of Neurology, University Hospital of Heraklion, Voutes, 71110 Crete, Greece
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Vita A, Barlati S, Cavallaro R, Mucci A, Riva MA, Rocca P, Rossi A, Galderisi S. Definition, assessment and treatment of cognitive impairment associated with schizophrenia: expert opinion and practical recommendations. Front Psychiatry 2024; 15:1451832. [PMID: 39371908 PMCID: PMC11450451 DOI: 10.3389/fpsyt.2024.1451832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2024] [Accepted: 08/22/2024] [Indexed: 10/08/2024] Open
Abstract
A considerable proportion of patients with schizophrenia perform below population norms on standardized neuropsychological tests, and the performance of those performing within normal range is lower than predicted based on parental education. Cognitive impairment predates the onset of psychosis, is observed during symptom remission and in non-affected first-degree relatives of patients. At the present time, cognitive deficits are regarded as key features of schizophrenia, important determinants of poor psychosocial outcome and targets for both pharmacological and non-pharmacological treatment strategies. A group of eight key opinion leaders reviewed and discussed latest advances in scientific research and current good clinical practices on assessment, management, and treatment of CIAS. In the present paper they summarize the current evidence, identify main gaps between current knowledge and mental health services clinical practice, and provide practical recommendations to reduce the gap.
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Affiliation(s)
- Antonio Vita
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
- Department of Mental Health and Addiction Services, Azienda Socio-Sanitaria Territoriale (ASST) Spedali Civili of, Brescia, Italy
| | - Stefano Barlati
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
- Department of Mental Health and Addiction Services, Azienda Socio-Sanitaria Territoriale (ASST) Spedali Civili of, Brescia, Italy
| | - Roberto Cavallaro
- Department of Clinical Neurosciences, Scientific Institute for Research, Hospitalization and Healthcare (IRCCS) San Raffaele Scientific Institute, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Armida Mucci
- Department of Mental and Physical Health and Preventive Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Marco A. Riva
- Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy
- Biological Psychiatry Unit, Scientific Institute for Research, Hospitalization and Healthcare (IRCCS) Istituto Centro San Giovanni di Dio Fatebenefratelli, Brescia, Italy
| | - Paola Rocca
- Department of Neuroscience “Rita Levi Montalcini”, University of Turin, Turin, Italy
| | - Alessandro Rossi
- Department of Biotechnological and Applied Clinical Sciences, Section of Psychiatry, University of L’Aquila, L’Aquila, Italy
| | - Silvana Galderisi
- Department of Mental and Physical Health and Preventive Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
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Dróżdż W, Wiciński M, Szota AM, Szambelan M, Radajewska I, Popławski I, Wojciechowski P. Augmentation Therapies as Treatments for Coexisting Somatic Problems in Schizophrenia-A Systematic Review. J Clin Med 2023; 12:4012. [PMID: 37373704 DOI: 10.3390/jcm12124012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 05/18/2023] [Accepted: 06/09/2023] [Indexed: 06/29/2023] Open
Abstract
The aim of this review is to appraise the data from available randomized clinical trials (RCT) regarding the possible combinations of neuroleptic and non-antipsychotic treatment which could enhance antipsychotic therapy efficacy whilst simultaneously addressing somatic symptoms in individuals with schizophrenia. A systematic search of the PubMed database up to February 2022 was conducted. Inclusion criteria: randomized controlled trials using augmentation therapy in chronic schizophrenia in adults, written in English, and only studies with psychometric assessments of schizophrenia were incorporated. Exclusion criteria: non-clinical, first episode of schizophrenia, patients on medication other than antipsychotics augmented, and not adjunctive therapy. Overall, 37 studies of 1931 patients with schizophrenia who received a combination of antipsychotic medication with other drugs were selected. A statistically significant reduction of negative and positive symptoms of schizophrenia, measured with the PANSS scale, when using a combination of antipsychotic treatment along with aspirin, simvastatin, N-acetylcysteine, or pioglitazone was found. A combination of antipsychotic medication with aspirin, simvastatin, N-acetylcysteine, or pioglitazone seems to be effective in the reduction of symptoms of schizophrenia in adults, but long-term studies are required to confirm this effect.
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Affiliation(s)
- Wiktor Dróżdż
- Department of Psychiatry, Ludwig Rydygier Collegium Medicum in Bydgoszcz of Nicolaus Copernicus University in Toruń, Curie Skłodowskiej Street 9, 85-094 Bydgoszcz, Poland
| | - Michał Wiciński
- Department of Pharmacology and Therapy, Ludwig Rydygier Collegium Medicum in Bydgoszcz of Nicolaus Copernicus University in Toruń, Curie Skłodowskiej Street 9, 85-094 Bydgoszcz, Poland
| | - Anna Maria Szota
- Department of Psychiatry, Ludwig Rydygier Collegium Medicum in Bydgoszcz of Nicolaus Copernicus University in Toruń, Curie Skłodowskiej Street 9, 85-094 Bydgoszcz, Poland
| | - Monika Szambelan
- Department of Pharmacology and Therapy, Ludwig Rydygier Collegium Medicum in Bydgoszcz of Nicolaus Copernicus University in Toruń, Curie Skłodowskiej Street 9, 85-094 Bydgoszcz, Poland
| | - Izabela Radajewska
- Department of Psychiatry, Ludwig Rydygier Collegium Medicum in Bydgoszcz of Nicolaus Copernicus University in Toruń, Curie Skłodowskiej Street 9, 85-094 Bydgoszcz, Poland
| | - Igor Popławski
- Department of Pharmacology and Therapy, Ludwig Rydygier Collegium Medicum in Bydgoszcz of Nicolaus Copernicus University in Toruń, Curie Skłodowskiej Street 9, 85-094 Bydgoszcz, Poland
| | - Paweł Wojciechowski
- Department of Pharmacology and Therapy, Ludwig Rydygier Collegium Medicum in Bydgoszcz of Nicolaus Copernicus University in Toruń, Curie Skłodowskiej Street 9, 85-094 Bydgoszcz, Poland
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Maroney M. Management of cognitive and negative symptoms in schizophrenia. Ment Health Clin 2022; 12:282-299. [DOI: 10.9740/mhc.2022.10.282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 09/08/2022] [Indexed: 11/06/2022] Open
Abstract
Abstract
Currently available antipsychotics provide only modest benefit in managing the cognitive and negative symptoms of schizophrenia even though these symptoms are often the most impairing in patients' daily lives. Certain antipsychotics may have slight benefits over others, and several nonpharmacologic and pharmacologic adjunctive treatments have been evaluated in recent clinical trials. Recently published meta-analyses and clinical studies of such treatments are reviewed. Potential strategies to manage cognitive and negative symptoms, including deprescribing of medications that may exacerbate these symptoms, are described using theoretical case examples.
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Affiliation(s)
- Megan Maroney
- 1 (Corresponding author) Clinical Associate Professor, Ernest Mario School of Pharmacy, Rutgers, the State University of New Jersey; Clinical Psychiatric Pharmacist, Monmouth Medical Center, Long Branch, New Jersey,
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Ainsworth NJ, Avina-Galindo AM, White RF, Zhan D, Gregory EC, Honer WG, Vila-Rodriguez F. Impact of medications, mood state, and electrode placement on ECT outcomes in treatment-refractory psychosis. Brain Stimul 2022; 15:1184-1191. [PMID: 36028155 DOI: 10.1016/j.brs.2022.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 08/13/2022] [Accepted: 08/18/2022] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Treatment-refractory psychosis (TRP) is a significant clinical challenge. While clozapine is frequently effective, alternate or augmentation strategies are often necessary. Evidence supports effectiveness of electroconvulsive therapy (ECT), but questions remain about optimal treatment parameters and impacts of concomitant pharmacotherapy. OBJECTIVE /Hypothesis: To analyze the impact of clozapine, anticonvulsant medication, mood state, and ECT electrode placement on outcomes in TRP. We hypothesized that ECT would lead to greater reduction in positive symptoms, particularly in patients receiving clozapine. METHODS Retrospective study in a tertiary TRP program. The Positive and Negative Syndrome Scale (PANSS) was used for clinical outcomes, with positive subscore as primary outcome. Clinical and ECT data were analyzed using a linear modelling approach, controlling for relevant covariates. RESULTS A total of 309 patients were included. ECT plus clozapine associated with greater improvement in positive, general, and total symptoms than ECT alone. ECT associated with greater improvement in negative symptoms in depressed patients. Bifrontal placement was mostly equivalent to bitemporal, with greater reduction of positive symptoms in patients receiving clozapine, and associated with lower electrical dose in patients on anticonvulsants. Clozapine increased seizure duration, while anticonvulsants decreased it. Anticonvulsant use in ECT patients associated with equivalent to slightly improved symptom reduction. CONCLUSIONS ECT's benefit in TRP may be greatest in patients receiving clozapine. ECT can improve negative symptoms in depressed TRP patients. Bifrontal placement is effective in TRP. Clozapine and anticonvulsants have opposite effects on seizure duration, but anticonvulsants may not adversely affect clinical outcomes of ECT for TRP.
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Affiliation(s)
- Nicholas J Ainsworth
- Non-Invasive Neurostimulation Therapies Laboratory, University of British Columbia, Vancouver, BC, Canada; Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - A Michelle Avina-Galindo
- Non-Invasive Neurostimulation Therapies Laboratory, University of British Columbia, Vancouver, BC, Canada
| | - Randall F White
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada; British Columbia Psychosis Program, Vancouver, BC, Canada
| | - Denghuang Zhan
- Non-Invasive Neurostimulation Therapies Laboratory, University of British Columbia, Vancouver, BC, Canada; Centre for Health Evaluation and Outcomes Sciences, St Paul's Hospital, Vancouver, BC, Canada
| | - Elizabeth C Gregory
- Non-Invasive Neurostimulation Therapies Laboratory, University of British Columbia, Vancouver, BC, Canada; Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - William G Honer
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada; British Columbia Psychosis Program, Vancouver, BC, Canada; British Columbia Mental Health and Substance Use Services Research Institute, Vancouver, BC, Canada
| | - Fidel Vila-Rodriguez
- Non-Invasive Neurostimulation Therapies Laboratory, University of British Columbia, Vancouver, BC, Canada; Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada.
