Clozapine decreases smoking in patients with chronic schizophrenia

Canonical and Non-Canonical Antipsychotics' Dopamine-Related Mechanisms of Present and Next Generation Molecules: A Systematic Review on Translational Highlights for Treatment Response and Treatment-Resistant Schizophrenia

Schizophrenia is a severe psychiatric illness affecting almost 25 million people worldwide and is conceptualized as a disorder of synaptic plasticity and brain connectivity. Antipsychotics are the primary pharmacological treatment after more than sixty years after their introduction in therapy. Two findings hold true for all presently available antipsychotics. First, all antipsychotics occupy the dopamine D2 receptor (D2R) as an antagonist or partial agonist, even if with different affinity; second, D2R occupancy is the necessary and probably the sufficient mechanism for antipsychotic effect despite the complexity of antipsychotics' receptor profile. D2R occupancy is followed by coincident or divergent intracellular mechanisms, implying the contribution of cAMP regulation, β-arrestin recruitment, and phospholipase A activation, to quote some of the mechanisms considered canonical. However, in recent years, novel mechanisms related to dopamine function beyond or together with D2R occupancy have emerged. Among these potentially non-canonical mechanisms, the role of Na²⁺ channels at the dopamine at the presynaptic site, dopamine transporter (DAT) involvement as the main regulator of dopamine concentration at synaptic clefts, and the putative role of antipsychotics as chaperones for intracellular D2R sequestration, should be included. These mechanisms expand the fundamental role of dopamine in schizophrenia therapy and may have relevance to considering putatively new strategies for treatment-resistant schizophrenia (TRS), an extremely severe condition epidemiologically relevant and affecting almost 30% of schizophrenia patients. Here, we performed a critical evaluation of the role of antipsychotics in synaptic plasticity, focusing on their canonical and non-canonical mechanisms of action relevant to the treatment of schizophrenia and their subsequent implication for the pathophysiology and potential therapy of TRS.

Clozapine's multiple cellular mechanisms: What do we know after more than fifty years? A systematic review and critical assessment of translational mechanisms relevant for innovative strategies in treatment-resistant schizophrenia

Almost fifty years after its first introduction into clinical care, clozapine remains the only evidence-based pharmacological option for treatment-resistant schizophrenia (TRS), which affects approximately 30% of patients with schizophrenia. Despite the long-time experience with clozapine, the specific mechanism of action (MOA) responsible for its superior efficacy among antipsychotics is still elusive, both at the receptor and intracellular signaling level. This systematic review is aimed at critically assessing the role and specific relevance of clozapine's multimodal actions, dissecting those mechanisms that under a translational perspective could shed light on molecular targets worth to be considered for further innovative antipsychotic development. In vivo and in vitro preclinical findings, supported by innovative techniques and methods, together with pharmacogenomic and in vivo functional studies, point to multiple and possibly overlapping MOAs. To better explore this crucial issue, the specific affinity for 5-HT₂R, D1R, α_2c, and muscarinic receptors, the relatively low occupancy at dopamine D2R, the interaction with receptor dimers, as well as the potential confounder effects resulting in biased ligand action, and lastly, the role of the moiety responsible for lipophilic and alkaline features of clozapine are highlighted. Finally, the role of transcription and protein changes at the synaptic level, and the possibility that clozapine can directly impact synaptic architecture are addressed. Although clozapine's exact MOAs that contribute to its unique efficacy and some of its severe adverse effects have not been fully understood, relevant information can be gleaned from recent mechanistic understandings that may help design much needed additional therapeutic strategies for TRS.

Clozapine reduces nicotine self-administration, blunts reinstatement of nicotine-seeking but increases responding for food

People with schizophrenia display significantly higher rates of smoking than the general population, which may be due to an interaction between nicotine and antipsychotic medication. While the conventional antipsychotic drug haloperidol sometimes increases cigarette smoking in patients with schizophrenia, there is some evidence suggesting that clozapine, an atypical antipsychotic drug, may reduce nicotine use in these patients. However, the effects of antipsychotic drugs like clozapine on aspects of nicotine self-administration and reinstatement have not been systematically examined. In the current study, we assessed the effect of clozapine on nicotine self-administration under fixed ratio and progressive ratio schedules of reinforcement, as well as reinstatement of nicotine-seeking following a period of abstinence. To determine the specificity of its effect on nicotine reward, we also tested the effect of clozapine on responding for food reinforcement under fixed ratio and progressive ratio schedules. For comparison, we also examined the effects of haloperidol, a first-generation antipsychotic drug, under some of the same behavioral conditions as clozapine. We show that clozapine inhibits nicotine self-administration and reinstatement of nicotine-seeking but also increases the amount of effort that rats will exert for food reward. In contrast, haloperidol at a wide range of doses attenuated responding for nicotine and food reward, suggestive of a non-specific reduction in reinforcer efficacy. These results show the potential utility of clozapine as a smoking cessation treatment for patients with schizophrenia, in addition to its antipsychotic properties.

The relationship between nicotine and psychosis

Cigarette smoking is strongly associated with psychotic disorders such as schizophrenia. For several decades it was assumed that the relationship could be explained by reverse causation; that smoking was secondary to the illness itself, either through self-medication or a process of institutionalization, or was entirely explained by confounding by cannabis use or social factors. However, studies have exposed that such hypotheses cannot fully explain the association, and more recently a bidirectional relationship has been proposed wherein cigarette smoking may be causally related to risk of psychosis, possibly via a shared genetic liability to smoking and psychosis. We review the evidence for these candidate explanations, using findings from the latest epidemiological, neuroimaging, genetic and preclinical work.

Tobacco smoking is associated with antipsychotic medication, physical aggressiveness, and alcohol use disorder in schizophrenia: results from the FACE-SZ national cohort

Tobacco smoking is common in schizophrenia and is one of the main causes of premature mortality in this disorder. Little is known about clinical correlates and treatments associated with tobacco smoking in patients with schizophrenia. Still, a better characterization of these patients is necessary, in a personalized care approach. Aggressiveness and childhood trauma have been associated with tobacco smoking in general population, but this association has never been explored in schizophrenia. Our study examines the clinical and therapeutic characteristics of tobacco smoking in schizophrenia. 474 stabilized patients (mean age = 32.2; 75.7% male gender; smokers n = 207, 54.6%) were consecutively included in the network of the FondaMental Expert centers for Schizophrenia and assessed with valid scales. Current tobacco status was self-declared. Aggressiveness was self-reported with Buss-Perry Aggressiveness Questionnaire and Childhood Trauma with Childhood Trauma Questionnaire. Ongoing treatment was reported. In univariate analysis, tobacco smoking was associated with lower education level (p < 0.01), positive syndrome (p < 0.01), higher physical aggressiveness (p < 0.001), alcohol dependence (p < 0.001), and First Generation Antipsychotics (FGAs) use (p = 0.018). In a multivariate model, tobacco smoking remained associated with physical aggressiveness (p < 0.05), current alcohol dependence (p < 0.01) and FGA use (p < 0.05). No association was observed with childhood trauma history, mood disorder, suicidal behavior, psychotic symptom, global functioning or medication adherence. Patients with tobacco use present clinical and therapeutic specificities, questioning the neurobiological links between tobacco and schizophrenia. They could represent a specific phenotype, with specific clinical and therapeutic specificities that may involve interactions between cholinergic-nicotinic system and dopaminergic system. Further longitudinal studies are needed to confirm the potential efficacy of second generation antipsychotics (SGAs) on tobacco use in schizophrenia and to develop effective strategies for tobacco cessation in this population.

What we have learned from the Methadone Maintenance Treatment of Dual Disorder Heroin Use Disorder patients

Mental Disorders and Heroin Use Disorder (HUD) often co-occur and constitute correlated risk factors that the authors believe are best considered from a unitary perspective. In this article we review and discuss data collected by the V.P. Dole Research Group in Dual Disorder (V.P. Dole DD-RG) patients according to the following six discussion points: (1) Treatment of personality disorders during Methadone Maintenance Treatment (MMT); (2) Treatment of Mood Disorders during MMT; (3) Treatment of Anxiety Disorders during MMT; (4) Treatment of Psychotic Disorders during MMT; (5) Treatment of violence during MMT; (6) Treatment of Alcohol Use Disorder (AUD) during MMT. In treating Mood Disorder in HUD patients, we must bear in mind the interactions (potentiation and side effects) between psychopharmacology, used substances and agonist opioid medications; the use of psychiatric medications as an anti-craving drug, and the possible use of agonist and antagonist opioid medications in treating the other mental disorders. In treating chronic psychosis in HUD patients, we must consider the potentiation and side effects of antipsychotic drugs consequent on HUD treatment, worsening addiction hypophoria and inducing a more severe reward deficiency syndrome (RDS) in hypophoric patients. Violence and AUD during MMT can benefit from adequate dosages of methadone and co-medication with Sodium gamma-hydroxybutyrate (GHB). The experience of our V.P. Dole DD-RG suggests the following: (a) DD is the new paradigm in neuroscience in deepening our understanding of mental health; (b) To successfully treat DD patients a double competence is needed; (c) In managing DD patients priority must be given to Substance Use Disorder (SUD) treatment (stabilizing patients); (d) Antidepressant use is ancillary to SUD treatment; antipsychotic use must be restricted to acute phases; mood stabilizers must be preferred; any use of Benzodiazepines (BDZs) must be avoided.

