Effects of zopiclone on sleep and symptoms in schizophrenia: comparison with benzodiazepine hypnotics

Pharmacologic Treatment Options for Insomnia in Patients with Schizophrenia

Background: Symptoms of sleep disorders, such as disturbances in sleep initiation and continuity, are commonly reported in patients with schizophrenia, especially in the acute phase of illness. Studies have shown that up to 80% of patients diagnosed with schizophrenia report symptoms of insomnia. Sleep disturbances have been shown to increase the risk of cognitive dysfunction and relapse in patients with schizophrenia. Currently, there are no medications approved specifically for the treatment of insomnia in patients with schizophrenia. Methods: A literature search was performed through OVID and PubMed to compile publications of pharmacotherapy options studied to treat insomnia in patients with schizophrenia. Articles were reviewed from 1 January 2000 through 1 March 2018 with some additional earlier articles selected if deemed by the authors to be particularly relevant. Results: Pharmacotherapies collected from the search results that were reviewed and evaluated included melatonin, eszopiclone, sodium oxybate, and antipsychotics. Conclusions: Overall, this review confirmed that there are a few evidence-based options to treat insomnia in patients with schizophrenia, including selecting a more sedating second-generation antipsychotic such as paliperidone, or adding melatonin or eszopiclone. Further randomized controlled trials are needed.

Pharmacological Treatment for Long-Term Patients with Schizophrenia and Its Effects on Sleep in Daily Clinical Practice: A Pilot Study

Background: Pharmacological treatment is still the key intervention in the disease management of long-term patients with schizophrenia; however, how it affects sleep and whether gender differences exist remains unclear. Methods: Forty-six long-term outpatients with schizophrenia entered the study. The numbers of antipsychotics, sleep medications, antidepressants, and anxiolytics were analyzed. Moreover, all patients were tested using the Pittsburgh Sleep Quality Index (PSQI) and the Epworth Sleepiness Scale (ESS). Correlation analyses were conducted between the medication used and the scores on the two subjective sleep inventories. Results: A large variability, ranging from 0 to 8, in the total number of psychiatric drugs per person was found between the patients. Despite ongoing pharmacological treatment, the patients scored high on the PSQI, but not on the ESS; this indicates that they report problems with sleep, but not with daytime sleepiness. A significant positive correlation between the use of antipsychotics and the ESS score, but not the PSQI score, was found; moreover, no gender differences were found. Conclusions: A large variability exists in the pharmacological treatment of long-term patients with schizophrenia. To date, patients’ sleep problems have been insufficiently treated, and gender differences have not been adequately accounted for in the pharmacological treatment of schizophrenia. More and larger international clinical studies are warranted to verify the findings of the present preliminary pilot study before any firm conclusions can be drawn and before any changes to the drug treatment of male and female patients with schizophrenia can be recommended.

Eszopiclone for persistent negative symptoms in schizophrenia - An unintended N-of-1 study

Persistent negative and cognitive symptoms in patients with schizophrenia pose a significant challenge to clinicians. Being a heterogeneous cluster of symptoms with potentially distinct underlying pathogenesis, it is important to examine novel therapies based on emerging neurobiological evidence. Eszopiclone is known to enhance the deficient sleep spindles that are related to impairments in learning and memory in schizophrenia. In this report we highlight the potential utility of eszopiclone in treating persistent negative symptoms in a patient with chronic schizophrenia. The unintended N-of-1 design that spanned out over a period of 24weeks demonstrated improvements in negative symptoms while the patient was on eszopiclone and worsening of these symptoms while unintentionally being off eszopiclone treatment. These observations suggest a reasonable degree of specificity of our patient's response to eszopiclone, thus warranting future sleep-EEG guided systematic studies.

The impact of eszopiclone on sleep and cognition in patients with schizophrenia and insomnia: a double-blind, randomized, placebo-controlled trial

BACKGROUND

Insomnia is frequent in schizophrenia and may contribute to cognitive impairment as well as overuse of weight inducing sedative antipsychotics. We investigated the effects of eszopiclone on sleep and cognition for patients with schizophrenia-related insomnia in a double-blind placebo controlled study, followed by a two-week, single-blind placebo phase.

METHODS

Thirty-nine clinically stable outpatients with schizophrenia or schizoaffective disorder and insomnia were randomized to either 3mg eszopiclone (n=20) or placebo (n=19). Primary outcome measure was change in Insomnia Severity Index (ISI) over 8 weeks. Secondary outcome measure was change in MATRICS Consensus Cognitive Battery (MATRICS). Sleep diaries, psychiatric symptoms, and quality of life were also monitored.