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Peng Y, Xu D, Ding Y, Zhou X. Supplementation of PQQ from pregnancy prevents MK-801-induced schizophrenia-like behaviors in mice. Psychopharmacology (Berl) 2022; 239:2263-2275. [PMID: 35294602 DOI: 10.1007/s00213-022-06113-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 03/01/2022] [Indexed: 10/18/2022]
Abstract
RATIONALE At present, the research on the prevention of schizophrenia is still in its infancy. Pyrroloquinoline quinone (PQQ) has potential to treat psychological and neurological diseases including schizophrenia. However, the preventive effect of PQQ on schizophrenia remains unclear. OBJECTIVES In this study, we aimed to examine the preventive effect of supplementation of dietary PQQ from pregnancy or after birth on dizocilpine (MK-801)-induced schizophrenia-like behaviors in mice. RESULTS Supplementation of dietary PQQ from pregnancy could effectively prevent MK-801-induced weight gain decrease, hyperlocomotion, stereotypical behavior, ataxia, exploratory activity decrease, social interaction disorder, memory deficit, and depression in mice. Supplementation of dietary PQQ after birth could effectively prevent MK-801-induced weight gain decrease, stereotypical behavior, ataxia, and memory deficit in mice. Female mice responded to a greater degree than males in preventing MK-801-induced weight gain decrease in both forms of PQQ supplementation. For mice that began PQQ supplementation after birth, females performed better than males in preventing MK-801-induced ataxia, memory deficit, and depression. For mice that began PQQ supplementation from pregnancy, males performed better than females in preventing MK-801-induced memory deficit. In vitro experiments indicated that PQQ supplementation in the earlier stage of life contributed to the growth of neurons and the development of neurites. CONCLUSIONS Our current study suggested that PQQ supplementation from pregnancy or postpartum could prevent some schizophrenia-like behaviors induced by MK-801 in mice. Our work supported the potential usage of dietary supplement of PQQ in preventing or alleviating symptoms associated with schizophrenia.
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Affiliation(s)
- Ying Peng
- NHC Key Laboratory of Nuclear Medicine, Jiangsu Key Laboratory of Molecular Nuclear Medicine, Jiangsu Institute of Nuclear Medicine, QianRong Road No. 20, Wuxi, 214063, Jiangsu, China.
- Department of Radiopharmaceuticals, School of Pharmacy, Nanjing Medical University, Nanjing, 211166, Jiangsu, China.
| | - Dong Xu
- NHC Key Laboratory of Nuclear Medicine, Jiangsu Key Laboratory of Molecular Nuclear Medicine, Jiangsu Institute of Nuclear Medicine, QianRong Road No. 20, Wuxi, 214063, Jiangsu, China
| | - Yuedi Ding
- NHC Key Laboratory of Nuclear Medicine, Jiangsu Key Laboratory of Molecular Nuclear Medicine, Jiangsu Institute of Nuclear Medicine, QianRong Road No. 20, Wuxi, 214063, Jiangsu, China
| | - Xingqin Zhou
- NHC Key Laboratory of Nuclear Medicine, Jiangsu Key Laboratory of Molecular Nuclear Medicine, Jiangsu Institute of Nuclear Medicine, QianRong Road No. 20, Wuxi, 214063, Jiangsu, China.
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Vita A, Gaebel W, Mucci A, Sachs G, Barlati S, Giordano GM, Nibbio G, Nordentoft M, Wykes T, Galderisi S. European Psychiatric Association guidance on treatment of cognitive impairment in schizophrenia. Eur Psychiatry 2022; 65:e57. [PMID: 36059103 PMCID: PMC9532218 DOI: 10.1192/j.eurpsy.2022.2315] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background Although cognitive impairment is a core symptom of schizophrenia related to poorer outcomes in different functional domains, it still remains a major therapeutic challenge. To date, no comprehensive treatment guidelines for cognitive impairment in schizophrenia are implemented. Methods The aim of the present guidance paper is to provide a comprehensive meta-review of the current available evidence-based treatments for cognitive impairment in schizophrenia. The guidance is structured into three sections: pharmacological treatment, psychosocial interventions, and somatic treatments. Results Based on the reviewed evidence, this European Psychiatric Association guidance recommends an appropriate pharmacological management as a fundamental starting point in the treatment of cognitive impairment in schizophrenia. In particular, second-generation antipsychotics are recommended for their favorable cognitive profile compared to first-generation antipsychotics, although no clear superiority of a single second-generation antipsychotic has currently been found. Anticholinergic and benzodiazepine burdens should be kept to a minimum, considering the negative impact on cognitive functioning. Among psychosocial interventions, cognitive remediation and physical exercise are recommended for the treatment of cognitive impairment in schizophrenia. Noninvasive brain stimulation techniques could be taken into account as add-on therapy. Conclusions Overall, there is definitive progress in the field, but further research is needed to develop specific treatments for cognitive impairment in schizophrenia. The dissemination of this guidance paper may promote the development of shared guidelines concerning the treatment of cognitive functions in schizophrenia, with the purpose to improve the quality of care and to achieve recovery in this population.
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Veselinović T, Neuner I. Progress and Pitfalls in Developing Agents to Treat Neurocognitive Deficits Associated with Schizophrenia. CNS Drugs 2022; 36:819-858. [PMID: 35831706 PMCID: PMC9345797 DOI: 10.1007/s40263-022-00935-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/06/2022] [Indexed: 12/11/2022]
Abstract
Cognitive impairments associated with schizophrenia (CIAS) represent a central element of the symptomatology of this severe mental disorder. CIAS substantially determine the disease prognosis and hardly, if at all, respond to treatment with currently available antipsychotics. Remarkably, all drugs presently approved for the treatment of schizophrenia are, to varying degrees, dopamine D2/D3 receptor blockers. In turn, rapidly growing evidence suggests the immense significance of systems other than the dopaminergic system in the genesis of CIAS. Accordingly, current efforts addressing the unmet needs of patients with schizophrenia are primarily based on interventions in other non-dopaminergic systems. In this review article, we provide a brief overview of the available evidence on the importance of specific systems in the development of CIAS. In addition, we describe the promising targets for the development of new drugs that have been used so far. In doing so, we present the most important candidates that have been investigated in the field of the specific systems in recent years and present a summary of the results available at the time of drafting this review (May 2022), as well as the currently ongoing studies.
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Affiliation(s)
- Tanja Veselinović
- Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany.
- Institute of Neuroscience and Medicine 4, INM-4, Forschungszentrum Jülich, Jülich, Germany.
| | - Irene Neuner
- Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany
- Institute of Neuroscience and Medicine 4, INM-4, Forschungszentrum Jülich, Jülich, Germany
- JARA-BRAIN, Aachen, Germany
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Han D, Sun D, Xiu M, Su X, Wang J, Li J, Wang D. Association between the improvement in depressive symptoms and serum BDNF levels in drug-naive first episode patients with schizophrenia: A longitudinal follow-up. Psychoneuroendocrinology 2021; 133:105392. [PMID: 34428640 DOI: 10.1016/j.psyneuen.2021.105392] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 07/13/2021] [Accepted: 08/15/2021] [Indexed: 11/28/2022]
Abstract
Depressive symptoms are frequent clinical manifestations in patients with schizophrenia. Decreased brain-derived neurotrophic factor (BDNF) has been shown to be involved in the development of depressive symptoms. However, the detailed molecular mechanism of BDNF in the depressive symptoms of schizophrenia patients remains to be fully elucidated. This study aimed to investigate the role of BDNF in the depressive symptoms in drug-naïve first-episode (DNFE) patients with schizophrenia and whether BDNF levels were associated with the improvement of depressive symptoms after olanzapine treatment. 50 DNFE schizophrenia patients and 55 healthy controls were recruited, and their serum BDNF levels were compared. All patients were treated with olanzapine monotherapy for 12 weeks, and 45 patients completed the trial. The serum BDNF levels and depressive symptoms were measured again at follow-up. We found that DNFE patients had lower BDNF levels, compared to controls. Last observation carried forward (LOCF) analysis was used for patients who dropped out after the second month, and 50 patients were included in the statistical analysis with LOCF. After 12 weeks of treatment with olanzapine, BDNF levels were significantly increased and depressive symptoms were significantly decreased. Correlation analysis showed that the change of BDNF levels after treatment was correlated with the change of HAMD total score from baseline. Further regression analysis showed that the change in BDNF levels was an independent predictor for the improvement in depressive symptoms, after controlling age, BMI change and the decrease of PANSS total score. However, the baseline BDNF levels were not associated with an improvement in depressive symptoms in patients. Our findings reveal that olanzapine treatment can increase BDNF levels and improve depressive symptoms in schizophrenia patients. Moreover, the changes in serum BDNF levels were related to the improvement in depressive symptoms.