Clozapine use in patients with schizophrenia and a comorbid substance use disorder: A systematic review

Lifetime prevalence of substance use disorders (SUD) in patients with schizophrenia is nearly 50%. Nicotine, alcohol, and cannabis are the substances most frequently used, with a high percentage of poly-substance users. There are few available data about pharmacological approaches in this population. Amongst antipsychotics, clozapine shows positive evidence in the literature. The aim of the present article is to provide systematic review on the efficacy of clozapine in SUD improvement in schizophrenic patients. PRISMA recommendations were followed (PROSPERO id: CRD42017059299). Five studies for nicotine use and nine studies for SUD (other than nicotine) were analyzed. Regarding nicotine use, results from randomized controlled trials (RCT) have found a decrease in nicotine use after 12 weeks of 200-600mg/day clozapine, as compared with lower doses. In SUD improvement (other than nicotine), RCT have shown superiority of clozapine when compared with risperidone, in short-term studies (from 4 to 12 weeks) performed in cannabis users. In long-term studies (1 year), clozapine was equal to ziprasidone in reducing cannabis use and equal to treatment as usual in reducing alcohol use. We conclude that positive results on nicotine use are scarce and derived from studies with a low degree of evidence. Evidence of clozapine on SUD (other than nicotine) is stronger, especially when clozapine is compared with first generation antipsychotics in poly-substance users. When compared with second generation antipsychotics, clozapine was superior to risperidone but equal to olanzapine or ziprasidone in poly-substance and cannabis users.

Schizophrenia and Nicotine Dependence: What Psychopharmacological Treatment Options are Available for the Duo Perturbationes?

Nicotine dependence has progressively become a foremost community health interest in both the developed and developing nations due to the economic burden and health-related problems. Smoking was significantly higher among patients with schizophrenia in comparison to the general population. Nicotine dependence is not only associated with public stress, but among patients with schizophrenia, smoking brings major challenges to the management. Nicotine may diminish the therapeutic efficacy of the bioavailability of the psychopharmacological agents in-vivo. These duo perturbations, i.e. two clinical conditions co-existed may prevent psychotic symptoms remission among patients suffering from schizophrenia who smoke at the same time. The aim of this review was to highlight the role of pharmacological treatment options and strategies for patients with nicotine dependence in schizophrenia with emphasis on the underlying neurobiological process. The role of nicotine replacement therapy, i.e. norepinephrine-dopamine reuptake inhibition (NDRI) e.g. bupropion and selective partial agonist of α4β2 and full α7-nicotinic acetylcholine receptor e.g. varenicline was deliberated. An ideal choice of drug targets for patients with schizophrenia with nicotine dependence is pivotal to foster a better therapeutic alliance.

Cigarette smoking and schizophrenia: a specific clinical and therapeutic profile? Results from the FACE-Schizophrenia cohort

BACKGROUND

Tobacco use is common in patients with schizophrenia (SZ) but little is known on the role of tobacco in the physiopathology or on the course of the disease. Only few studies embrace an extensive examination of clinical and therapeutic characteristics in stabilized patients. The objective of the present study was to determine the prevalence of tobacco smoking in stabilized SZ outpatients and the clinical and treatment characteristics associated with daily tobacco use in a large community-dwelling sample of patients.

METHODS

Three-hundred-and-sixty-one patients were included in the network of the FondaMental Expert Centers for Schizophrenia. Current tobacco status was self-declared.

RESULTS

53.7% were smokers. Mean age at tobacco onset was 17.2years old. In multivariate analyses, after adjustment for confounding factors, positive symptoms and mean daily antipsychotic dose were associated with a higher frequency of tobacco use (OR=1.06 95%IC[1.02-1.12], for positive symptoms, OR=1.1, 95%IC[1.02-1.18] for daily antipsychotic dose). Education level, negative symptoms, anticholinergic agents, clozapine or aripiprazole administration were independently associated with a lower frequency of tobacco use (respectively OR=0.87, 95%IC [0.79, 0.95], OR=0.95, 95%IC[0.91-0.98], OR=0.41, 95%IC[0.22-0.76], OR=0.56, 95%IC=[0.32, 0.99] and OR=0.49, 95%IC [0.26-0.91]).

CONCLUSION

The prevalence of current tobacco smoking in a French community-dwelling SZ patients is higher that observed in the general population. Patients with tobacco use present clinical and therapeutic specificities that may involve interaction between cholinergic-nicotinic and dopaminergic systems. The present study suggests that some therapeutics may improve daily smoking behavior in smokers. These results should be confirmed in longitudinal studies.

Predictors of tobacco abstinence in outpatient smokers with schizophrenia or bipolar disorder treated with varenicline and cognitive behavioral smoking cessation therapy

BACKGROUND

The estimated mortality gap between those with and without serious mental illness (SMI) is increasing, now estimated at 28years, which is largely due to smoking-related diseases.

AIMS

We sought to identify predictors of 14-day continuous abstinence in stable outpatient smokers with SMI.

METHOD

Adult smokers with schizophrenia spectrum (n=130) or bipolar disorder (n=23) were enrolled in a 12-week course of varenicline and cognitive-behavioral therapy for smoking cessation.

RESULTS

Independent predictors of abstinence included reduction in withdrawal symptoms prior to the quit day, fewer cigarettes smoked per day at baseline, better baseline attention, remitted alcohol dependence, and lower expectation of peer support to aid quitting.

CONCLUSIONS

Interventions that consider these targets may improve smoking cessation outcomes in those with SMI.

Clozapine dose for schizophrenia

BACKGROUND

Schizophrenia and related disorders such as schizophreniform and schizoaffective disorder are serious mental illnesses characterised by profound disruptions in thinking and speech, emotional processes, behaviour and sense of self. Clozapine is useful in the treatment of schizophrenia and related disorders, particularly when other antipsychotic medications have failed. It improves positive symptoms (such as delusions and hallucinations) and negative symptoms (such as withdrawal and poverty of speech). However, it is unclear what dose of clozapine is most effective with the least side effects.

OBJECTIVES

To compare the efficacy and tolerability of clozapine at different doses and to identify the optimal dose of clozapine in the treatment of schizophrenia, schizophreniform and schizoaffective disorders.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's Study-Based Register of Trials (August 2011 and 8 December 2016).

SELECTION CRITERIA

All relevant randomised controlled trials (RCTs), irrespective of blinding status or language, that compared the effects of clozapine at different doses in people with schizophrenia and related disorders, diagnosed by any criteria.

DATA COLLECTION AND ANALYSIS

We independently inspected citations from the searches, identified relevant abstracts, obtained full articles of relevant abstracts, and classified trials as included or excluded. We included trials that met our inclusion criteria and reported useable data. For dichotomous data, we calculated the relative risk (RR) and the 95% confidence interval (CI) on an intention-to-treat basis based on a random-effects model. For continuous data, we calculated mean differences (MD) again based on a random-effects model. We assessed risk of bias for included studies and created 'Summary of findings' tables using GRADE.

