Treatment of depression in first episode of schizophrenia: results from EUFEST

Treatment of post-psychotic depression in first-episode psychosis. A systematic review

BACKGROUND

Post-psychotic depression (PPD) after a FEP (first-episode psychosis) differs from other depressive symptoms in chronic schizophrenia in its aetiology, symptomatology, and prognostic implications. The objective was to search if any pharmacological or non-pharmacological interventions have proven to be effective on depressive symptoms after a FEP.

METHODS

for this systematic review we systematically searched and screened PubMed for articles published from August 1975 to October 15, 2020, with the terms: treatment AND first-episode psychosis OR post-psychotic OR post-schizophrenic AND depression.

RESULTS

we identified 139 articles of which 20 met the inclusion criteria. These interventions were then categorized into four subgroups (antipsychotics, antidepressants, psychological and miscellaneous).

LIMITATIONS

this review has several limitations. The reviewed studies were heterogeneous as to assessments, interventions, and samples; furthermore, only one study had PPD in FEP as its primary outcome.

CONCLUSIONS

to our knowledge, this is the first review of PPD in a FEP's treatment. PPD continues to be a diagnostic and therapeutic challenge. The available evidence for the use of treatment whether pharmacological or non-pharmacological is limited. However, certain approaches such as online therapy and treatment with n-3 polyunsaturated fatty acids (PUFA) show promising results. It could be of interest for future studies to focus not only on the treatment of PPD but also on the diagnostic heterogeneity of the sample and the adaptation of the content of the intervention to the individual.

Anxious-depressive symptoms after a first episode of schizophrenia: Response to treatment and psychopathological considerations from the 2-year "Parma Early Psychosis" program

Depression is common in schizophrenia and is correlated with suicide risk and poor long-term outcomes. However, the presence of depressive symptoms is often underestimated in both research and treatment, particularly at the illness onset. The goals of this study were: (a) to longitudinally observe anxious-depressive symptom levels in patients with First Episode Schizophrenia (FES) during a 24 months of follow-up period, and (b) to examine their associations with other psychopathology and the intervention patients received in an "Early Intervention in Psychosis" (EIP) program during the follow-up period. The Global Assessment of Functioning (GAF) and the Positive And Negative Syndrome Scale (PANSS) were completed by 159 FES patients both at baseline and across the follow-up. Data were analyzed by linear regression analysis and Spearman's coefficients. Anxious-depressive symptoms had significant longitudinal associations with GAF deterioration and PANSS "Positive Symptoms", "Negative Symptoms" and "Disorganization" subscores. During the follow-up period, FES participants significantly improved the level of anxious-depressive symptoms. This was significantly associated with the number of case management and individual psychotherapy meetings the patient engaged in, as well as with lower antipsychotic doses prescribed during the follow-up period. In conclusion, anxious-depressive symptoms are prominent in FES and at the initial entry into EIP programs. Anxious-depressive symptom severity tends to diminish overtime, especially with the provision of specialized EIP treatments. However, since we did not have a control population studied in parallel, we cannot say whether these results are specific to the protocols of EIP programs or just to the intensity of engagement in care.

Association between depression in chronic phase and future clinical outcome of patients with schizophrenia

RATIONALE

Depression in schizophrenia is an important symptom. We investigated whether depression and suicidal symptoms in the chronic phase are related to remote future clinical outcomes in patients with schizophrenia and whether psychotropics improved clinical outcomes.

OBJECTIVES

The subjects included 462 outpatients of working age (15 to 64 years old) with schizophrenia treated at Okayama University Hospital from January 2010 to December 2011. We investigated the relationship between the Clinical Global Impression-Severity score at the last visit (average 19.2 years) and the existence of previous depression, suicidal ideas, and suicide attempts. We adjusted by several possible confounders including medical history using multiple regression analysis or logistic regression analysis.

RESULTS

Of 462 patients, 168 (36.4%) presented with depression 2 years after schizophrenia onset. A history of suicidal ideas and attempts was related to worse clinical outcome. In males, a history of depression was related to worse clinical outcome, but not in females. Lithium carbonate was related to better clinical outcome in all schizophrenia patients with depression, especially in males. Treatment with antidepressants was related to better clinical outcome only in males.