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Affiliation(s)
- Dongmei Han
- Hebei Province Veterans Hospital, Baoding, China
| | - Daliang Sun
- Department of Psychiatry, Tianjin Anding Hospital, Tianjin Mental Health Center, Tianjin, China
| | - Meihong Xiu
- Peking University HuiLongGuan Clinical Medical School, Beijing HuiLongGuan Hospital, Beijing, China
| | - Xiu Su
- Peking University HuiLongGuan Clinical Medical School, Beijing HuiLongGuan Hospital, Beijing, China
| | - Jun Wang
- Peking University HuiLongGuan Clinical Medical School, Beijing HuiLongGuan Hospital, Beijing, China
| | - Jun Li
- Shanghai Xuhui District Mental Health Center, Shanghai, China.
| | - Dong Wang
- Department of Clinical Psychology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China.
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Bai MY, Lovejoy DB, Guillemin GJ, Kozak R, Stone TW, Koola MM. Galantamine-Memantine Combination and Kynurenine Pathway Enzyme Inhibitors in the Treatment of Neuropsychiatric Disorders. Complex Psychiatry 2021; 7:19-33. [PMID: 35141700 PMCID: PMC8443947 DOI: 10.1159/000515066] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 02/04/2021] [Indexed: 12/25/2022] Open
Abstract
The kynurenine pathway (KP) is a major route for L-tryptophan (L-TRP) metabolism, yielding a variety of bioactive compounds including kynurenic acid (KYNA), 3-hydroxykynurenine (3-HK), quinolinic acid (QUIN), and picolinic acid (PIC). These tryptophan catabolites are involved in the pathogenesis of many neuropsychiatric disorders, particularly when the KP becomes dysregulated. Accordingly, the enzymes that regulate the KP such as indoleamine 2,3-dioxygenase (IDO)/tryptophan 2,3-dioxygenase, kynurenine aminotransferases (KATs), and kynurenine 3-monooxygenase (KMO) represent potential drug targets as enzymatic inhibition can favorably rebalance KP metabolite concentrations. In addition, the galantamine-memantine combination, through its modulatory effects at the alpha7 nicotinic acetylcholine receptors and N-methyl-D-aspartate receptors, may counteract the effects of KYNA. The aim of this review is to highlight the effectiveness of IDO-1, KAT II, and KMO inhibitors, as well as the galantamine-memantine combination in the modulation of different KP metabolites. KAT II inhibitors are capable of decreasing the KYNA levels in the rat brain by a maximum of 80%. KMO inhibitors effectively reduce the central nervous system (CNS) levels of 3-HK, while markedly boosting the brain concentration of KYNA. Emerging data suggest that the galantamine-memantine combination also lowers L-TRP, kynurenine, KYNA, and PIC levels in humans. Presently, there are only 2 pathophysiological mechanisms (cholinergic and glutamatergic) that are FDA approved for the treatment of cognitive dysfunction for which purpose the galantamine-memantine combination has been designed for clinical use against Alzheimer's disease. The alpha7 nicotinic-NMDA hypothesis targeted by the galantamine-memantine combination has been implicated in the pathophysiology of various CNS diseases. Similarly, KYNA is well capable of modulating the neuropathophysiology of these disorders. This is known as the KYNA-centric hypothesis, which may be implicated in the management of certain neuropsychiatric conditions. In line with this hypothesis, KYNA may be considered as the "conductor of the orchestra" for the major pathophysiological mechanisms underlying CNS disorders. Therefore, there is great opportunity to further explore and compare the biological effects of these therapeutic modalities in animal models with a special focus on their effects on KP metabolites in the CNS and with the ultimate goal of progressing to clinical trials for many neuropsychiatric diseases.
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Affiliation(s)
- Michael Y. Bai
- Department of Biomedical Sciences, Neuroinflammation Group, Macquarie University Centre for Motor Neuron Disease Research, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - David B. Lovejoy
- Department of Biomedical Sciences, Neuroinflammation Group, Macquarie University Centre for Motor Neuron Disease Research, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Gilles J. Guillemin
- Department of Biomedical Sciences, Neuroinflammation Group, Macquarie University Centre for Motor Neuron Disease Research, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Rouba Kozak
- Neuroscience Drug Discovery Unit, Takeda Pharmaceuticals International Co, Cambridge, Massachusetts, USA
| | - Trevor W. Stone
- Nuffield Department of Orthopedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, United Kingdom
| | - Maju Mathew Koola
- Department of Psychiatry and Behavioral Health, Stony Brook University Renaissance School of Medicine, Stony Brook, Stony Brook, New York, USA
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Galderisi S, Kaiser S, Bitter I, Nordentoft M, Mucci A, Sabé M, Giordano GM, Nielsen MØ, Glenthøj LB, Pezzella P, Falkai P, Dollfus S, Gaebel W. EPA guidance on treatment of negative symptoms in schizophrenia. Eur Psychiatry 2021; 64:e21. [PMID: 33726883 PMCID: PMC8057437 DOI: 10.1192/j.eurpsy.2021.13] [Citation(s) in RCA: 73] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Negative symptoms of schizophrenia remain a major therapeutic challenge. The progress in the conceptualization and assessment is not yet fully reflected by treatment research. Nevertheless, there is a growing evidence base regarding the effects of biological and psychosocial interventions on negative symptoms. The importance of the distinction between primary and secondary negative symptoms for treatment selection might seem evident, but the currently available evidence remains limited. Good clinical practice is recommended for the treatment of secondary negative symptoms. Antipsychotic treatment should be optimized to avoid secondary negative symptoms due to side effects and due to positive symptoms. For most available interventions, further evidence is needed to formulate sound recommendations for primary, persistent, or predominant negative symptoms. However, based on currently available evidence recommendations for the treatment of undifferentiated negative symptoms (including both primary and secondary negative symptoms) are provided. Although it has proven difficult to formulate an evidence-based recommendation for the choice of an antipsychotic, a switch to a second-generation antipsychotic should be considered for patients who are treated with a first-generation antipsychotic. Antidepressant add-on to antipsychotic treatment is an option. Social skills training is recommended as well as cognitive remediation for patients who also show cognitive impairment. Exercise interventions also have shown promise. Finally, access to treatment and to psychosocial rehabilitation should be ensured for patients with negative symptoms. Overall, there is definitive progress in the field, but further research is clearly needed to develop specific treatments for negative symptoms.
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Affiliation(s)
- S Galderisi
- Department of Psychiatry, University of Campania Luigi Vanvitelli, Naples, Italy
| | - S Kaiser
- Division of Adult Psychiatry, Department of Psychiatry, Geneva University Hospitals, Geneva, Switzerland
| | - I Bitter
- Department of Psychiatry and Psychotherapy, Semmelweis University, Budapest, Hungary
| | - M Nordentoft
- Copenhagen Research Centre for Mental Health (CORE), Copenhagen University Hospital, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Science, University of Copenhagen, Copenhagen, Denmark.,Centre for Clinical Intervention and Neuropsychiatric Schizophrenia Research, CINS, Glostrup, Denmark
| | - A Mucci
- Department of Psychiatry, University of Campania Luigi Vanvitelli, Naples, Italy
| | - M Sabé
- Division of Adult Psychiatry, Department of Psychiatry, Geneva University Hospitals, Geneva, Switzerland
| | - G M Giordano
- Department of Psychiatry, University of Campania Luigi Vanvitelli, Naples, Italy
| | - M Ø Nielsen
- Department of Clinical Medicine, Faculty of Health and Medical Science, University of Copenhagen, Copenhagen, Denmark.,Centre for Clinical Intervention and Neuropsychiatric Schizophrenia Research, CINS, Glostrup, Denmark.,Center for Neuropsychiatric Schizophrenia Research, CNSR, Glostrup, Denmark
| | - L B Glenthøj
- Copenhagen Research Centre for Mental Health (CORE), Copenhagen University Hospital, Copenhagen, Denmark.,Centre for Clinical Intervention and Neuropsychiatric Schizophrenia Research, CINS, Glostrup, Denmark
| | - P Pezzella
- Department of Psychiatry, University of Campania Luigi Vanvitelli, Naples, Italy
| | - P Falkai
- Department of Psychiatry, University of Munich, Munich, Germany
| | - S Dollfus
- Service de Psychiatrie, CHU de Caen, 14000Caen, France.,Normandie Univ, UNICAEN, ISTS EA 7466, GIP Cyceron, 14000Caen, France.,Normandie Univ, UNICAEN, UFR de Médecine, 14000Caen, France
| | - W Gaebel
- Department of Psychiatry and Psychotherapy, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany
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13
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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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14
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Memantine in neurological disorders - schizophrenia and depression. J Mol Med (Berl) 2021; 99:327-334. [PMID: 33447926 PMCID: PMC7900025 DOI: 10.1007/s00109-020-01982-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 06/22/2020] [Accepted: 09/18/2020] [Indexed: 12/13/2022]
Abstract
Memantine is used in Alzheimer's disease treatment as a non-competitive modern-affinity strong voltage-dependent N-methyl-D-aspartate receptor antagonist. The fundamental role of these receptors is to bind glutamate: the main excitatory neurotransmitter in the brain, believed to play a crucial role in neuronal plasticity and learning mechanisms. Glutamate transmission plays an important role in all internal CNS structures and maintains the physiological state of the brain. Excessive glutamate transmission can lead to enlarged calcium ion current which may cause neurotoxicity; however, insufficient transmission can drastically alter the information flow in neurons and the brain, potentially causing schizophrenia-like symptoms by replacing lost information with completely new stimuli. Hence, it is possible that the modulation of NMDA activity may give rise to pathophysiological states. Available literature and clinical trials indicate that memantine is well tolerated by patients, with very few and light side effects. There is a belief that memantine may also benefit other conditions such as schizophrenia and depression.