MAIN RESULTS

We identified five studies that could be included. Each compared the effects of clozapine at very low dose (up to 149 mg/day), low dose (150 mg/day to 300 mg/day) and standard dose (301 mg/day to 600 mg/day). Four of the five included studies were based on a small number of participants. We rated all the evidence reported for the main outcomes of interest as low or very low quality. No data were available for the main outcomes of global state, service use or quality of life. Very low dose compared to low doseWe found no evidence of effect on mental state between low and very low doses of clozapine in terms of average Brief Psychiatric Rating Scale-Anchored (BPRS-A) endpoint score (1 RCT, n = 31, MD 3.55, 95% CI -4.50 to 11.60, very low quality evidence). One study found no difference between groups in body mass index (BMI) in the short term (1 RCT, n = 59, MD -0.10, 95% CI -0.95 to 0.75, low-quality evidence). Very low dose compared to standard doseWe found no evidence of effect on mental state between very low doses and standard doses of clozapine in terms of average BPRS-A endpoint score (1 RCT, n = 31, MD 6.67, 95% CI -2.09 to 15.43, very low quality evidence). One study found no difference between groups in BMI in the short term (1 RCT, n = 58, MD 0.10, 95% CI -0.76 to 0.96, low-quality evidence) Low dose compared to standard doseWe found no evidence of effect on mental state between low doses and standard doses of clozapine in terms of both clinician-assessed clinical improvement (2 RCTs, n = 141, RR 0.76, 95% CI 0.36 to 1.61, medium-quality evidence) and clinically important response as more than 30% change in BPRS score (1 RCT, n = 176, RR 0.93, 95% CI 0.78 to 1.10, medium-quality evidence). One study found no difference between groups in BMI in the short term (1 RCT, n = 57, MD 0.20, 95% CI -0.84 to 1.24, low-quality evidence).We found some evidence of effect for other adverse effect outcomes; however, the data were again limited. Very low dose compared to low doseThere was limited evidence that serum triglycerides were lower at low-dose clozapine compared to very low dose in the short term (1 RCT, n = 59, MD 1.00, 95% CI 0.51 to 1.49). Low dose compared to standard doseWeight gain was lower at very low dose compared to standard dose (1 RCT, n = 27, MD -2.70, 95% CI -5.38 to -0.02). Glucose level one hour after meal was also lower at very lose dose (1 RCT, n = 58, MD -1.60, 95% CI -2.90 to -0.30). Total cholesterol levels were higher at very low compared to standard dose (1 RCT, n = 58, n = 58, MD 1.00, 95% CI 0.20 to 1.80). Low dose compared to standard doseThere was evidence of fewer adverse effects, measured as lower TESS scores, in the low-dose group in the short term (2 RCTs, n = 266, MD -3.99, 95% CI -5.75 to -2.24); and in one study there was evidence that the incidence of lethargy (RR 0.77, 95% CI 0.60 to 0.97), hypersalivation (RR 0.70, 95% CI 0.57 to 0.84), dizziness (RR 0.56, 95% CI 0.39 to 0.81) and tachycardia (RR 0.57, 95% CI 0.45 to 0.71) was less at low dose compared to standard dose.

AUTHORS' CONCLUSIONS

We found no evidence of effect on mental state between standard, low and very low dose regimes, but we did not identify any trials on high or very high doses of clozapine. BMI measurements were similar between groups in the short term, although weight gain was less at very low dose compared to standard dose in one study. There was limited evidence that the incidence of some adverse effects was greater at standard dose compared to lower dose regimes. We found very little useful data and the evidence available is generally of low or very low quality. More studies are needed to validate our findings and report on outcomes such as relapse, remission, social functioning, service utilisation, cost-effectiveness, satisfaction with care, and quality of life. There is a particular lack of medium- or long-term outcome data, and on dose regimes above the standard rate.

Nicotinic modulation of salience network connectivity and centrality in schizophrenia

Although functional abnormalities of the salience network are associated with schizophrenia, the acute effects of nicotine on its function and network dynamics during the resting state in patients are poorly understood. In this study, the effects of a 7 mg nicotine patch (vs. placebo) on salience network connectivity were examined in 17 patients with schizophrenia and 19 healthy subjects. We hypothesized abnormal connectivity between the salience network and other major networks (e.g. executive network) in patients under placebo administration and amelioration of this difference after nicotine. We also examined effects of nicotine on betweenness centrality (a measure of the influence of a region on information transfer throughout the brain) and local efficiency (a measure of local information transfer) of the network. A hybrid independent component analysis (ICA)/seed-based connectivity approach was implemented in which the salience network was extracted by ICA and cortical network peaks (anterior cingulate cortex (ACC), left and right insula) were used as seeds for whole-brain seed-to-voxel connectivity analysis. Significant drug X diagnosis interactions were observed between the ACC seed and superior parietal lobule and ventrolateral prefrontal cortex. A significant interaction effect was also observed between the left insula seed and middle cingulate cortex. During placebo conditions, abnormal connectivity predicted negative symptom severity and lower global functioning in patients. A significant drug X diagnosis interaction was also observed for betweenness centrality of the ACC. These results suggest that nicotine may target abnormalities in functional connectivity between salience and executive network areas in schizophrenia as well as affect the ability of the salience network to act as an integrator of global signaling in the disorder.

A drug-drug conditioning paradigm reveals multiple antipsychotic-nicotine interactions

Clinical studies indicate a reciprocal impact between nicotine use and antipsychotic medications in patients with schizophrenia. The present study used a conditioned avoidance response (CAR) test (a behavioral test of antipsychotic effect) and examined the specific drug-drug interactions between nicotine and haloperidol or clozapine. Following acquisition of the avoidance response, rats were first tested under either vehicle, nicotine (0.2, 0.4 mg/kg, sc), haloperidol (0.025, 0.05 mg/kg, sc), clozapine (5.0, 10.0 mg/kg, sc), or a combination of nicotine and haloperidol or nicotine and clozapine for seven consecutive days. Afterward, they were challenged with nicotine (0.2 mg/kg), haloperidol (0.025 mg/kg), or clozapine (5.0 mg/kg) in the CAR to assess if haloperidol or clozapine affected the behavioral effect of nicotine on avoidance response and if nicotine altered the avoidance suppressive effect of haloperidol and clozapine. During the seven avoidance drug test days, nicotine did not alter the avoidance suppressive effect of haloperidol or clozapine. However, in the challenge test, prior nicotine treatment (0.2 mg/kg) attenuated haloperidol's (0.05 mg/kg) sensitized effect on avoidance response. On the other hand, prior haloperidol treatment increased nicotine's (0.2 mg/kg) avoidance disruptive effect, and even engendered nicotine 0.4 mg/kg to exhibit an "acquired" avoidance suppressive effect. The combined nicotine and clozapine treatment did not produce any detectable interactive effects on avoidance response and motor activity. These findings suggest that nicotine is capable of altering the long-term antipsychotic efficacy of haloperidol, while haloperidol can alter the behavioral effects of nicotine. Clozapine and nicotine are less likely to influence each other.

Antipsychotic Treatment and Tobacco Craving in People With Schizophrenia

OBJECTIVE

Nicotine dependence is high in schizophrenia, and craving is known to impact relapse during quit attempts.

METHODS

We compared tobacco craving in smokers with schizophrenia treated with different antipsychotics.

RESULTS

Mean craving scores were lowest in participants receiving first-generation antipsychotics, although these differences were not statistically significant. Craving with clozapine was not lower than with other antipsychotics.

CONCLUSIONS

Further research is needed to determine whether differences in craving exist between antipsychotic classes.

Reduction of nicotine self-administration by chronic nicotine infusion with H1 histamine blockade in female rats

RATIONALE

Chronic nicotine infusion via transdermal patches has been widely shown to assist with smoking cessation. In particular, transdermal nicotine treatment prior to quitting smoking helps reduce ad libitum smoking and aids cessation Rose et al. (Nicotine Tob Res 11:1067-75, 2009). However, despite this success, the majority of smokers who use transdermal nicotine fail to permanently quit smoking. Additional treatments are needed. Tobacco addiction does not just depend on nicotinic receptor systems; a variety of neural systems are involved, including dopamine, norepinepherine, serotonin, and histamine.

OBJECTIVES

Given the involvement of a variety of neural systems in the circuits of addiction, combination therapy may offer improved efficacy for successful smoking cessation beyond single treatments alone. We have found that pyrilamine, an H1 histamine antagonist, significantly decreases nicotine self-administration in rats.

METHODS

The current study was conducted to confirm the effect of chronic nicotine infusion on ongoing nicotine self-administration and resumed access after enforced abstinence and to determine the interaction of chronic nicotine with an H1 antagonist treatment.

RESULTS

Chronic nicotine infusion via osmotic minipump (2.5 and 5 mg/kg/day for 28 days) significantly reduced nicotine self-administration in a dose-dependent manner. Chronic nicotine infusion also reduced the resumption of nicotine self-administration after enforced abstinence. Chronic pyrilamine infusion (25 mg/kg/day for 14 days) also significantly reduced nicotine self-administration.