CONCLUSIONS

A history of depression or suicidal symptoms in the chronic phase predicted the future worse clinical outcome in patients with schizophrenia. The administration of lithium carbonate or antidepressants might be recommended, especially to male schizophrenia patients with depression.

Diagnosis and Treatment of Depression in Patients with Schizophrenia

Depression is the third most common illness among patients with schizophrenia which negatively affects the course of the disease and significantly contributes to the mortality rate, due to increased suicide. Depression, along with negative symptoms and cognitive deficits, is one of the main factors that significantly decreases the quality of life and the disease prognosis in patients with schizophrenia. In addition, depression increases the frequency of exacerbations and readmissions, decreases the quality and duration of remissions and is associated with more frequent substance abuse and an increased economic burden. Data on the prevalence of depression among patients with schizophrenia are contradictory and are associated with a low detection rate of depression in such patients, a lack of clear diagnostic criteria and difficulties in differentiation between extrapyramidal and negative symptoms. The average prevalence of depression that meets the diagnostic criteria of major depressive episodes in patients with schizophrenia is 25% at a specific point, and 60% over the course of a lifetime; the frequency of subsyndromal depression is much higher. It is essential to distinguish between primary (axial syndrome) and secondary depressive symptoms (extrapyramidal symptoms, psychogenic or nosogenic reactions, social factors, etc.) to determine treatment strategies. The published data relating to randomized clinical trials for the development of evidence-based guidelines are limited. Current recommendations are based mainly on the results of small-scale trials and reviews. Certain atypical antipsychotics (quetiapine, lurasidone, amisulpride, aripiprazole, olanzapine, clozapine) are superior to typical antipsychotics in the reduction of depressive symptoms. Clozapine is effective in the management of patients at risk from suicide. The additional prescription of antidepressants, transcranial magnetic stimulation and electroconvulsive therapy are not always effective and are only possible following the management of acute psychosis in cases when antipsychotic monotherapy proved to be ineffective.

The factors associated with depression in schizophrenia patients: the role of self-efficacy, self-esteem, hope and resilience

Previous studies have shown a significant correlation between depression, resilience, self-efficacy, self-esteem and hope among schizophrenia patients, but few studies have examined the mechanisms among these factors. This study aimed to analyse the relationships among resilience, self-efficacy, self-esteem and hope as influencing factors of depression in schizophrenia patients. A cross-sectional study was conducted, and 361 schizophrenia patients were recruited. They were interviewed about their self-efficacy, self-esteem, hope, resilience and depressive symptoms. A structural equation model was used to examine the direct and indirect associations between them. The global model showed good model fit and the structural equation model revealed that the direct pathway of resilience on depression was significant, and the indirect pathway of self-efficacy, self-esteem and hope on depression via resilience was also significant. Notably, self-efficacy, self-esteem and hope did not directly affect depressive symptoms. These findings support the mediating model of self-efficacy, self-esteem and hope relevant to the depressive symptoms of schizophrenia patients in China, in which resilience plays a pivotal role. These findings elucidate the factors which may be associated with depressive symptoms and imply that enhancing resilience in people with schizophrenia could be beneficial. Moreover, studies with detailed longitudinal assessments are necessary to confirm these findings.

The relationship between self-stigma and depression among people with schizophrenia-spectrum disorders: A longitudinal study

Harmful consequences of self-stigma in schizophrenia are well established in the literature, but its relationship with symptomatology remains unclear. Self-stigma describes the process by which some patients eventually accept, adhere to and apply to themselves the stereotypes associated with schizophrenia. This study aims to describe self-stigma experienced by people with schizophrenia in French-speaking Switzerland and to examine the relationship between self-stigma and depression. This was a longitudinal study including 80 participants. Correlation and regression analyses were used to examine the relationship between self-stigma and depression over three points of time. Correlations between Stigma Scale subdimensions and sociodemographic variables indicated that age and duration of illness were associated with the discrimination subscale. Self-stigma was strongly correlated with depression over time, whereby higher scores of self-stigma were associated with higher depression. More precisely, the more the patient felt discriminated against and the less he or she perceived the positive aspects of his or her illness, the greater the symptoms of depression. This study highlights the severity of self-stigma endorsed by people with schizophrenia in French-speaking Switzerland. The results provide new knowledge about self-stigma and its potential impact on depressive symptoms. Implementation of self-stigma assessment in clinical practice will allow distinctions to be made between the impact of self-stigma and the consequences of schizophrenia to recommend appropriate intervention.