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15
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Swerdlow NR, Bhakta SG, Talledo J, Kotz J, Roberts BZ, Clifford RE, Thomas ML, Joshi YB, Molina JL, Light GA. Memantine effects on auditory discrimination and training in schizophrenia patients. Neuropsychopharmacology 2020; 45:2180-2188. [PMID: 32961542 PMCID: PMC7784956 DOI: 10.1038/s41386-020-00865-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 09/08/2020] [Accepted: 09/11/2020] [Indexed: 12/16/2022]
Abstract
The uncompetitive low-affinity NMDA receptor antagonist, memantine, acutely increases electrophysiological measures of auditory information processing in both healthy subjects (HS) and patients with schizophrenia. Memantine effects on functional measures of auditory discrimination performance and learning are not known; conceivably, beneficial effects on these measures might suggest a role for memantine in augmenting the cognitive and functional impact of auditory targeted cognitive training (TCT). Here, carefully characterized HS (n = 20) and schizophrenia patients (n = 22) were tested in measures of auditory discrimination performance (words-in-noise (WIN), quick speech-in-noise (QuickSIN), gaps-in-noise) and auditory frequency modulation learning (a component of TCT) on 2 days about a week apart, after ingesting either placebo or 20 mg memantine po, in a double-blind, within-subject cross-over random order design. Memantine modestly enhanced functional measures of auditory discrimination in both schizophrenia patients (WIN) and HS (WIN and QuickSIN), as well as auditory frequency modulation learning in schizophrenia patients. These findings converge with a growing literature showing that memantine can enhance a range of metrics of auditory function. These properties could contribute to the apparent benefits of memantine as an adjunctive treatment in schizophrenia, and suggest that memantine might augment learning and potentially clinical gains from auditory-based TCT.
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Affiliation(s)
- Neal R. Swerdlow
- grid.266100.30000 0001 2107 4242Department of Psychiatry, School of Medicine, University of California, San Diego, La Jolla, CA USA
| | - Savita G. Bhakta
- grid.266100.30000 0001 2107 4242Department of Psychiatry, School of Medicine, University of California, San Diego, La Jolla, CA USA
| | - Jo Talledo
- grid.266100.30000 0001 2107 4242Department of Psychiatry, School of Medicine, University of California, San Diego, La Jolla, CA USA
| | - Juliana Kotz
- grid.266100.30000 0001 2107 4242Department of Psychiatry, School of Medicine, University of California, San Diego, La Jolla, CA USA
| | - Benjamin Z. Roberts
- grid.266100.30000 0001 2107 4242Department of Psychiatry, School of Medicine, University of California, San Diego, La Jolla, CA USA
| | - Royce Ellen Clifford
- grid.266100.30000 0001 2107 4242Department of Psychiatry, School of Medicine, University of California, San Diego, La Jolla, CA USA
| | - Michael L. Thomas
- grid.47894.360000 0004 1936 8083Department of Psychology, Colorado State University, Fort Collins, CO USA
| | - Yash B. Joshi
- grid.266100.30000 0001 2107 4242Department of Psychiatry, School of Medicine, University of California, San Diego, La Jolla, CA USA ,grid.410371.00000 0004 0419 2708VISN-22 Mental Illness, Research, Education and Clinical Center (MIRECC), VA San Diego Healthcare System, San Diego, CA USA
| | - Juan L. Molina
- grid.266100.30000 0001 2107 4242Department of Psychiatry, School of Medicine, University of California, San Diego, La Jolla, CA USA
| | - Gregory A. Light
- grid.266100.30000 0001 2107 4242Department of Psychiatry, School of Medicine, University of California, San Diego, La Jolla, CA USA ,grid.410371.00000 0004 0419 2708VISN-22 Mental Illness, Research, Education and Clinical Center (MIRECC), VA San Diego Healthcare System, San Diego, CA USA
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16
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Wu ZW, Shi H, Chen DC, Chen S, Xiu MH, Zhang XY. BDNF serum levels and cognitive improvement in drug-naive first episode patients with schizophrenia: A prospective 12-week longitudinal study. Psychoneuroendocrinology 2020; 122:104879. [PMID: 33049658 DOI: 10.1016/j.psyneuen.2020.104879] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 09/13/2020] [Accepted: 09/14/2020] [Indexed: 12/11/2022]
Abstract
Abnormal brain-derived neurotrophic factor (BDNF) levels are involved in cognitive decline in patients with schizophrenia. The role of atypical antipsychotic risperidone in improving cognitive function remains unclear. The study aimed to investigate the effect of risperidone monotherapy on cognitive impairment in drug-naïve first-episode (DNFE) patients with schizophrenia and whether BDNF levels were correlated to the improvement of cognition. 354 DNFE patients and 152 healthy controls were recruited, and we compared their serum BDNF levels and cognition shown on the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). High and low BDNF subgroups were defined by median split. Then, 211 patients were treated with risperidone monotherapy for 12 weeks, and their serum BDNF levels and cognition were measured again after treatment. DNFE patients had poorer cognitive functions and lower BDNF levels compared to controls. Lower BDNF levels were correlated with delayed memory in DNFE patients with high baseline BDNF levels. After 12 weeks of treatment, risperidone significantly improved immediate memory, delayed memory and RBANS total scores and BDNF levels were slightly increased. In patients with low-BDNF, BDNF levels were significantly increased after risperidone treatment, while in patients with high-BDNF, BDNF levels were significantly decreased. In addition, baseline BDNF levels were associated with improvement of delayed memory and were a prognostic factor for the improvement of the delayed memory and RBANS total score in patients with high-BDNF. Our result suggests risperidone treatment can partially improve certain domains of the cognitive impairment and baseline BDNF levels are related to cognitive response to risperidone in DNFE patients with schizophrenia.
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Affiliation(s)
- Zhi Wei Wu
- Department of Psychiatry, Shenzhen Kangning Hospital, Shenzhen, Guangdong, China; Shenzhen Mental Health Center, Shenzhen, Guangdong, China
| | - Hui Shi
- Department of clinial psychology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Da Chun Chen
- Beijing HuiLongGuan Hospital, Peking University HuiLongGuan Clinical Medical School, Beijing, China
| | - Song Chen
- Beijing HuiLongGuan Hospital, Peking University HuiLongGuan Clinical Medical School, Beijing, China
| | - Mei Hong Xiu
- Beijing HuiLongGuan Hospital, Peking University HuiLongGuan Clinical Medical School, Beijing, China.
| | - Xiang Yang Zhang
- CAS Key Laboratory of Mental Health, Institute of Psychology, Chinese Academy of Sciences, Beijing, China.
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17
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Kikuchi T. Is Memantine Effective as an NMDA-Receptor Antagonist in Adjunctive Therapy for Schizophrenia? Biomolecules 2020; 10:biom10081134. [PMID: 32751985 PMCID: PMC7466074 DOI: 10.3390/biom10081134] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 07/28/2020] [Accepted: 07/28/2020] [Indexed: 01/07/2023] Open
Abstract
Memantine, an n-methyl-d-aspartate (NMDA) receptor antagonist approved for treating Alzheimer's disease, has a good safety profile and is increasingly being studied for possible use in a variety of non-dementia psychiatric disorders. There is an abundance of basic and clinical data that support the hypothesis that NMDA receptor hypofunction contributes to the pathophysiology of schizophrenia. However, there are numerous randomized, double-blind, placebo-controlled clinical trials showing that add-on treatment with memantine improves negative and cognitive symptoms, particularly the negative symptoms of schizophrenia, indicating that memantine as adjunctive therapy in schizophrenia helps to ameliorate negative symptoms and cognitive deficits. It remains unclear why memantine does not show undesirable central nervous system (CNS) side effects in humans unlike other NMDA receptor antagonists, such as phencyclidine and ketamine. However, the answer could lie in the fact that it would appear that memantine works as a low-affinity, fast off-rate, voltage-dependent, and uncompetitive antagonist with preferential inhibition of extrasynaptic receptors. It is reasonable to assume that the effects of memantine as adjunctive therapy on negative symptoms and cognitive deficits in schizophrenia may derive primarily, if not totally, from its NMDA receptor antagonist activity at NMDA receptors including extrasynaptic receptors in the CNS.
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Affiliation(s)
- Tetsuro Kikuchi
- New Drug Research Division, Pharmaceutical Business Division, Otsuka Pharmaceutical Co., Ltd., 463-10 Kagasuno, Kawauchi-cho, Tokushima 771-0192, Japan
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18
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Barnes TR, Drake R, Paton C, Cooper SJ, Deakin B, Ferrier IN, Gregory CJ, Haddad PM, Howes OD, Jones I, Joyce EM, Lewis S, Lingford-Hughes A, MacCabe JH, Owens DC, Patel MX, Sinclair JM, Stone JM, Talbot PS, Upthegrove R, Wieck A, Yung AR. Evidence-based guidelines for the pharmacological treatment of schizophrenia: Updated recommendations from the British Association for Psychopharmacology. J Psychopharmacol 2020; 34:3-78. [PMID: 31829775 DOI: 10.1177/0269881119889296] [Citation(s) in RCA: 142] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
These updated guidelines from the British Association for Psychopharmacology replace the original version published in 2011. They address the scope and targets of pharmacological treatment for schizophrenia. A consensus meeting was held in 2017, involving experts in schizophrenia and its treatment. They were asked to review key areas and consider the strength of the evidence on the risk-benefit balance of pharmacological interventions and the clinical implications, with an emphasis on meta-analyses, systematic reviews and randomised controlled trials where available, plus updates on current clinical practice. The guidelines cover the pharmacological management and treatment of schizophrenia across the various stages of the illness, including first-episode, relapse prevention, and illness that has proved refractory to standard treatment. It is hoped that the practice recommendations presented will support clinical decision making for practitioners, serve as a source of information for patients and carers, and inform quality improvement.