CONCLUSION

The combination of chronic nicotine and pyrilamine reduced nicotine self-administration to a greater extent than treatment with either drug alone.

Increased ventro-medial prefrontal activations in schizophrenia smokers during cigarette cravings

BACKGROUND

Highly prevalent in schizophrenia, tobacco smoking substantially increases the risk of cardiac-related death. Compared to the general population, tobacco smoking cessation rates are lower in schizophrenia. Unfortunately, the reasons for these low cessation rates remain poorly understood. Recently, it has been shown that tobacco cravings are increased in schizophrenia smokers compared to smokers with no comorbid psychiatric disorder. In view of these results, we sought to examine - for the first time - the neurophysiologic responses elicited by cigarette cues in schizophrenia smokers. We hypothesized that cigarettes cues would elicit increased activations in brain regions involved in drug cravings in schizophrenia smokers relative to control smokers.

METHODS

Smokers with (n=18) and without (n=24) schizophrenia (DSM-IV criteria) were scanned using functional magnetic resonance imaging (fMRI) while viewing appetitive cigarette images.

RESULTS

Schizophrenia smokers and smokers with no psychiatric comorbidity did not differ in subjective cravings in response to appetitive smoking cues. However, in schizophrenia smokers relative to control smokers, we found that appetitive cigarette cues triggered increased activations of the bilateral ventro-medial prefrontal cortex, a core region of the brain reward system. Moreover, a negative correlation was observed between cigarette cravings and activations of the right ventro-medial prefrontal cortex in schizophrenia smokers.

DISCUSSION

The current results highlight a key role of the brain reward system in cigarette craving in schizophrenia, and suggest that the neurophysiologic mechanisms involved in the regulation of cue-induced cigarette craving are impaired in this population.

The human CHRNA7 and CHRFAM7A genes: A review of the genetics, regulation, and function

The human α7 neuronal nicotinic acetylcholine receptor gene (CHRNA7) is ubiquitously expressed in both the central nervous system and in the periphery. CHRNA7 is genetically linked to multiple disorders with cognitive deficits, including schizophrenia, bipolar disorder, ADHD, epilepsy, Alzheimer's disease, and Rett syndrome. The regulation of CHRNA7 is complex; more than a dozen mechanisms are known, one of which is a partial duplication of the parent gene. Exons 5-10 of CHRNA7 on chromosome 15 were duplicated and inserted 1.6 Mb upstream of CHRNA7, interrupting an earlier partial duplication of two other genes. The chimeric CHRFAM7A gene product, dupα7, assembles with α7 subunits, resulting in a dominant negative regulation of function. The duplication is human specific, occurring neither in primates nor in rodents. The duplicated α7 sequence in exons 5-10 of CHRFAM7A is almost identical to CHRNA7, and thus is not completely queried in high throughput genetic studies (GWAS). Further, pre-clinical animal models of the α7nAChR utilized in drug development research do not have CHRFAM7A (dupα7) and cannot fully model human drug responses. The wide expression of CHRNA7, its multiple functions and modes of regulation present challenges for study of this gene in disease. This article is part of the Special Issue entitled 'The Nicotinic Acetylcholine Receptor: From Molecular Biology to Cognition'.

The therapeutic potential of α7 nicotinic acetylcholine receptor (α7 nAChR) agonists for the treatment of the cognitive deficits associated with schizophrenia

Homomeric α7 nicotinic acetylcholine receptors (α7 nAChRs) have implications in the regulation of cognitive processes such as memory and attention, and have shown promise as a therapeutic target for the treatment of the cognitive deficits associated with schizophrenia. Multiple α7 nAChR agonists have entered human trials; however, unfavorable side effects and pharmacokinetic issues have hindered the development of a clinical α7 nAChR agonist. Currently, EVP-6124 is in phase III clinical trials, and several other α7 nAChR agonists (GTS-21 and AQW051) are in earlier stages of development. This review will summarize the recent advances and failures of α7 nAChR agonists in clinical trials for the treatment of the aforementioned pathology.

The effect of nicotine dependence on psychopathology in patients with schizophrenia

Introduction. Our study aims to determine the prevalence of nicotine dependence and investigate the effect of nicotine dependence on psychopathology among schizophrenia patients. Methods. A cross-sectional study was carried out in an outpatient psychiatric clinic at a general hospital in Malaysia. 180 recruited subjects were administered the Malay version of Mini International Neuropsychiatric Interview (MINI), the Positive and Negative Symptom Scale (PANSS), and the Malay version of Fagerstrom Test for Nicotine Dependence (FTND-M) questionnaires. Results. The prevalence of nicotine dependence among the subjects was 38.1% (n = 69) and they were mainly composed of male gender, Malay ethnicity, being treated with atypical antipsychotics, and taking other illicit drugs or alcohol. Subjects with severe nicotine dependence scored less in the negative subscale of PANSS compared with the nonsmokers (P = 0.011). On performing the hierarchy multiple regressions, dependence status still significantly predicted negative scores after adjusting the confounders (t = −2.87, P = 0.005). Conclusion. The rate of nicotine use disorder among schizophrenia patients in this study is higher than that of the general population in Malaysia. The significant association between nicotine dependence and negative psychopathology symptoms will help the healthcare practitioners in their management of nicotine dependence among schizophrenia patients.

Smoking in schizophrenic patients: A critique of the self-medication hypothesis

A common remark among laypeople, and notably also among mental health workers, is that individuals with mental illnesses use drugs as self-medication to allay clinical symptoms and the side effects of drug treatments. Roots of the self-medication concept in psychiatry date back at least to the 1980s. Observations that rates of smokers in schizophrenic patients are multiple times the rates for regular smoking in the general population, as well as those with other disorders, proved particularly tempting for a self-medication explanation. Additional evidence came from experiments with animal models exposed to nicotine and the identification of neurobiological mechanisms suggesting self-medication with smoking is a plausible idea. More recently, results from studies comparing smoking and non-smoking schizophrenic patients have led to the questioning of the self-medication hypothesis. Closer examination of the literature points to the possibility that smoking is less beneficial on schizophrenic symptomology than generally assumed while clearly increasing the risk of cancer and other smoking-related diseases responsible for early mortality. It is a good time to examine the evidence for the self-medication concept as it relates to smoking. Our approach is to focus on data addressing direct or implied predictions of the hypothesis in schizophrenic smokers.

The Psychosis Recent Onset GRoningen Survey (PROGR-S): defining dimensions and improving outcomes in early psychosis

Psychotic disorders are among the most complex medical conditions. Longitudinal cohort studies may offer further insight into determinants of functional outcome after a psychotic episode. This paper describes the Psychosis Recent Onset in GRoningen Survey (PROGR-S) that currently contains data on 1076 early-episode patients with psychosis, including symptoms, personality, cognition, life events and other outcome determinants. Our goal in this report is to give an overview of PROGR-S, as a point of reference for future publications on the effect of cognition, personality and psychosocial functioning on outcomes. PROGR-S contains an extensive, diagnostic battery including anamnesis, biography, socio-demographic characteristics, clinical status, drug use, neuropsychological assessment, personality questionnaires, and physical status tests. Extensive follow-up data is available on psychopathology, physical condition, medication use, and care consumption. Sample characteristics were determined and related to existing literature. PROGR-S (period 1997-2009, n = 718) included the majority of the expected referrals in the catchment area. The average age was 27 (SD = 8.6) and two-thirds were male. The average IQ was lower than that in the healthy control group. The majority had been diagnosed with a psychotic spectrum disorder. A substantial number of the patients had depressive symptoms (479/718, 78%) and current cannabis or alcohol use (465/718, 75%). The level of community functioning was moderate, i.e. most patients were not in a relationship and were unemployed. The PROGR-S database contains a valuable cohort to study a range of aspects related to symptomatic and functional outcomes of recent onset psychosis, which may play a role in the treatment of this complex and disabling disorder. Results reported here show interesting starting points for future research. Thus, we aim to investigate long-term outcomes on the basis of cognition, personality, negative symptoms and physical health. Ultimately, we hope that this paper will contribute improving the health of patients with psychotic disorders.