Personal resources and depression in schizophrenia: The role of self-esteem, resilience and internalized stigma

Depression in schizophrenia represents a challenge from a diagnostic, psychopathological and therapeutic perspective. The objective of this study is to test the hypothesis that resilience and self-stigma affect depression severity and to evaluate the strength of their relations in 921 patients with schizophrenia. A structural equation model was tested where depression is hypothesized as affected by resilience, internalized stigma, gender and negative symptoms, with the latter two variables used as exogenous covariates and the former two as mediators. The analysis reveals that low resilience, high negative symptoms, female gender were directly associated with depression severity, and internalized stigma acted only as a mediator between avolition and resilience, with similar magnitude. The cross-sectional study design and the variable selection limit the generalizability of the study results. The model supports a complex interaction between personal resources and negative symptoms in predicting depression in schizophrenia. The clinical implication of these findings is that personal resources could be a significant target of psychosocial treatments.

Gender differences in the treatment of first-episode schizophrenia: Results from the European First Episode Schizophrenia Trial

Gender differences in the response to antipsychotic treatment have been detected in the past, but not studied in great detail. The results of the European First-Episode Schizophrenia Trial (EUFEST) were analyzed with a focus on gender differences in the response to randomized treatment of first-episode schizophrenia. A total of 498 patients (298 men and 200 women) were randomly assigned by a web-based online system to open-label treatment with haloperidol, amisulpride, olanzapine, quetiapine, and ziprasidone. Treatment response was evaluated using the positive and negative syndrome scale (PANSS). Data were collected at baseline and then prospectively for one year. Baseline characteristics (age and proportion of patients assigned to individual antipsychotics) were the same between the male and female patients with the exception of ziprasidone: significantly fewer men, proportionately, were prescribed ziprasidone. There was no significant difference between genders between the initial total PANSS and subscale scores. A significant interaction between time and gender was found, with more robust PPANSS and TPANSS score improvement in women during the course of treatment. Of all of the antipsychotics used, only olanzapine led to significantly greater improvement in the total PANSS score in women during the follow-up period. Gender differences should be given more attention in research and clinical practice. Their causes require clarification, and future strategies for dealing with them may be considered in early intervention programs and guidelines.

Systematic Literature Review of the Methods Used to Compare Newer Second-Generation Agents for the Management of Schizophrenia: A focus on Health Technology Assessment

BACKGROUND

The challenges of comparative effectiveness to support health technology assessment (HTA) agencies are important considerations in the choices of antipsychotic medications for the treatment of schizophrenia.

OBJECTIVES

Our aim was to assess the study methods used and outcomes reported in the published literature to address the question of comparative effectiveness of newer antipsychotic agents and the adequacy and availability of evidence to support HTA agencies.

DATA SOURCE

A systematic search of the PubMed database from 1 January 2009 to 30 September 2013 was conducted to identify studies evaluating new atypical antipsychotics reporting on comparative effectiveness.

STUDY SELECTION

The systematic review comprised of studies on schizophrenia patients where at least two drugs were being compared and at least one treatment group received one of the following second-generation antipsychotics: risperidone, olanzapine, aripiprazole, paliperidone, asenapine, iloperidone, lurasidone, and quetiapine. The included studies were also required to have an efficacy, safety or economic outcome, such as Positive and Negative Syndrome Scale (PANSS) score, weight gain, resource utilization, or costs.

STUDY APPRAISAL AND SYNTHESIS METHODS

Two reviewers (BW and GK) independently applied the inclusion criteria. Disagreements between reviewers were resolved by consensus, referring to the original sources. Information on the methodology and outcomes was collected for each included study. This included study description, head-to-head drug comparison, patient population, study methodology, statistical methods, reported outcomes, study support, and journal type.