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Affiliation(s)
- Thomas Re Barnes
- Emeritus Professor of Clinical Psychiatry, Division of Psychiatry, Imperial College London, and Joint-head of the Prescribing Observatory for Mental Health, Centre for Quality Improvement, Royal College of Psychiatrists, London, UK
| | - Richard Drake
- Clinical Lead for Mental Health in Working Age Adults, Health Innovation Manchester, University of Manchester and Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Carol Paton
- Joint-head of the Prescribing Observatory for Mental Health, Centre for Quality Improvement, Royal College of Psychiatrists, London, UK
| | - Stephen J Cooper
- Emeritus Professor of Psychiatry, School of Medicine, Queen's University Belfast, Belfast, UK
| | - Bill Deakin
- Professor of Psychiatry, Neuroscience & Psychiatry Unit, University of Manchester and Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - I Nicol Ferrier
- Emeritus Professor of Psychiatry, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Catherine J Gregory
- Honorary Clinical Research Fellow, University of Manchester and Higher Trainee in Child and Adolescent Psychiatry, Manchester University NHS Foundation Trust, Manchester, UK
| | - Peter M Haddad
- Honorary Professor of Psychiatry, Division of Psychology and Mental Health, University of Manchester, UK and Senior Consultant Psychiatrist, Department of Psychiatry, Hamad Medical Corporation, Doha, Qatar
| | - Oliver D Howes
- Professor of Molecular Psychiatry, Imperial College London and Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Ian Jones
- Professor of Psychiatry and Director, National Centre of Mental Health, Cardiff University, Cardiff, UK
| | - Eileen M Joyce
- Professor of Neuropsychiatry, UCL Queen Square Institute of Neurology, London, UK
| | - Shôn Lewis
- Professor of Adult Psychiatry, Faculty of Biology, Medicine and Health, The University of Manchester, UK, and Mental Health Academic Lead, Health Innovation Manchester, Manchester, UK
| | - Anne Lingford-Hughes
- Professor of Addiction Biology and Honorary Consultant Psychiatrist, Imperial College London and Central North West London NHS Foundation Trust, London, UK
| | - James H MacCabe
- Professor of Epidemiology and Therapeutics, Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, and Honorary Consultant Psychiatrist, National Psychosis Service, South London and Maudsley NHS Foundation Trust, Beckenham, UK
| | - David Cunningham Owens
- Professor of Clinical Psychiatry, University of Edinburgh. Honorary Consultant Psychiatrist, Royal Edinburgh Hospital, Edinburgh, UK
| | - Maxine X Patel
- Honorary Clinical Senior Lecturer, King's College London, Institute of Psychiatry, Psychology and Neuroscience and Consultant Psychiatrist, Oxleas NHS Foundation Trust, London, UK
| | - Julia Ma Sinclair
- Professor of Addiction Psychiatry, Faculty of Medicine, University of Southampton, Southampton, UK
| | - James M Stone
- Clinical Senior Lecturer and Honorary Consultant Psychiatrist, King's College London, Institute of Psychiatry, Psychology and Neuroscience and South London and Maudsley NHS Trust, London, UK
| | - Peter S Talbot
- Senior Lecturer and Honorary Consultant Psychiatrist, University of Manchester and Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Rachel Upthegrove
- Professor of Psychiatry and Youth Mental Health, University of Birmingham and Consultant Psychiatrist, Birmingham Early Intervention Service, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Angelika Wieck
- Honorary Consultant in Perinatal Psychiatry, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Alison R Yung
- Professor of Psychiatry, University of Manchester, School of Health Sciences, Manchester, UK and Centre for Youth Mental Health, University of Melbourne, Australia, and Honorary Consultant Psychiatrist, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
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19
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Zheng W, Zhu XM, Zhang QE, Cai DB, Yang XH, Zhou YL, Ungvari GS, Ng CH, He SH, Peng XJ, Ning YP, Xiang YT. Adjunctive memantine for major mental disorders: A systematic review and meta-analysis of randomized double-blind controlled trials. Schizophr Res 2019; 209:12-21. [PMID: 31164254 DOI: 10.1016/j.schres.2019.05.019] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Revised: 05/05/2019] [Accepted: 05/06/2019] [Indexed: 02/08/2023]
Abstract
OBJECTIVE As a non-competitive N-methyl-d-aspartate receptor antagonist, memantine has been used to treat major mental disorders including schizophrenia, bipolar disorder, and major depressive disorder (MDD). This meta-analysis systematically investigated the effectiveness and tolerability of adjunctive memantine for patients with schizophrenia, bipolar disorder, and MDD. METHODS Only randomized controlled trials (RCTs) were identified and included in the study. Data of the three disorders were separately synthesized using the RevMan 5.3 software. RESULTS Fifteen RCTs (n = 988) examining memantine (5-20 mg/day) as an adjunct treatment for schizophrenia (9 trials with 512 patients), bipolar disorder (3 trials with 319 patients), and MDD (3 trials with 157 patients) were analyzed. Memantine outperformed the comparator regarding total psychopathology with a standardized mean difference (SMD) of -0.56 [95% confidence interval (CI): -1.01, -0.11; I2 = 76%, P = 0.01] and negative symptoms with an SMD of -0.71 (95% CI: -1.09, -0.33; I2 = 74%, P = 0.0003) in schizophrenia, but no significant effects were found with regard to positive symptoms and general psychopathology in schizophrenia, or depressive and manic symptoms in bipolar disorder or depressive symptoms in MDD. Memantine outperformed the comparator in improving cognitive performance in schizophrenia with an SMD of 1.07 (95% CI: 0.53, 1.61; P < 0.0001, I2 = 29%). No group differences were found in the rates of adverse drug reactions and discontinuation due to any reason in the three major mental disorders. CONCLUSIONS Memantine as an adjunct treatment appears to have significant efficacy in improving negative symptoms in schizophrenia. The efficacy and safety of adjunctive memantine for bipolar disorder or MDD needs to be further examined. REVIEW REGISTRATION PROSPERO: 42018099045.
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Affiliation(s)
- Wei Zheng
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Xiao-Min Zhu
- Suzhou Guangji Hospital, Affiliated Guangji Hospital of Soochow University, Suzhou, China
| | - Qing-E Zhang
- The National Clinical Research Center for Mental Disorders & Beijing Key Laboratory of Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China
| | - Dong-Bin Cai
- Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China
| | - Xin-Hu Yang
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Yan-Ling Zhou
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Gabor S Ungvari
- The University of Notre Dame Australia, Fremantle, Australia; Division of Psychiatry, School of Medicine, University of Western Australia, Perth, Australia
| | - Chee H Ng
- Department of Psychiatry, University of Melbourne, Melbourne, Victoria, Australia
| | | | | | - Yu-Ping Ning
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China.
| | - Yu-Tao Xiang
- Unit of Psychiatry, Institute of Translational Medicine, Faculty of Health Sciences, University of Macau, Macao SAR, China.
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20
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Kishi T, Matsuda Y, Iwata N. Combination Therapy of Serotonin Reuptake Inhibitors and Memantine for Obsessive- Compulsive Disorder: A Meta-Analysis of Double-Blind, Randomized, Placebo-Controlled Trials. J Alzheimers Dis 2019; 64:43-48. [PMID: 29865079 DOI: 10.3233/jad-180237] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
We performed a meta-analysis to determine whether combination therapy with serotonin reuptake inhibitors (SRIs) and memantine (MEM) was beneficial for the treatment of obsessive- compulsive disorder. This study included three double-blind, randomized, placebo-controlled trials. MEM+SRI was superior to placebo+SRI with regard to response rate [primary outcome, n = 97; risk ratio = 0.22; 95% confidence intervals (CI) = 0.12-0.42; p < 0.00001; I2 = 0%; number needed to treat = 2], the Yale- Brown Obsessive- Compulsive Scale total [standardized mean difference (SMD) = - 4.56; 95% CI = - 8.50, - 0.62; p = 0.02], obsession subscale (SMD = - 4.39; 95% CI = - 5.94, - 2.85; p < 0.00001), and compulsion subscale score (SMD = - 4.60; 95% CI = - 7.64, - 1.55; p = 0.003). No significant differences in any safety outcome were found between the groups.
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Affiliation(s)
- Taro Kishi
- Department of Psychiatry, Fujita Health University School of Medicine, Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, Japan
| | - Yuki Matsuda
- Department of Psychiatry, Fujita Health University School of Medicine, Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, Japan.,Department of Psychiatry, Jikei University School of Medicine, Minato-ku, Tokyo, Japan
| | - Nakao Iwata
- Department of Psychiatry, Fujita Health University School of Medicine, Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, Japan
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21
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Yoshimura B, Sakamoto S, Sato K, Takaki M, Yamada N. Predictors of remission during acute treatment of first-episode schizophrenia patients involuntarily hospitalized and treated with algorithm-based pharmacotherapy: Secondary analysis of an observational study. Early Interv Psychiatry 2019; 13:589-597. [PMID: 29498481 DOI: 10.1111/eip.12531] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 10/13/2017] [Accepted: 11/08/2017] [Indexed: 12/24/2022]
Abstract
AIM Early clinical response predicts symptomatic remission and recovery in the maintenance treatment phase of first-episode schizophrenia (FES). However, little is known about predictors of symptomatic remission during acute treatment of severely ill patients with FES. Here, we conducted a secondary analysis of our retrospective observational study, which examined response, remission and treatment-resistance rates in seriously ill patients with FES spectrum disorders involuntarily hospitalized and treated with algorithm-based pharmacotherapy. METHODS We performed a retrospective chart review of 131 involuntarily admitted patients with schizophrenia or schizoaffective disorder. Our algorithm aimed to delay olanzapine treatment, standardize medications and suggest initiation of clozapine after failure of third-line antipsychotic treatment. The duration of each adequate antipsychotic treatment at an optimal dosage was 4 weeks or more. Remission was defined using the symptom-severity component of consensus remission criteria. A logistic regression model was applied to identify significant predictors of remission at discharge. RESULTS Overall, 74 patients (56%) were in remission at discharge. Non-remitters were hampered from becoming remitters mainly by the presence of negative symptoms. There were no differences in first-line antipsychotics, dosage of antipsychotics at time of response and adherence rates to algorithm-based pharmacotherapy between remitters and non-remitters. Shorter duration of untreated psychosis, favourable early response and less negative symptoms at baseline were identified as independent predictors of remission at discharge. CONCLUSIONS The importance of early intervention and specific and adequate treatments of negative symptoms is highlighted.