IV nicotine self-administration in rats using a consummatory operant licking response: sensitivity to serotonergic, glutaminergic and histaminergic drugs

Tobacco smoking is characterized by repeated self-administration of nicotine by placing the cigarette in the mouth. The repeated hand-to-mouth self-administration is essentially a consummatory act. We recently developed a paradigm in which rats lick one of two spouts to trigger intravenous (IV) delivery of nicotine, which combines a consummatory act with rapid delivery of nicotine to model the act of tobacco smoking. We have found that rats will lick hundreds of times per nicotine infusion. In the current study, using the operant licking nicotine self-administration model with young adult Sprague-Dawley rats (0.03mg/kg/infusion of nicotine), we tested the effect of antagonists of H1 histamine receptors pyrilamine, serotonin (5HT) type 2 receptors ketanserin and N-methyl-d-aspartate (NMDA) glutamate receptors with d-cycloserine as well as an agonist of 5HT2c receptors lorcaserin, in dose ranges that we have found in previous studies to significantly reduce IV nicotine self-administration with the operant lever press operand. The H1 antagonist pyrilamine significantly reduced operant licking for nicotine self-administration. Pyrilamine caused significant reductions in the operant licking paradigm at lower doses (10 and 20mg/kg) than those we previously observed to affect responding in the operant lever press paradigm. In contrast, the 5HT2A and C antagonist ketanserin did not show an effect of reducing nicotine self-administration in the same dose range we had found in a previous study to significantly reduce operant lever press nicotine self-administration. The 5HT2C agonist lorcaserin significantly decreased nicotine self-administration in the licking paradigm at the same dose threshold as with lever press responding. The NMDA glutamate partial agonist d-cycloserine did not produce any change in nicotine self-administration with the licking operand, in contrast to its effect on the classic lever-pressing task. The rat model incorporating consummatory aspects of tobacco addiction can provide distinct and potentially more relevant information concerning possible new avenues of treatment to combat tobacco addiction.

Antipsychotic medication and tobacco use among outpatients with schizophrenia: a cross-sectional study

BACKGROUND

Many studies have shown that the prevalence of smoking in schizophrenia is higher than in the general population. Biological, psychological and social factors influence smoking in patients with schizophrenia.

METHODS

The study was carried out in psychiatry outpatient clinics in a tertiary care hospital in Sri Lanka. Every third patient was selected using systematic sampling from patients diagnosed with schizophrenia according to ICD-10 clinical criteria. Smoking behaviours were assessed using self-reports. Severity of illness was assessed using Brief Psychiatric Rating Scale (BPRS). Fagerstrom Test for Nicotine Dependence assessed level of dependence. Readiness to Change Questionnaire assessed motivation to change smoking behaviour.

RESULTS

The sample consisted of 306 patients with schizophrenia. Mean age was 38.93 years (SD 10.98). There were 148 males (48.4%). Mean duration of illness was 12.63 years (SD 8.38). Current medication was oral atypical antipsychotics 103, clozapine 136, oral typicals 29 and depot typicals 38. Prevalence of tobacco use among males was 30.41% (95% CI 22.91 to 37.90) and among females 1.90% (95% CI -0.25 to 4.05). Prevalence of current smoking among males was 20.27% (95% CI 13.72 to 26.82). None of the females smoked. Prevalence of smokeless tobacco use among males was 10.14 (95% CI 5.22 to 15.05) and among females 1.90 (95% CI -0.03 to 4.05). When patients treated with clozapine were excluded from the analysis, prevalence of tobacco use was 41.6% among males and 3.2% among females and prevalence of smoking was 29.9% among males. Prevalence of tobacco use was lowest in patients treated with clozapine 18.31 (95% CI 9.09 to 27.53) and highest in those treated with depot antipsychotics 47.83 (95% CI 25.74 to 69.91).

CONCLUSIONS

Prevalence of smoking was less than in many countries. This is influenced by prevalence in the general population and low affordability. Risk of tobacco use was significantly less among patients treated with clozapine.

Allostatic load as a tool for monitoring physiological dysregulations and comorbidities in patients with severe mental illnesses

Severe mental illnesses like schizophrenia and bipolar disorder are disabling, chronic conditions that are often accompanied by medical comorbidities. In this theoretical article, we review the allostatic load model representing the "wear and tear" that chronic stress exacts on the brain and body. We propose an innovative way of monitoring physical and psychiatric comorbidities by integrating the allostatic load model into clinical practice. By interpreting peripheral biomarkers differently, medical professionals can calculate a simple, count-based, allostatic load index known to predict diverse stress-related pathologies. In addition to screening for comorbidities, allostatic load indices can be used to monitor the effects of pharmacological and psychosocial interventions. This framework can also be used to generate a dialogue between patient and practitioner to promote preventive and proactive approaches to health care.

Smoking behaviour and mental health disorders--mutual influences and implications for therapy

Tobacco use is strongly associated with a variety of psychiatric disorders. Smokers are more likely than non-smokers to meet current criteria for mental health conditions, such as mood disorders, anxiety disorders and psychosis. Evidence also suggest that smokers with psychiatric disorders may have more difficulty quitting, offering at least a partial explanation for why smoking rates are higher in this population. The mechanisms linking mental health conditions and cigarette smoking are complex and likely differ across each of the various disorders. The most commonly held view is that patients with mental health conditions smoke in an effort to regulate the symptoms associated with their disorder. However some recent evidence suggests that quitting smoking may actually improve mental health symptoms. This is particularly true if the tobacco cessation intervention is integrated into the context of ongoing mental health treatment. In this paper we reviewed and summarized the most relevant knowledge about the relationship between tobacco use and dependence and psychiatric disorders. We also reviewed the most effective smoking cessation strategies available for patients with psychiatric comorbidity and the impact of smoking behavior on psychiatric medication.

Do atypical antipsychotics really enhance smoking reduction more than typical ones?: the effects of antipsychotics on smoking reduction in patients with schizophrenia

Whether atypical antipsychotics (AAs) can enhance smoking reduction in schizophrenic patients remains controversial because of methodological limitations in existing studies. This study explored whether certain types of antipsychotics predict smoking reduction in schizophrenic patients. Three hundred eight smoking, predominantly male schizophrenic patients (271/308 [88.9%]) participated in an 8-week open-label study with antismoking medications (high-dose, low-dose nicotine transdermal patch and bupropion). Antipsychotics were classified into (1) typical antipsychotics (TAs) and (2) AAs, including multiacting receptor-targeted antipsychotics (clozapine, olanzapine, and quetiapine), serotonin-dopamine antagonists (risperidone), D2/D3 receptor antagonists (amisulpride), and partial dopamine receptor agonists (aripiprazole). A general linear model was used to explore whether types of antipsychotic predict changes in the number of cigarettes smoked per day (CPD) and the score of the Fagerstrom Test for Nicotine Dependence (FTND) while controlling for confounding factors. The type of antipsychotic (TAs or AAs) was not significantly associated with smoking cessation (n = 21; χ = 1.8; df = 4; P = 0.77). Regarding smoking reduction, the type of antipsychotic was significantly predictive of a change in the CPD (P = 0.027; partial eta square = 0.055) and FTND scores (P = 0.002; partial eta square = 0.073). The 95% confidence intervals of the estimated means of change in the CPD and FTND scores did not contain zero only among subjects on TAs or clozapine.These findings suggest that TAs and clozapine enhance smoking reduction compared with nonclozapine atypical antipsychotics in schizophrenic patients. The mechanisms underlying the effects of various antipsychotics on smoking reduction remain unclear and warrant future study.

Nicotine and clozapine cross-prime the locus coeruleus noradrenergic system to induce long-lasting potentiation in the rat hippocampus

A priming-challenge schedule of nicotine treatment causes long-lasting potentiation (LLP), a form of synaptic plasticity closely associated with the norepinephrine (NE) neurotransmitter system, at the medial perforant path (MPP)-dentate gyrus (DG) synapse in the rat hippocampus. Previous reports revealed that nicotine activates the locus coeruleus (LC) noradrenergic (NAergic) system and this mechanism may underlie its beta-adrenoceptor sensitive LLP effects. Clozapine, an atypical antipsychotic, is also known to activate the LC. Interactions between nicotine and clozapine are of interest because of the prevalence of smoking in patients with schizophrenia and increasing interest in the use of nicotinic receptor ligands as cognitive enhancers. Rats were subchronically primed with nicotine, clozapine or saline. Twenty-one to twenty-eight days later, the effects of the nicotine, clozapine or saline challenge on the evoked field excitatory postsynaptic potentials (fEPSP) at the MPP-DG monosynaptic pathway were recorded as a measure of LLP. We confirmed the hypothesis that a challenge dose of either nicotine or clozapine induces LLP exclusively in nicotine- and clozapine-primed rats, and not in saline-primed rats, thus indicating a cross-priming effect. Moreover, unilateral suppression of LC using lidocaine abolished the LLP induced by nicotine in clozapine-primed rats. Furthermore, systemic treatment with clonidine (an α2 adrenoceptor agonist that reduces NAergic activity via autoreceptors) prior to the challenge doses blocked the nicotine/clozapine-induced LLP in nicotine- and clozapine-primed rats. These findings may add to understanding of the cognitive enhancing effects of nicotine.