RESULTS

A total of 198 studies were identified from electronic search methods. The largest category of studies was randomized controlled trials [RCTs] (N = 73; 36.9%), which were largely directed at the regulatory endpoint. Fewer studies were undertaken for HTA-purposes cohort studies (N = 53; 26.8%), meta-analyses (N = 32; 16.2%), economic studies (N = 14; 7.1%), and cross-sectional studies (N = 13; 6.6%). Direct head-to-head comparisons preferred by HTA were dominated by the comparison involving olanzapine and risperidone, representing 149 (75.3%) and 119 (60.1%) studies, respectively. RCTs, which are the primary study type for regulatory submissions, showed a lack of bias. Studies aimed at HTA were not as well performed. Cohort studies suffered from bias in the selection of comparison groups, lack of control for confounders, and differential dropout rates. As a group, cross-sectional studies scored poorly for bias, with a primary failure to identify a representative sample. Economic studies showed highly variable bias, with bias in the representation of effectiveness data, model assumptions without validation, and lack of sensitivity analyses.

LIMITATIONS

One limitation of this systematic review is that it only included studies from 2009 to 2013, potentially excluding some earlier comparator studies, particularly those involving first-generation antipsychotics.

CONCLUSIONS

This review of comparative effectiveness studies of second-generation antipsychotic agents for schizophrenic patients revealed a wide range of study types, study methodologies, and outcomes. For traditional efficacy outcomes and select safety outcomes, there is strong evidence from many well-conducted studies; however, there are fewer studies of types preferred by HTA with limited head-to-head comparisons and a higher risk of bias in the execution of these studies.

World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for Biological Treatment of Schizophrenia. Part 3: Update 2015 Management of special circumstances: Depression, Suicidality, substance use disorders and pregnancy and lactation

These updated guidelines are based on the first edition of the World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of schizophrenia published in the years 2005 and 2006. For this 2015 revision, all available publications pertaining to the biological treatment of schizophrenia were reviewed systematically to allow for an evidence-based update. These guidelines provide evidence-based practice recommendations which are clinically and scientifically relevant. They are intended to be used by all physicians diagnosing and treating patients with schizophrenia. Based on the first version of these guidelines a systematic review, as well as a data extraction from national guidelines have been performed for this update. The identified literature was evaluated with respect to the strength of evidence for its efficacy and subsequently categorised into six levels of evidence (A-F) and five levels of recommendation (1-5). This third part of the updated guidelines covers the management of the following specific treatment circumstances: comorbid depression, suicidality, various comorbid substance use disorders (legal and illegal drugs), and pregnancy and lactation. These guidelines are primarily concerned with the biological treatment (including antipsychotic medication and other pharmacological treatment options) of patients with schizophrenia.

Open prospective study of ziprasidone in patients with schizophrenia with depressive symptoms: a multicenter study

AIMS

The goal of this study was to examine the efficacy and safety of ziprasidone to treat depressive symptoms in Korean patients with schizophrenia who showed stable symptoms.

METHODS

In this 8-week, open-label, prospective, non-randomized, multicenter study, 34 patients with schizophrenia who showed a stable response to previous medications, maintained a stable dose, and who had depressive symptoms, were recruited. Ziprasidone was the only antipsychotic agent allowed for 8 weeks after a 2-7-week washout period.

RESULTS

Steady decreases were observed on the Montgomery-Asberg Depression Rating Scale, the Calgary Depression Scale for Schizophrenia, the Positive and Negative Syndrome Scale, and the Clinical Global Impression-Severity Scale scores. The Montgomery-Asberg Depression Rating Scale score was 20.26 ± 4.77 at baseline and 12.21 ± 7.94 at the end-point (P < 0.01). The Calgary Depression Scale for Schizophrenia score was 9.76 ± 4.11 at baseline and 5.00 ± 3.94 at the end-point (P < 0.01). The Positive and Negative Syndrome Scale total score was 75.24 ± 22.63 at baseline and 66.53 ± 24.28 at the end-point (P < 0.01). The Clinical Global Impression-Severity Scale score was 3.44 ± 0.66 at baseline and 3.15 ± 0.86 at the end-point (P < 0.05). No significant differences were observed for total scores on the Simpson and Angus Rating Scale, the Barnes Akathisia Rating Scale, or the Abnormal Involuntary Movement Scale between the baseline and end-point.

CONCLUSIONS

Ziprasidone was effective for improving depressive symptom scores and was well tolerated. Switching to ziprasidone is a good strategy in patients with schizophrenia who are experiencing depressive symptoms.