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Affiliation(s)
- Bunta Yoshimura
- Department of Psychiatry, Okayama Psychiatric Medical Center, Okayama, Japan.,Department of Psychiatry, Okinawa Miyako Hospital, Miyakojima, Japan.,Department of Neuropsychiatry, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Shinji Sakamoto
- Department of Neuropsychiatry, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Kojiro Sato
- Department of Psychiatry, Okayama Psychiatric Medical Center, Okayama, Japan
| | - Manabu Takaki
- Department of Neuropsychiatry, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Norihito Yamada
- Department of Neuropsychiatry, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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22
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Uno Y, Coyle JT. Glutamate hypothesis in schizophrenia. Psychiatry Clin Neurosci 2019; 73:204-215. [PMID: 30666759 DOI: 10.1111/pcn.12823] [Citation(s) in RCA: 195] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 01/08/2019] [Accepted: 01/16/2019] [Indexed: 12/13/2022]
Abstract
Schizophrenia is a chronic and severe psychiatric disorder that has profound impact on an individual's life and on society. Thus, developing more effective therapeutic interventions is essential. Over the past quarter-century, an abundance of evidence from pharmacologic challenges, post-mortem studies, brain imaging, and genetic studies supports the role of glutamatergic dysregulation in the pathophysiology of schizophrenia, and the results of recent randomized clinical trials based on this evidence have yielded promising results. In this article, we review the evidence that alterations in glutamatergic neurotransmission, especially focusing on the N-methyl-d-aspartate receptor (NMDAR) function, may be a critical causative feature of schizophrenia, how this contributes to pathologic circuit function in the brain, and how these insights are revealing whole new avenues for treatment development that could reduce treatment-resistant symptoms, which account for persistent disability.
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Affiliation(s)
- Yota Uno
- Department of Psychiatry, Harvard Medical School, Boston, USA.,Laboratory for Psychiatric and Molecular Neuroscience, McLean Hospital, Belmont, USA.,Department of Psychology, University of Bath, Bath, UK
| | - Joseph T Coyle
- Department of Psychiatry, Harvard Medical School, Boston, USA.,Laboratory for Psychiatric and Molecular Neuroscience, McLean Hospital, Belmont, USA
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23
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Kantrowitz JT. N-methyl-d-aspartate-type glutamate receptor modulators and related medications for the enhancement of auditory system plasticity in schizophrenia. Schizophr Res 2019; 207:70-79. [PMID: 29459050 DOI: 10.1016/j.schres.2018.02.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 01/30/2018] [Accepted: 02/02/2018] [Indexed: 12/14/2022]
Abstract
Deficits in N-methyl-d-aspartate-type (NMDAR) function contribute to cognitive deficits in schizophrenia, particularly dysfunction in neuroplasticity, defined as reduced learning during training on exercises that place implicit, increasing demands on early sensory (auditory and visual) information processing. Auditory mismatch negativity (MMN) can be both a target engagement biomarker for the NMDAR and a proxy measure of neurophysiological plasticity. This review covers the evidence for using NMDAR modulator and related compounds for enhancement of cognition, with a particular focus on early auditory processing/plasticity. Compounds covered include glycine site agonists, glycine and system A-type transporter inhibitors, d-amino acid oxidase inhibitors, memantine and nicotinic alpha-7 acetylcholine receptor agonists. As opposed to daily treatment studies focusing on schizophrenia in general, intermittent, non-daily treatment combining NMDAR modulators with neuroplasticity-based paradigms, using MMN as target-engagement biomarkers show promise as treatments to both remediate plasticity deficits and overall functional deficits.
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Affiliation(s)
- Joshua T Kantrowitz
- Schizophrenia Research Center, Nathan Kline Institute for Psychiatric Research, Orangeburg, NY 10962, USA; Division of Experimental Therapeutics, Department of Psychiatry, Columbia University, New York, NY 10032, USA.
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24
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Hochberger WC, Joshi YB, Thomas ML, Zhang W, Bismark AW, Treichler EBH, Tarasenko M, Nungaray J, Sprock J, Cardoso L, Swerdlow N, Light GA. Neurophysiologic measures of target engagement predict response to auditory-based cognitive training in treatment refractory schizophrenia. Neuropsychopharmacology 2019; 44:606-612. [PMID: 30377381 PMCID: PMC6333927 DOI: 10.1038/s41386-018-0256-9] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 10/01/2018] [Indexed: 01/20/2023]
Abstract
Cognitive impairment is a core feature of schizophrenia and a strong predictor of psychosocial disability. Auditory-based targeted cognitive training (TCT) aims to enhance verbal learning and other domains of cognitive functioning through "bottom-up" tuning of the neural systems underlying early auditory information processing (EAIP). Although TCT has demonstrated efficacy at the group level, individual response to TCT varies considerably, with nearly half of patients showing little-to-no benefit. EEG measures of EAIP, mismatch negativity (MMN) and P3a, are sensitive to the neural systems engaged by TCT exercises and might therefore predict clinical outcomes after a full course of treatment. This study aimed to determine whether initial malleability of MMN and P3a to 1-h of auditory-based TCT predicts improvements in verbal learning and clinical symptom reduction following a full (30-h) course of TCT. Treatment refractory patients diagnosed with schizophrenia were randomly assigned to receive treatment-as-usual (TAU; n = 22) or TAU augmented with TCT (n = 23). Results indicated that malleability (i.e., change from baseline after the initial 1-h dose of TCT) of MMN and P3a predicted improvements in verbal learning as well as decreases in the severity of positive symptoms. Examination of MMN and P3a malleability in patients after their first dose of TCT can be used to predict clinical response to a full course of treatment and shows promise for future biomarker-informed treatment assignment.
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Affiliation(s)
- William C Hochberger
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA
- VISN-22 Mental Illness, Research, Education and Clinical Center (MIRECC), VA San Diego Healthcare System, San Diego, CA, USA
| | - Yash B Joshi
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA
- VISN-22 Mental Illness, Research, Education and Clinical Center (MIRECC), VA San Diego Healthcare System, San Diego, CA, USA
| | - Michael L Thomas
- Department of Psychology, Colorado State University, Fort Collins, CO, USA
| | - Wendy Zhang
- San Diego State University/University of California, San Diego (SDSU/UCSD) Joint Doctoral Program (JDP) in Clinical Psychology, San Diego, CA, USA
| | - Andrew W Bismark
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA
- VISN-22 Mental Illness, Research, Education and Clinical Center (MIRECC), VA San Diego Healthcare System, San Diego, CA, USA
| | - Emily B H Treichler
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA
- VISN-22 Mental Illness, Research, Education and Clinical Center (MIRECC), VA San Diego Healthcare System, San Diego, CA, USA
| | - Melissa Tarasenko
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA
- VISN-22 Mental Illness, Research, Education and Clinical Center (MIRECC), VA San Diego Healthcare System, San Diego, CA, USA
| | - John Nungaray
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA
| | - Joyce Sprock
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA
- VISN-22 Mental Illness, Research, Education and Clinical Center (MIRECC), VA San Diego Healthcare System, San Diego, CA, USA
| | - Lauren Cardoso
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA
- Alpine Special Treatment Center Inc., Alpine, CA, USA
| | - Neal Swerdlow
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA
| | - Gregory A Light
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA.
- VISN-22 Mental Illness, Research, Education and Clinical Center (MIRECC), VA San Diego Healthcare System, San Diego, CA, USA.
- San Diego State University/University of California, San Diego (SDSU/UCSD) Joint Doctoral Program (JDP) in Clinical Psychology, San Diego, CA, USA.
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25
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Koola MM. Potential Role of Antipsychotic-Galantamine-Memantine Combination in the Treatment of Positive, Cognitive, and Negative Symptoms of Schizophrenia. MOLECULAR NEUROPSYCHIATRY 2018; 4:134-148. [PMID: 30643787 PMCID: PMC6323397 DOI: 10.1159/000494495] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 10/12/2018] [Indexed: 12/11/2022]
Abstract
Schizophrenia is, in part, a cognitive illness. There are no approved medications for cognitive impairments associated with schizophrenia (CIAS) and primary negative symptoms. Cholinergic and glutamatergic systems, alpha-7 nicotinic acetylcholine (α-7nACh) and N-methyl-D-aspartate (NMDA) receptors, kynurenic acid (KYNA), and mismatch negativity have been implicated in the pathophysiology of CIAS and negative symptoms. Galantamine is an acetylcholinesterase inhibitor that is also a positive allosteric modulator at the α4β2 and α7nACh receptors. Memantine is a noncompetitive NMDA receptor antagonist. Galantamine and memantine alone and in combination were effective for cognition in animals and people with Alzheimer's disease. The objective of this article is to critically dissect the published randomized controlled trials with galantamine and memantine for CIAS to highlight the efficacy signal. These studies may have failed to detect a clinically meaningful efficacy signal due to limitations, methodological issues, and possible medication nonadherence. There is evidence from a small open-label study that the galantamine-memantine combination may be effective for CIAS with kynurenine pathway metabolites as biomarkers to detect the severity of cognitive impairments. Given that there are no available treatments for cognitive impairments and primary negative symptoms in schizophrenia, testing of this "five-pronged strategy" (quintuple hypotheses: dopamine, nicotinic-cholinergic, glutamatergic/NMDA, GABA, and KYNA) is a "low-risk high-gain" approach that could be a major breakthrough in the field. The galantamine-memantine combination has the potential to treat positive, cognitive, and negative symptoms, and targeting the quintuple hypotheses concurrently may lead to a major scientific advancement - from antipsychotic treatment to antischizophrenia treatment.