Interventions for smoking cessation and reduction in individuals with schizophrenia

BACKGROUND

Individuals with schizophrenia smoke more heavily than the general population and this contributes to their higher morbidity and mortality from smoking-related illnesses. It remains unclear what interventions can help them to quit or to reduce smoking.

OBJECTIVES

To evaluate the benefits and harms of different treatments for nicotine dependence in schizophrenia.

SEARCH METHODS

We searched electronic databases including MEDLINE, EMBASE and PsycINFO from inception to October 2012, and the Cochrane Tobacco Addiction Group Specialized Register in November 2012.

SELECTION CRITERIA

We included randomised trials for smoking cessation or reduction, comparing any pharmacological or non-pharmacological intervention with placebo or with another therapeutic control in adult smokers with schizophrenia or schizoaffective disorder.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed the eligibility and quality of trials, as well as extracted data. Outcome measures included smoking abstinence, reduction in the amount smoked and any change in mental state. We extracted abstinence and reduction data at the end of treatment and at least six months after the intervention. We used the most rigorous definition of abstinence or reduction and biochemically validated data where available. We noted any reported adverse events. Where appropriate, we pooled data using a random-effects model.

MAIN RESULTS

We included 34 trials (16 trials of cessation; nine trials of reduction; one trial of relapse prevention; eight trials that reported smoking outcomes for interventions aimed at other purposes). Seven trials compared bupropion with placebo; meta-analysis showed that cessation rates after bupropion were significantly higher than placebo at the end of treatment (seven trials, N = 340; risk ratio [RR] 3.03; 95% confidence interval [CI] 1.69 to 5.42) and after six months (five trials, N = 214, RR 2.78; 95% CI 1.02 to 7.58). There were no significant differences in positive, negative and depressive symptoms between bupropion and placebo groups. There were no reports of major adverse events such as seizures with bupropion.Smoking cessation rates after varenicline were significantly higher than placebo, at the end of treatment (2 trials, N = 137; RR 4.74, 95% CI 1.34 to 16.71). Only one trial reported follow-up at six months and the CIs were too wide to provide evidence of a sustained effect (one trial, N = 128, RR 5.06, 95% CI 0.67 to 38.24). There were no significant differences in psychiatric symptoms between the varenicline and placebo groups. Nevertheless, there were reports of suicidal ideation and behaviours from two people on varenicline.Two studies reported that contingent reinforcement (CR) with money may increase smoking abstinence rates and reduce the level of smoking in patients with schizophrenia. However, it is uncertain whether these benefits can be maintained in the longer term. There was no evidence of benefit for the few trials of other pharmacological therapies (including nicotine replacement therapy (NRT)) and psychosocial interventions in helping smokers with schizophrenia to quit or reduce smoking.

AUTHORS' CONCLUSIONS

Bupropion increases smoking abstinence rates in smokers with schizophrenia, without jeopardizing their mental state. Varenicline may also improve smoking cessation rates in schizophrenia, but its possible psychiatric adverse effects cannot be ruled out. CR may help this group of patients to quit and reduce smoking in the short term. We failed to find convincing evidence that other interventions have a beneficial effect on smoking in schizophrenia.

Iptakalim Preferentially Decreases Nicotine-induced Hyperlocomotion in Phencyclidine-sensitized Rats: A Potential Dual Action against Nicotine Addiction and Psychosis

Objective

Iptakalim is a putative ATP-sensitive potassium (K_ATP) channel opener. It is also a novel nicotinic acetylcholine receptor (nAChR) blocker and can antagonize nicotine-induced increase in dopamine release in the nucleus accumbens. Our recent work also shows that iptakalim exhibits a clozapine-like atypical antipsychotic profile, indicating that iptakalim may possess a dual action against nicotine addiction and schizophrenia.

Methods

The present study examined the potential therapeutic effects of iptakalim on nicotine use in schizophrenia. We created an animal model of comorbidity of nicotine addiction and schizophrenia by injecting male Sprague-Dawley rats with nicotine (0.40 mg/kg, subcutaneously[sc]) or saline, in combination with phencyclidine (PCP, 3.0 mg/kg, sc) or saline daily for 14 consecutive days.

Results

During the PCP/nicotine sensitization phase, PCP and nicotine independently increased motor activity over time. PCP also disrupted prepulse inhibition (PPI) of acoustic startle response. Acute nicotine treatment attenuated the PCP-induced hyperlocomotion and PCP-induced disruption of PPI, whereas repeated nicotine treatment potentiated these effects. Importantly, pretreatment with iptakalim (10-20 mg/kg, intraperitoneally) reduced nicotine-induced hyperlocomotion in a dose-dependent fashion. This reduction effect was highly selective: it was more effective in rats previously sensitized to the combination of PCP and nicotine, but less effective in rats sensitized to saline, nicotine alone or PCP alone.

Conclusion

To the extent that the combined nicotine and PCP sensitization mimics comorbid nicotine addiction in schizophrenia, the preferential inhibitory effect of iptakalim on nicotine-induced hyperlocomotion suggests that iptakalim may be a potential useful drug for the treatment nicotine abuse in schizophrenia.

Is it time to consider comorbid substance abuse as a new indication for antipsychotic drug development?

Comorbid drug abuse in schizophrenia has been consistently reported as high, with estimates ranging between 10-70%. Comorbid addictive states in schizophrenia are possibly multifactorial, yet recent research assigns a significant neurobiological role in its genesis. Abnormalities in hippocampal/cortical function in schizophrenia which mediate reward and reinforcement behavior are identified as central to the development and maintenance of comorbid addictive states. Preliminary data suggest that the vulnerability of patients with schizophrenia to substance use disorders may be a primary disease symptom. The management of comorbid substance abuse in schizophrenia relies on the use of antipsychotic medications. Recent data raise the concern about whether first-generation antipsychotics in long-term use can conversely lead to enhancement of the abused substance's reinforcing properties. Some recent reports have assigned a favorable outcome to clozapine and second-generation antipsychotics, pointing to a possible differential role for various antipsychotics. In view of the high prevalence of comorbid drug abuse in schizophrenia, its impact on outcome of treatment and the recent emerging neurobiological information, it is my contention that comorbid drug abuse constitutes a dimension by itself and deserves to receive an indication in the development of new antipsychotics similar to negative symptoms or cognitive deficits.

Olanzapine vs. risperidone in patients with first-episode schizophrenia and a lifetime history of cannabis use disorders: 16-week clinical and substance use outcomes

The purpose of this study is to compare the efficacy of olanzapine and risperidone for the acute treatment of first-episode schizophrenia patients with cannabis use disorders. This secondary analysis of a previously published study included 49 first-episode patients with a diagnosis of schizophrenia, schizophreniform disorder, or schizoaffective disorder and a co-occurring lifetime diagnosis of cannabis use disorders randomly assigned to treatment with either olanzapine (n=28) or risperidone (n=21) for 16weeks. The olanzapine group did not differ significantly from the risperidone group for initial response rates of positive symptoms, and rates of cannabis use or alcohol use during the study. Positive symptoms and the Scale for Assessment of Negative Symptoms (SANS) global asociality-anhedonia scores improved over time but did not differ between study medications. In both groups, cannabis use during the study was higher in patients who used cannabis within three months of the admission. Thus, our results suggest that olanzapine and risperidone had a similar initial efficacy on psychotic symptoms and substance use in first-episode patients with co-occurring cannabis use disorders. If clinicians are choosing between olanzapine versus risperidone treatment for this population, their decision should be based upon factors other than symptom response and short-term substance misuse.

A transdisciplinary perspective of chronic stress in relation to psychopathology throughout life span development

The allostatic load (AL) model represents an interdisciplinary approach to comprehensively conceptualize and quantify chronic stress in relation to pathologies throughout the life cycle. This article first reviews the AL model, followed by interactions among early adversity, genetics, environmental toxins, as well as distinctions among sex, gender, and sex hormones as integral antecedents of AL. We next explore perspectives on severe mental illness, dementia, and caregiving as unique human models of AL that merit future investigations in the field of developmental psychopathology. A complimenting transdisciplinary perspective is applied throughout, whereby we argue that the AL model goes beyond traditional stress–disease theories toward the advancement of person-centered research and practice that promote not only physical health but also mental health.