RESULTS

ISI significantly improved more in eszopiclone (mean=-10.7, 95% CI=-13.2; -8.2) than in placebo (mean=-6.9, 95% CI=-9.5; -4.3) with a between-group difference of -3.8 (95% CI=-7.5; -0.2). MATRICS score change did not differ between groups. On further analysis there was a significant improvement in the working memory test, letter-number span component of MATRICS (mean=9.8±9.2, z=-2.00, p=0.045) only for subjects with schizophrenia on eszopiclone. There were improvements in sleep diary items in both groups with no between-group differences. Psychiatric symptoms remained stable. Discontinuation rates were similar. Sleep remained improved during single-blind placebo phase after eszopiclone was stopped, but the working memory improvement in patients with schizophrenia was not durable.

CONCLUSIONS

Eszopiclone stands as a safe and effective alternative for the treatment of insomnia in patients with schizophrenia. Its effects on cognition require further study.

In thrombin stimulated human platelets Citalopram, Promethazine, Risperidone, and Ziprasidone, but not Diazepam, may exert their pharmacological effects also through intercalation in membrane phospholipids in a receptor-independent manner

Intercalation of drugs in the platelet membrane affects phospholipid-requiring enzymatic processes according to the drugs' intercalation capability. We investigated effects of Promethazine, Citalopram, Ziprasidone, Risperidone, and Diazepam on phospholipase A(2) (PLA(2)) and polyphosphoinositide (PPI) metabolism in thrombin-stimulated human platelets. We also examined effects of the drugs on monolayers of glycerophospholipids using the Langmuir technique. Diazepam did not influence PLA( 2 ) activity, had no effects on PPI cycle, and caused no change in mean molecular area of phospholipid monolayers. The remaining psychotropic drugs affected these parameters in different ways and levels of potency suggesting that they act by being intercalated between the molecules of adjacent membrane phospholipids, thus causing changes in substrate availability for phospholipid-hydrolyzing enzymes (PLA(2) and Phospholipase C). We show that several psychotropic drugs can also have other cellular effects than receptor antagonism. These effects may be implicated in the psychotropic effects of the drugs and/or their side effects.

GABA and schizophrenia: a review of basic science and clinical studies

BACKGROUND

A converging body of evidence implicates the gamma-aminobutyric acid (GABA) neurotransmitter system in the pathogenesis of schizophrenia.

METHODS

The authors review neuroscience literature and clinical studies investigating the role of the GABA system in the pathophysiology of schizophrenia. First, a background on the GABA system is provided, including GABA pharmacology and neuroanatomy of GABAergic neurons. Results from basic science schizophrenia animal models and human studies are reviewed. The role of GABA in cognitive dysfunction in schizophrenia is then presented, followed by a discussion of GABAergic compounds used in monotherapy or adjunctively in clinical schizophrenia studies.

RESULTS

In basic studies, reductions in GABAergic neuronal density and abnormalities in receptors and reuptake sites have been identified in several cortical and subcortical GABA systems. A model has been developed suggesting GABA's role (including GABA-dopamine interactions) in schizophrenia. In several clinical studies, the use of adjunctive GABA agonists was associated with greater improvement in core schizophrenia symptoms.

CONCLUSIONS

Alterations in the GABA neurotransmitter system are found in clinical and basic neuroscience schizophrenia studies as well as animal models and may be involved in the pathophysiology of schizophrenia. The interaction of GABA with other well-characterized neurotransmitter abnormalities remains to be understood. Future studies should elucidate the potential therapeutic role for GABA ligands in schizophrenia treatment.

Association between delta waves during sleep and negative symptoms in schizophrenia. Pharmaco-eeg studies by using structurally different hypnotics

We examined the effects of benzodiazepine (BZD) hypnotics and zopiclone (ZPC), a nonbenzodiazepine hypnotic, on sleep and psychiatric symptoms in schizophrenia, as well as the clinical correlates of these variables. Seven male schizophrenic patients chronically taking neuroleptics together with BZD were studied. We replaced BZD with ZPC and performed polysomnography (PSG) and Brief Psychiatric Rating Scale (BRPS) scoring before and after an 8-week ZPC treatment. The replacement of BZD with ZPC increased the mean amplitude of high-amplitude low-frequency delta waves on the frontal derivation recognized by period-amplitude analysis, and it decreased the BPRS negative-symptom score. Under the BZD treatment, the negative-symptom score correlated inversely with the mean amplitude of high-amplitude low-frequency delta waves. This correlation was weak and not significant under the ZPC treatment. Therefore, delta waves during sleep have a close correlation to negative symptoms in schizophrenia, and such a correlation could be influenced by hypnotics. Although these are preliminary findings, it was suggested that, compared with BZD, ZPC might be a beneficial hypnotic in regard to both sleep and negative symptoms of chronic schizophrenic patients.