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Affiliation(s)
- Maju Mathew Koola
- Department of Psychiatry and Behavioral Sciences, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
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26
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Santos B, González-Fraile E, Zabala A, Guillén V, Rueda JR, Ballesteros J. Cognitive improvement of acetylcholinesterase inhibitors in schizophrenia. J Psychopharmacol 2018; 32:1155-1166. [PMID: 30324844 DOI: 10.1177/0269881118805496] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Schizophrenia is a severe, persistent mental disorder, and a leading cause of disability worldwide. Cognitive impairments presented in schizophrenia lead to a worse prognostic, thus treatments targeted to enhance cognition in schizophrenia may be clinically relevant. AIMS The purpose of this study was to assess the efficacy of acetylcholinesterase inhibitors as add-on medication to antipsychotics on cognition in patients with schizophrenia. METHODS Search strategies were developed for Medline, Embase and Cochrane Central Register of Controlled Trials, and are current to March 2018. We included randomised controlled trials that compared antipsychotics plus acetylcholinesterase inhibitors versus antipsychotics plus placebo on prespecified cognitive domains (speed of processing, attention and working memory). Two review authors independently evaluated study eligibility, extracted data and assessed the risk of bias of included studies. We used random-effects model for meta-analyses and assessed the quality of evidence using Grading of Recommendations Assessment, Development and Evaluation (GRADE). RESULTS We included nine randomised controlled trials. Six randomised controlled trials ( n=219) presented evidence that acetylcholinesterase inhibitors improve speed of processing (standardised mean difference -0.52, 95% confidence interval (-0.79 to -0.25); p value=0.0002). However, eight randomised controlled trials ( n=252) did find placebo was better than acetylcholinesterase inhibitors in the attention domain (-0.43, (-0.72 to -0.13); p value=0.005) and eight randomised controlled trials ( n=273) did not find differences in the working memory (-0.14, (-0.51 to 0.24), p value=0.47). CONCLUSIONS The current evidence is too weak to base recommendations on the use of acetylcholinesterase inhibitors as adjunctive treatments to antipsychotics to improve basic cognitive functions. We have limited confidence in the effect estimates.
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Affiliation(s)
- Borja Santos
- 1 Department of Genetics, Physical Anthropology and Animal Physiology, University of the Basque Country, Leioa, Spain
| | | | - Arantzazu Zabala
- 3 Department of Neuroscience, Psychiatry, University of the Basque Country, Leioa, Spain.,5 CIBERSAM, Madrid, Spain
| | - Virginia Guillén
- 3 Department of Neuroscience, Psychiatry, University of the Basque Country, Leioa, Spain
| | - José R Rueda
- 6 Department of Public Health, University of the Basque Country, Leioa, Spain
| | - Javier Ballesteros
- 3 Department of Neuroscience, Psychiatry, University of the Basque Country, Leioa, Spain.,5 CIBERSAM, Madrid, Spain
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27
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Koola MM. Attenuated Mismatch Negativity in Attenuated Psychosis Syndrome Predicts Psychosis: Can Galantamine-Memantine Combination Prevent Psychosis? MOLECULAR NEUROPSYCHIATRY 2018; 4:71-74. [PMID: 30397594 PMCID: PMC6206967 DOI: 10.1159/000488797] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 03/26/2018] [Indexed: 12/13/2022]
Abstract
Although first proposed in 1987, early diagnosis and intervention of psychotic disorders has only recently become a priority in the field. The interest in clinical high risk (CHR) for psychosis skyrocketed after attenuated psychosis syndrome (APS) was added to the DSM-5. There is evidence that in individuals with APS, attenuated mismatch negativity (MMN: functioning of the auditory sensory memory system) is a robust biomarker that can predict transition to psychosis. The underlying pathophysiological mechanism of MMN is via the interaction of N-methyl-D-aspartate (NMDA) and alpha-7 nicotinic acetylcholine (α-7nACh) receptors. Galantamine is an acetylcholinesterase inhibitor and a positive allosteric modulator of the α-7nACh receptors. Memantine is an NMDA receptor antagonist. Memantine has been shown to enhance MMN in people with schizophrenia. Although no studies with galantamine have measured MMN, encenicline, an α-7 nicotinic partial agonist, increased MMN in people with schizophrenia. MMN has been suggested as a potential biomarker with the galantamine-memantine combination for the treatment of neuropsychiatric disorders. Hence, the galantamine-memantine combination may enhance MMN, thereby preventing CHR to psychosis. With no treatments available, randomized controlled trials are warranted with the galantamine-memantine combination to delay or prevent conversion to psychosis in individuals with CHR.
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Affiliation(s)
- Maju Mathew Koola
- Department of Psychiatry and Behavioral Sciences, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
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28
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Room to move: Plasticity in early auditory information processing and auditory learning in schizophrenia revealed by acute pharmacological challenge. Schizophr Res 2018; 199:285-291. [PMID: 29627173 PMCID: PMC6151271 DOI: 10.1016/j.schres.2018.03.037] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 03/22/2018] [Accepted: 03/26/2018] [Indexed: 11/23/2022]
Abstract
Many patients with chronic psychotic disorders including schizophrenia (SZ) maintain meaningful levels of plasticity (i.e., capacity for change) within neurocognition-relevant brain mechanisms, as evidenced by gains in neurocognition and function after interventions such as targeted cognitive training. However, like many clinical features of these disorders, therapeutic responses in SZ are heterogeneous, and prospectively identifying treatment-sensitive individuals and individualized treatment modalities remains an unmet challenge. We propose that available plasticity in neurocognition-relevant brain mechanisms in individual SZ patients can be detected by gains in laboratory measures of early auditory information processing (EAIP) and auditory learning after a single challenge-dose of a pharmacologic agent; here, we present supportive data for this strategy with the non-competitive NMDA antagonist, memantine, and the psychostimulant, amphetamine. We describe a novel therapeutic model where this "challenge dose" strategy is used to prospectively identify a sensitive cohort of patients, and in these patients, a therapeutic response is elicited by pairing drug-enhanced EAIP and auditory learning with auditory-based targeted cognitive training.
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29
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Kantrowitz JT, Swerdlow NR, Dunn W, Vinogradov S. Auditory System Target Engagement During Plasticity-Based Interventions in Schizophrenia: A Focus on Modulation of N-Methyl-D-Aspartate-Type Glutamate Receptor Function. BIOLOGICAL PSYCHIATRY. COGNITIVE NEUROSCIENCE AND NEUROIMAGING 2018; 3:581-590. [PMID: 29656951 PMCID: PMC6062454 DOI: 10.1016/j.bpsc.2018.02.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 01/24/2018] [Accepted: 02/12/2018] [Indexed: 12/31/2022]
Abstract
Cognitive deficits are predictive of long-term social and occupational functional deficits in schizophrenia but are currently without gold-standard treatments. In particular, augmentation of auditory cortical neuroplasticity may represent a rate-limiting first step before addressing higher-order cognitive deficits. We review the rationale for N-methyl-d-aspartate-type glutamate receptor (NMDAR) modulators as treatments for auditory plasticity deficits in schizophrenia, along with potential serum and electroencephalographic target engagement biomarkers for NMDAR function. Several recently published NMDAR-modulating treatment studies are covered, involving D-serine, memantine, and transcranial direct current stimulation. While all three interventions appear to modulate auditory plasticity, direct agonists (D-serine) appear to have the largest and most consistent effects on plasticity, at least acutely. We hypothesize that there may be synergistic effects of combining procognitive NMDAR-modulating approaches with auditory cortical neuroplasticity cognitive training interventions. Future studies should assess biomarkers for target engagement and patient stratification, along with head-to-head studies comparing putative interventions and potential long-term versus acute effects.
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Affiliation(s)
- Joshua T Kantrowitz
- Schizophrenia Research Center, Nathan Kline Institute for Psychiatric Research, Orangeburg, New York; Division of Experimental Therapeutics, Department of Psychiatry, Columbia University, New York, New York.
| | - Neal R Swerdlow
- Department of Psychiatry, University of California, San Diego, La Jolla
| | - Walter Dunn
- Department of Psychiatry, University of California, Los Angeles, Los Angeles, California
| | - Sophia Vinogradov
- Department of Psychiatry, University of Minnesota Medical School, Minneapolis, Minnesota
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30
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Tsukada T, Sato I, Matsuoka N, Imai T, Doi Y, Arai M, Fujii Y, Matsunaga T, Kawakami K. Prescription of Antidementia Drugs and Antipsychotics for Elderly Patients in Japan: A Descriptive Study Using Pharmacy Prescription Data. J Geriatr Psychiatry Neurol 2018; 31:194-202. [PMID: 30016896 DOI: 10.1177/0891988718785775] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Antipsychotics are commonly used for managing behavioral and psychological symptoms of dementia among elderly patients with dementia receiving antidementia drugs (ADDs). However, the use of antipsychotics among these patients has not been investigated since 3 ADDs were approved in 2011 in Japan. METHOD We conducted a descriptive study using pharmacy prescription data and identified patients aged ≥65 years who were newly prescribed donepezil, memantine, rivastigmine, and galantamine between January 1, 2012, and September 30, 2014. We determined the proportion of antipsychotic prescription and the factors affecting antipsychotic prescription using multivariable Cox proportional hazard models. RESULT Of 13 876 patients, 1705 were memantine users, and the proportion of antipsychotic prescription among them was the highest (11.1%). Adjusted hazard ratios for donepezil, rivastigmine, and galantamine were 0.66, 0.56, and 0.66, respectively, relative to that for memantine. CONCLUSION Compared to other ADD users, new memantine users were most likely to be prescribed antipsychotics.