The role of antipsychotics in smoking and smoking cessation

Persons with severe and persistent mental illnesses, e.g. schizophrenia spectrum disorders and bipolar disorder, smoke at a much higher rate than the general population. Treatment options for schizophrenia spectrum disorders and bipolar disorder often include the first-generation (typical) and second-generation (atypical) antipsychotics, which have been shown to be effective in treating both psychotic and mood symptoms. This article reviews studies examining the relationship between antipsychotic medication and cigarette smoking. These studies suggest that in persons with schizophrenia and schizoaffective disorder, typical antipsychotics may increase basal smoking and decrease people's ability to stop smoking, whereas atypical antipsychotics decrease basal smoking and promote smoking cessation. However, we found that the data available were generally of moderate quality and from small studies, and that there were conflicting findings. The review also critically assesses a number of potential mechanisms for this effect: the use of smoking as a form of self-medication for the side effects of antipsychotics, the effect of antipsychotics on smoking-related cues and the effect of antipsychotics on the appreciation of the economic cost of smoking behaviour. Gaps in the research are noted and recommendations for further study are included. More study of this important issue is needed to clarify the effect of antipsychotics on smoking behaviours.

Antipsychotic agents for the treatment of substance use disorders in patients with and without comorbid psychosis

Substance dependence has serious negative consequences upon society such as increased health care costs, loss of productivity, and rising crime rates. Although there is some preliminary evidence that atypical antipsychotic agents may be effective in treating substance dependence, results have been mixed, with some studies demonstrating positive and others negative or no effect. The present study was aimed at determining whether this disparity originates from that reviewers separately discussed trials in patients with (DD) and without (SD) comorbid psychosis. Using electronic databases, we screened the relevant literature, leaving only studies that used a randomized, double-blind, placebo-controlled or case-control design that had a duration of 4 weeks or longer. A total of 43 studies were identified; of these, 23 fell into the category of DD and 20 into the category of SD. Studies in the DD category suggest that atypical antipsychotic agents, especially clozapine, may decrease substance use in individuals with alcohol and drug (mostly cannabis) use disorders. Studies in the SD category suggest that atypical antipsychotic agents may be beneficial for the treatment of alcohol dependence, at least in some subpopulations of alcoholics. They also suggest that these agents are not effective at treating stimulant dependence and may aggravate the condition in some cases.

Interventions for smoking cessation and reduction in individuals with schizophrenia

BACKGROUND

Patients with schizophrenia smoke more heavily than the general population and this contributes to their higher morbidity and mortality from smoking-related illnesses. It remains unclear what interventions can help them to quit or reduce smoking.

OBJECTIVES

To evaluate the benefits and harms of different treatments for nicotine dependence in schizophrenia.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group Specialized Register and electronic databases including MEDLINE, EMBASE and PsycINFO from inception to April 2010.

SELECTION CRITERIA

We included randomized trials for smoking cessation or reduction, comparing any pharmacological or non-pharmacological intervention with placebo or with another therapeutic control in adult smokers with schizophrenia or schizoaffective disorder.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed the eligibility and quality of trials and extracted data. Outcome measures included smoking abstinence, reduction in the amount smoked and any change in mental state. We extracted abstinence and reduction data at the end of treatment and at least six months after the intervention. We used the most rigorous definition of abstinence or reduction and biochemically validated data where available. Any reported adverse events were noted. Where appropriate, we pooled data using a random effects model.

MAIN RESULTS

We included 21 trials (11 trials of smoking cessation; four trials of smoking reduction; one trial for relapse prevention; five trials reported smoking outcomes for interventions aimed at other purposes). Seven trials compared bupropion with placebo; meta-analysis showed that smoking cessation rates after bupropion were significantly higher than placebo at the end of treatment (seven trials, N=340; risk ratio [RR] 2.84; 95% confidence interval [CI] 1.61 to 4.99) and after six months (five trials, N=214, RR 2.78; 95% CI 1.02 to 7.58). Expired carbon monoxide (CO) level and the number of cigarettes smoked daily were significantly lower with bupropion at the end of therapy but not after six months. There were no significant differences in positive, negative and depressive symptoms between bupropion and placebo group. There was no report of major adverse event such as seizures with bupropion.Contingent reinforcement (CR) with money may increase smoking abstinence rates and reduce the level of smoking in patients with schizophrenia. However, it is uncertain whether these benefits are maintained in the longer term. There was no evidence of benefit for the few trials of other pharmacological therapies (including nicotine replacement therapy (NRT)) and psychosocial interventions in helping smokers with schizophrenia to quit or reduce smoking.

AUTHORS' CONCLUSIONS

Bupropion increases smoking abstinence rates in smokers with schizophrenia, without jeopardising their mental state. Bupropion may also reduce the amount these patients smoke. CR may help this group of patients to quit and reduce smoking. We failed to find convincing evidence that other interventions have a beneficial effect on smoking behaviour in schizophrenia.

Validity of self-reported smoking in schizophrenia patients

AIMS

It is important to evaluate smoking status among schizophrenia patients because such patients are highly inclined to take up smoking, but only a few studies have focused on the validity of self-reported smoking in relation to schizophrenia. The aim of the present study was therefore to determine the validity of self-reported smoking and to investigate whether self-reported smoking is biased in schizophrenia patients.

METHODS

A total of 158 schizophrenia patients answered self-rated questions of smoking status, and the level of carbon monoxide (CO) in expired air was measured. The relationship of the self-reported smoking to the CO levels was determined, and interaction of the disease duration and education level on this relationship was evaluated using correlation and receiver operating characteristic analyses.

RESULTS

The CO levels in the expired air were found to be positively related to the self-reported data (P < 0.01). The stratified data on the duration of schizophrenia indicated that the positive relationship between self-reported smoking and the CO concentration became less obvious with the increase in duration of schizophrenia (P(trend) < 0.01). In contrast, the stratified data on education level did not indicate any such significant modifying effect.

CONCLUSIONS

Although self-reporting is useful for evaluating smoking status, psychiatrists should use objective methods of measurement to assess the smoking status of chronic schizophrenia patients.

Is implementation of the 5 A's of smoking cessation at community mental health centers effective for reduction of smoking by patients with serious mental illness?

We tested whether implementing the "5 A's" (Ask, Advise, Assess, Assist, Arrange) at six mental health centers reduces smoking among persons with serious mental illness. One hundred and fifty six patients were evaluated just before initiating the 5 A's and after six and 12 months. A delayed control condition evaluated 148 patients six months before 5 A's implementation, just before and then after six months. Six months of the 5 A's produced no effect. Modest cessation and reduction benefits were noted after 12 months. Implementing the 5 A's at community mental health centers may have modest benefit after twelve months.

Nicotine-induced memory impairment by increasing brain oxidative stress

Male Wistar rats were subjected to chronic nicotine treatment (0.3 mg/kg; 7 continuous days) and their memory performance was studied by means of Y-maze and multi-trial passive avoidance tasks. Nicotine significantly decreased spontaneous alternation in Y-maze task and step-through-latency in the multi-trial passive avoidance task, suggesting effects on both short-term memory and long-term memory, respectively. In addition, nicotine induced neuronal apoptosis, DNA fragmentation, reduced antioxidant enzymes activity, and increased production of lipid peroxidation and reactive oxygen species, suggesting pro-oxidant activity. Our results provide further support that nicotine-induced memory impairment is due to an increase in brain oxidative stress in rats.

Management of patients presenting with acute psychotic episodes of schizophrenia

The initial management of patients with schizophrenia presenting to psychiatric emergency departments with an acute psychotic episode requires rapid decisions to be made by physicians concerning the treatment of individuals who are likely to be relatively uncooperative, agitated and lacking insight. The treatment decision must be adapted to the individual characteristics and needs of each patient. This article reviews the issues from the perspective of the initial management of acute psychosis as it is currently practised in Europe, and discusses the pragmatic implications for initial treatment decisions and the elaboration of a long-term treatment plan. Initially, administration of antipsychotics to control psychotic symptoms and benzodiazepines to control agitation represents the cornerstone of treatment. Oral medication is preferable to injectable forms wherever possible, and atypical antipsychotics are to be preferred over conventional agents because of their lower risk of extrapyramidal adverse effects, which are a major determinant of poor adherence to treatment. Whatever antipsychotic is chosen by the physician during the initial period, it is likely that it will need to be continued for many years, and it is thus important to take into account the long-term safety profile of the drug chosen, particularly in relation to extrapyramidal adverse effects, metabolic complications and quality of life. Building a therapeutic alliance with the patient and his/her family or carers is an important element that should be included in the initial management of psychosis. The long-term goal should be to minimize the risk of psychotic relapse through adequate treatment adherence.