Schizophrenia and depression

Depressive symptoms are common in people with schizophrenia and can be associated with suicidality, but are often either missed or dismissed by clinicians. General practitioners have a key role in initial assessment and subsequent monitoring of depressive symptoms, associated risks and physical health in patients with schizophrenia. Liaison with appropriate non-government organisations and public or private specialist mental health services can enhance GPs' management of depression in schizophrenia. Antidepressants, prescribed in tandem with antipsychotics, have a likely therapeutic role for persistent depressive symptoms in schizophrenia, but side effects can be troublesome. Although some of the atypical antipsychotics appear to have primary antidepressant effects, the utility of these agents alone in the setting of persistent depressive symptoms in schizophrenia has not been established.

Extrapyramidal symptoms during treatment of first schizophrenia episode: results from EUFEST

The European First Episode Schizophrenia Trial (EUFEST) included first-episode schizophrenia patients, assessing the efficacy of five antipsychotic drugs (haloperidol, amisulpride, olanzapine, quetiapine and ziprasidone) over one year. Baseline frequency of extrapyramidal symptoms (EPS) in this group of patients (n=490) was as follows: parkinsonism 10.8%, akathisia 10.0%, dystonia 1.8%, and dyskinesia 0.6%. The frequency of parkinsonism at baseline was greater in patients with a brief prior exposure to antipsychotics (≤2 weeks) compared with antipsychotic-naïve ones, and was positively correlated with the intensity of negative symptoms and negatively with depressive symptoms. After one month of treatment, the increase of parkinsonism was highest in patients receiving haloperidol (+13%), that of akathisia in patients treated with ziprasidone (+14%), and 10.1% of the patients were taking anticholinergic drugs, most frequently in the haloperidol group (24%). In 291 patients remaining on treatment after one year, both parkinsonism and akathisia had decreased: the frequency of parkinsonism was 3%, highest in the haloperidol group (9.1%), that of akathisia was 3%, highest in the quetiapine group (7.5%), and 4% of patients were taking anticholinergic drugs, most frequently those receiving haloperidol (10.5%). The results obtained suggest that in first-episode schizophrenia patients during the first year of antipsychotic treatment (in this case amisulpride, haloperidol in low doses, olanzapine, quetiapine and ziprasidone), EPS were present as manageable clinical problems.

Amisulpride versus other atypical antipsychotics for schizophrenia

BACKGROUND

In many countries of the industrialised world second generation (atypical) antipsychotics have become first line drug treatments for people with schizophrenia. The question as to whether, and if so how much, the effects of the various second generation antipsychotics differ is a matter of debate. In this review we examine how the efficacy and tolerability of amisulpride differs from that of other second generation antipsychotics.

OBJECTIVES

To evaluate the effects of amisulpride compared with other atypical antipsychotics for people with schizophrenia and schizophrenia-like psychoses.

SEARCH STRATEGY

We searched the Cochrane Schizophrenia Group Trials Register (April 2007) which is based on regular searches of BIOSIS, CINAHL, EMBASE, MEDLINE and PsycINFO.

SELECTION CRITERIA

We included randomised, at least single-blind, trials comparing oral amisulpride with oral forms of aripiprazole, clozapine, olanzapine, quetiapine, risperidone, sertindole, ziprasidone or zotepine in people with schizophrenia or schizophrenia-like psychoses.

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

The review currently includes ten short to medium term trials with 1549 participants on three comparisons: amisulpride versus olanzapine, risperidone and ziprasidone. The overall attrition rate was considerable (34.7%) with no significant difference between groups. Amisulpride was similarly effective as olanzapine and risperidone and more effective than ziprasidone (leaving the study early due to inefficacy: n=123, 1 RCT, RR 0.21 CI 0.05 to 0.94, NNT 8 CI 5 to 50). Amisulpride induced less weight gain than risperidone (n=585, 3 RCTs, MD -0.99 CI -1.61 to -0.37) or olanzapine (n=671, 3 RCTs, MD -2.11 CI -2.94 to -1.29). Olanzapine was also associated with a higher increase of glucose (n=406, 2 RCTs, MD -7.30 CI -7.62 to -6.99). There was no difference in terms of cardiac effects and extra pyramidal symptoms (EPS) compared with olanzapine (akathisia: n= 587, 2 RCTs, RR 0.66 CI 0.36 to 1.21), compared with risperidone (akathisia: n=586, 3 RCTs, RR 0.80 CI 0.58 to 1.11) and compared with ziprasidone (akathisia: n=123, 1 RCT, RR 0.63, CI 0.11 to 3.67).