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Affiliation(s)
- Takahisa Tsukada
- 1 Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
| | - Izumi Sato
- 1 Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan.,2 The Keihanshin Consortium for Fostering the Next Generation of Global Leaders in Research (K-CONNEX), Kyoto, Japan
| | | | - Takumi Imai
- 4 Department of Clinical Biostatistics, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
| | - Yuko Doi
- 5 Ain Holdings Inc, Sapporo, Hokkaido, Japan
| | | | | | | | - Koji Kawakami
- 1 Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
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31
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Kishi T, Ikuta T, Oya K, Matsunaga S, Matsuda Y, Iwata N. Anti-Dementia Drugs for Psychopathology and Cognitive Impairment in Schizophrenia: A Systematic Review and Meta-Analysis. Int J Neuropsychopharmacol 2018; 21:748-757. [PMID: 29762677 PMCID: PMC6070030 DOI: 10.1093/ijnp/pyy045] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 04/23/2018] [Accepted: 05/12/2018] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND We conducted a systematic review and meta-analysis of double-blind, randomized, placebo-controlled trials of anti-dementia drugs plus antipsychotics for schizophrenia. METHODS Primary outcomes of efficacy and safety included improving overall symptoms (Positive and Negative Syndrome Scale and Brief Psychiatric Rating Scale scores) and all-cause discontinuation, respectively. Other outcomes included psychopathology subscales (positive, negative, general, and anxiety/depressive symptoms), cognitive function (attention/vigilance, reasoning/problem solving, social cognition, speed of processing, verbal learning, visual learning, working memory, and cognitive control/executive function), Mini-Mental State Examination scores, treatment discontinuation due to adverse events and inefficacy, and individual adverse events. We evaluated the effect size using a random effects model. RESULTS We identified 37 studies (n=1574): 14 donepezil-based (n=568), 10 galantamine-based (n=371), 4 rivastigmine-based (n=146), and 9 memantine-based (n=489) studies. Pooled anti-dementia drugs plus antipsychotics treatments were superior to placebo plus antipsychotics in improving the overall symptoms (24 studies, 1069 patients: standardized mean difference=-0.34, 95% CI=-0.61 to -0.08, P=.01), negative symptoms (24 studies, 1077 patients: standardized mean difference =-0.62, 95% CI=-0.92 to -0.32, Pcorrected=.00018), and Mini-Mental State Examination scores (7 studies, 225 patients: standardized mean difference=-0.79, 95% CI=-1.23 to -0.34, P=.0006). No significant differences were found between anti-dementia drugs plus antipsychotics and placebo plus antipsychotics regarding other outcomes. CONCLUSIONS Although the results suggest that anti-dementia drugs plus antipsychotics treatment improves negative symptoms and Mini-Mental State Examination scores in schizophrenia patients, they possibly were influenced by a small-study effect and some bias. However, it was not superior to placebo plus antipsychotics in improving composite cognitive test score, which more systematically evaluates cognitive impairment than the Mini-Mental State Examination score. Overall, the anti-dementia drugs plus antipsychotics treatment was well tolerated.
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Affiliation(s)
- Taro Kishi
- Department of Psychiatry, Fujita Health University School of Medicine, Aichi, Japan,Correspondence: Taro Kishi, MD, PhD, Department of Psychiatry, Fujita Health University School of Medicine, 1–98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi 470–1192, Japan ()
| | - Toshikazu Ikuta
- Department of Communication Sciences and Disorders, School of Applied Sciences, University of Mississippi, MS USA
| | - Kazuto Oya
- Department of Psychiatry, Fujita Health University School of Medicine, Aichi, Japan
| | - Shinji Matsunaga
- Department of Psychiatry, Fujita Health University School of Medicine, Aichi, Japan,Department of Department of Geriatrics and Cognitive Disorders, Fujita Health University School of Medicine, Aichi, Japan
| | - Yuki Matsuda
- Department of Psychiatry, Jikei University School of Medicine, Tokyo, Japan
| | - Nakao Iwata
- Department of Psychiatry, Fujita Health University School of Medicine, Aichi, Japan
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32
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Joshi YB, Light GA. Using EEG-Guided Basket and Umbrella Trials in Psychiatry: A Precision Medicine Approach for Cognitive Impairment in Schizophrenia. Front Psychiatry 2018; 9:554. [PMID: 30510520 PMCID: PMC6252381 DOI: 10.3389/fpsyt.2018.00554] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 10/15/2018] [Indexed: 12/21/2022] Open
Abstract
Due to advances over the last several decades, many fields of medicine are moving toward a precision medicine approach where treatments are tailored to nuanced patient factors. While in some disciplines these innovations are commonplace leading to unique biomarker-guided experimental medicine trials, there are no such analogs in psychiatry. In this brief review, we will overview two unique biomarker-guided trial designs for future use in psychiatry: basket and umbrella trials. We will illustrate how such trials could be useful in psychiatry using schizophrenia as a candidate illness, the EEG measure mismatch negativity as the candidate biomarker, and cognitive impairment as the target disease dimension.
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Affiliation(s)
- Yash B Joshi
- Department of Psychiatry, University of California, San Diego, La Jolla, CA, United States
| | - Gregory A Light
- Department of Psychiatry, University of California, San Diego, La Jolla, CA, United States.,VISN-22 Mental Illness, Research, Education and Clinical Center (MIRECC), VA San Diego Health Care System, San Diego, CA, United States
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33
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Veerman S, Schulte P, de Haan L. Memantine add-on to clozapine treatment for residual negative symptoms of schizophrenia. Psychopharmacology (Berl) 2017; 234:3535-3536. [PMID: 29038824 DOI: 10.1007/s00213-017-4756-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Accepted: 10/02/2017] [Indexed: 12/20/2022]
Affiliation(s)
- Selene Veerman
- Community Mental Health Division, Flexible Assertive Community Treatment, Mental Health Service Organisation Noord-Holland Noord, Oude Hoeverweg 10, Alkmaar, 1816 BT, The Netherlands.
| | - Peter Schulte
- Specialised Treatment Division, Treatment Centre for Bipolar Disorders, Mental Health Service Noord-Holland Noord, Oude Hoeverweg 10, Alkmaar, 1816 BT, The Netherlands
| | - Lieuwe de Haan
- Academic Psychiatric Centre, Early Psychosis Department, Arkin, Academic Medical Center, University of Amsterdam, Meibergdreef 5, Amsterdam, 1105 AZ, The Netherlands
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34
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Kishi T, Matsunaga S, Iwata N. The effects of memantine on behavioral disturbances in patients with Alzheimer's disease: a meta-analysis. Neuropsychiatr Dis Treat 2017; 13:1909-1928. [PMID: 28790827 PMCID: PMC5530072 DOI: 10.2147/ndt.s142839] [Citation(s) in RCA: 31] [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] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Memantine is effective in the treatment of behavioral disturbances in patients with Alzheimer's disease. It has not yet been fully determined which behavioral disturbances respond best to memantine. METHODS We conducted a meta-analysis of memantine vs control (placebo or usual care) for the treatment of individual behavioral disturbances (delusion, hallucination, agitation/aggression, dysphoria, anxiety/phobia, euphoria, apathy, disinhibition, irritability/lability, aberrant motor activity/activity disturbances, nighttime disturbance/diurnal rhythm disturbances, and eating disturbances). Randomized controlled studies of memantine in patients with Alzheimer's disease were included in this study. To evaluate these outcomes, standardized mean difference (SMD), with 95% confidence intervals (95% CIs), based upon a random-effects model was evaluated in the meta-analysis. RESULTS A total of 11 studies (n=4,261; memantine vs placebo: N=4, n=1,500; memantine + cholinesterase inhibitors [M + ChEIs] vs ChEIs: N=7, n=2,761) were included in the meta-analysis. Compared to control, memantine showed significant improvement in agitation/aggression (SMD =-0.11; 95% CIs =-0.20, -0.03; P=0.01; I2=47%), delusion (SMD =-0.12; 95% CIs =-0.18, -0.06; P=0.0002; I2=0%), disinhibition (SMD =-0.08; 95% CIs =-0.15, -0.00; P=0.04; I2=0%), and nighttime disturbance/diurnal rhythm disturbances (SMD =-0.10; 95% CIs =-0.18, -0.02; P=0.02; I2=36%). Memantine was also marginally superior to control in hallucination (SMD =-0.06; 95% CIs =-0.12, 0.01; P=0.07; I2=0%) and irritability/lability (SMD =-0.09; 95% CIs =-0.19, 0.01; P=0.07; I2=42%). Memantine is similar to control in dysphoria, anxiety/phobia, euphoria, apathy, and eating disturbance. CONCLUSION The meta-analysis suggest that memantine has benefits for the treatment of most of the behavioral disturbances in patients with Alzheimer's disease. Memantine does not deteriorate negative symptoms as behavioral disturbances in patients with Alzheimer's disease.
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Affiliation(s)
- Taro Kishi
- Department of Psychiatry, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Shinji Matsunaga
- Department of Psychiatry, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Nakao Iwata
- Department of Psychiatry, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
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