Management of smoking cessation in patients with psychiatric disorders

BACKGROUND

There is a close relationship between tobacco smoking and psychiatric disorders, and a higher proportion of individuals with mental health conditions smoke compared with the general population. Due to the increased smoking prevalence in this population, patients with psychiatric conditions are at greater risk of smoking-related morbidity and mortality and experience detrimental effects on their quality of life. However, while the majority of individuals with a history of mental health conditions appreciate that smoking is detrimental to their health, they are less likely to quit smoking and have a lower success rate during quit attempts compared with the general population.

SCOPE

Peer-reviewed articles were identified from PubMed using the inclusive date-range of 1990 - October 2008 and the search terms; depression, mental health, psychiatric disorders, schizophrenia, and smoking cessation. Articles were selected from the search results to provide a general overview of some of the main issues for smokers with psychiatric disorders in general and specifically, those with schizophrenia and depression. The evidence from smoking cessation trials within these populations was also reviewed.

FINDINGS

Nicotine has some positive effects on symptoms of psychiatric disorders and it has been proposed that patients with mental health conditions may smoke as a form of self-medication. Further, several studies have shown that some symptoms of psychiatric disorders may be exacerbated by nicotine withdrawal. Therefore, attempts to quit smoking pose additional problems to patients with mental health problems.

CONCLUSION

Traditional programmes for smoking cessation may not always be suitable for psychiatric patients due to their neuropsychological profile. Preliminary evidence suggests that more flexible, open-ended, combination approaches of pharmacotherapy and counselling may be more successful. In addition, identification and treatment of nicotine addiction remains very low in patients with mental health conditions and far more needs to be done to raise the awareness and ability of psychiatrists to diagnose and treat patients with nicotine problems.

Clozapine versus typical neuroleptic medication for schizophrenia

BACKGROUND

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

OBJECTIVES

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

SEARCH STRATEGY

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

SELECTION CRITERIA

All relevant randomised clinical trials (RCTs).

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Ketanserin, a 5-HT2 receptor antagonist, decreases nicotine self-administration in rats

Nicotine intake constitutes a principal mechanism for tobacco addiction. In addition to primary effects on nicotinic acetylcholine receptors, nicotine has cascading effects, which may also underlie its neurobehavioral actions. Nicotine induces serotonin (5-HT) release, which has not classically been thought to be involved in tobacco addiction as dopamine has. However, addiction can be characterized more as a disorder of compulsion than a disorder of enjoyment. 5-HT mechanisms play key roles in compulsive disorders. Nicotine-induced 5-HT release may be a key to tobacco addiction. Ketanserin, a 5-HT2a and 5-HT2c receptor antagonist, significantly attenuates nicotine effects on attention and memory. These studies were conducted to determine if ketanserin would reduce nicotine self-administration in rats. Male Sprague-Dawley rats (N=12) were given initial food pellet training and then 10 sessions of nicotine self-administration training (0.03 mg/kg/infusion, i.v.). Then the rats were administered ketanserin (1 or 2 mg/kg, s.c.) or the saline vehicle. Ketanserin (2 mg/kg) significantly decreased nicotine self-administration. This did not seem to be due to sedative or amnestic effects of ketanserin. In a second study, the effects of repeated administration of 2 mg/kg ketanserin (N=11) vs. saline injections (N=10) were examined. In the initial phase, the acute effectiveness of ketanserin in significantly reducing nicotine self-administration was replicated. The effect became attenuated during the following several sessions, but the significant effect became re-established during the final phases of this two-week study. 5-HT mechanisms play critical roles in the maintenance of nicotine self-administration. Better understanding of those roles may help lead to new 5-HT-based treatments for tobacco addiction.

Effects of nicotine on quinpirole- and dizocilpine (MK-801)-induced sensorimotor gating impairments in rats

RATIONALE

Prepulse inhibition (PPI) of the acoustic startle response (ASR) is used as an index of sensorimotor gating to assess preattentive processes. Impairments in PPI have been observed in many neuropsychiatric disorders, especially schizophrenia. Administration of the glutamate N-methyl-D-aspartate receptor antagonist dizocilpine (MK-801) or dopamine receptor (D2/D3) agonist quinpirole (QNP) results in impairment (reduction) of PPI in rats. Nicotine, on the other hand, may have beneficial effects on attentional/cognitive functions.

OBJECTIVE

The purpose of the current set of experiments was to investigate the effects of acute and chronic nicotine on MK-801- and QNP-induced PPI impairments.

MATERIALS AND METHODS

Adult female Sprague-Dawley rats were treated acutely or chronically by various doses of nicotine alone or followed by an acute dose of MK-801 (0.15 mg/kg) or QNP (0.5 mg/kg). All drugs were administered intraperitoneally. Controls received saline in lieu of any drug, and ASR and PPI in each animal was evaluated 10 min after the last injection.

RESULTS

Both MK-801 and QNP consistently impaired PPI. Administration of nicotine acutely (0.05-0.4 mg/kg) or chronically (0.2 or 0.4 mg/kg daily for 1 week) did not have any effect of its own on ASR or PPI or on MK-801-induced PPI impairment. Acute administration of 0.2 mg/kg nicotine did not have any effect on QNP-induced reduction in PPI, whereas the higher dose of 0.4 mg/kg significantly attenuated this impairment. Chronic daily administration of either 0.2 or 0.4 mg/kg nicotine for 1 week nearly normalized the QNP-induced impairments in PPI.

CONCLUSION

The effect of nicotine on sensorimotor gating is dependent on the procedure as well as the dose of nicotine and appears to be efficacious against dopaminergic rather than glutamatergic disruption of PPI in rats.

Olanzapine improves deficient sensory inhibition in DBA/2 mice

Most schizophrenia patients do not inhibit their P50 auditory evoked potential to the second of duplicate auditory stimuli, reflecting a failure to inhibit responses to irrelevant sensory input. Typical antipsychotic drugs do not improve this deficit while some atypical antipsychotics do. A previous study using an animal model, deficient P20-N40 (which corresponds to the human P50) inhibitory processing in DBA/2 mice found that sensory inhibition was improved by clozapine, the prototypical atypical antipsychotic, but not by haloperidol, a typical antipsychotic. The improvement after clozapine was mediated by alpha7 nicotinic receptors. The present study addresses whether another atypical antipsychotic, olanzapine, will also improve sensory inhibition deficits in the mouse model. In vivo electrophysiological recordings of the P20-N40 auditory evoked potential in anesthetized DBA/2 mice, which spontaneously exhibit a schizophrenia-like inhibitory processing deficit, were obtained after olanzapine alone (0.01, 0.033, 0.1, 0.33 mg/kg, IP) and the efficacious dose of olanzapine (0.033 mg/kg, IP) in combination with either the alpha7 nicotinic receptor antagonist alpha-bungarotoxin or the alpha4beta2 nicotinic receptor antagonist di-hydro-beta-erythroidine. All doses of olanzapine produced improved P20-N40 inhibitory processing in DBA/2 mice. The normalization observed after the 0.033 mg/kg dose of olanzapine was due to a selective decrease in response to the second auditory stimulus indicating an increase in inhibitory processing. This improvement was blocked by pre-administration of alpha-bungarotoxin but not di-hydro-beta-erythroidine. Like clozapine, olanzapine acts via alpha7 nicotinic receptors to elicit improved inhibitory processing of auditory stimuli.

Acute risperidone treatment did not increase daily cigarette consumption or plasma levels of cotinine and caffeine: a pilot study

Excessive cigarette smoking and caffeine intake are often seen in schizophrenic patients being treated with antipsychotic drugs, particularly typical antipsychotic drugs. Using nicotine and caffeine sometimes influences psychotic symptoms in these patients. Clozapine is the only antipsychotic drug reported to reduce the amount of cigarette smoking, however, still remains controversial of its efficacy. In the present study, we examined the effect of acute risperidone treatment on the amount of cigarette smoking and plasma levels of cotinine and caffeine in schizophrenic patients. Treatment with risperidone for 4 weeks did not increase daily cigarette consumption or plasma levels of cotinine and caffeine. The results suggest that acute risperidone treatment does not promote the intake of nicotine and caffeine at least by 4 weeks in schizophrenic patients.