AUTHORS' CONCLUSIONS

There is little randomised evidence comparing amisulpride with other second generation antipsychotic drugs. We could only find trials comparing amisulpride with olanzapine, risperidone and ziprasidone. We found amisulpride may be somewhat more effective than ziprasidone, and more tolerable in terms of weight gain and other associated problems than olanzapine and risperidone. These data, however, are based on only ten short to medium term studies and therefore too limited to allow for firm conclusions.

Ziprasidone versus other atypical antipsychotics for schizophrenia

BACKGROUND

In many countries of the industrialised world second generation ('atypical') antipsychotics have become the first line drug treatment for people with schizophrenia. The question as to whether, and if so how much, the effects of the various new generation antipsychotics differ is a matter of debate. In this review we examined how the efficacy and tolerability of ziprasidone differs from that of other second generation antipsychotics.

OBJECTIVES

To evaluate the effects of ziprasidone compared with other atypical antipsychotics for people with schizophrenia and schizophrenia-like psychoses.

SEARCH STRATEGY

We searched the Cochrane Schizophrenia Group Specialised Register (April 2007) and references of all identified studies for further trial citations. We contacted pharmaceutical companies and authors of trials for additional information.

SELECTION CRITERIA

We included all randomised, at least single-blind, controlled trials comparing oral ziprasidone with oral forms of amisulpride, aripiprazole, clozapine, olanzapine, quetiapine, risperidone or zotepine in people with schizophrenia or schizophrenia-like psychoses.

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

The review currently includes nine randomised controlled trials (RCTs) with 3361 participants. The overall rate of premature study discontinuation was very high (59.1%). Data for the comparisons of ziprasidone with amisulpride, clozapine, olanzapine, quetiapine and risperidone were available. Ziprasidone was a less acceptable treatment than olanzapine (leaving the studies early for any reason: 5 RCTs, n=1937, RR 1.26 CI 1.18 to 1.35, NNH 7 CI 5 to 10) and risperidone (3 RCTs, n=1029, RR 1.11 CI 1.02 to 1.20, NNH 14 CI 8 to 50), but not than the other second generation antipsychotic drugs. Ziprasidone was less efficacious than amisulpride (leaving the study early due to inefficacy: 1 RCT, n=123, RR 4.72 CI 1.06 to 20.98, NNH 8 CI 5 to 50) olanzapine (PANSS total score: 4 RCTs, n=1291, MD 8.32 CI 5.64 to 10.99) and risperidone (PANSS total score: 3 RCTs, n=1016, MD 3.91 CI 0.27 to 7.55). Based on limited data there were no significant differences in tolerability between ziprasidone and amisulpride or clozapine. Ziprasidone produced less weight gain than olanzapine (5 RCTs, n=1659, MD -3.82 CI -4.69 to -2.96), quetiapine (2 RCTs, n=754, RR 0.45 CI 0.28 to 0.74) or risperidone (3 RCTs, n=1063, RR 0.49 CI 0.33 to 0.74). It was associated with less cholesterol increase than olanzapine, quetiapine and risperidone. Conversely ziprasidone produced slightly more extrapyramidal side-effects than olanzapine (4 RCTs, n=1732, RR 1.43 CI 1.03 to 1.99, NNH not estimable) and more prolactin increase than quetiapine (2 RCTs, n=754, MD 4.77 CI 1.37 to 8.16), but less movement disorders (2 RCTs, n=822, RR 0.70 CI 0.51 to 0.97, NNT not estimable) and less prolactin increase (2 RCTs, n=767, MD -21.97 CI -27.34 to -16.60) than risperidone.

AUTHORS' CONCLUSIONS

Ziprasidone may be a slightly less efficacious antipsychotic drug than amisulpride, olanzapine and risperidone. Its main advantage is the low propensity to induce weight gain and associated adverse effects. However, the high overall rate of participants leaving the studies early limits the validity of any findings.