Pharmacological approaches to treating negative symptoms: a review of clinical trials

Placebo Response in Trials of Negative Symptoms in Schizophrenia: A Critical Reassessment of the Evidence

BACKGROUND

Summarizing evidence from clinical trials of patients with schizophrenia with predominant or prominent negative symptoms (NS), a prior meta-analysis reported a large placebo effect in negative symptoms (Cohen's d = 2.909). Assuming that such an effect was clinically not plausible, we performed a critical re-assessment and an update of the previous results with newly available data from add-on and monotherapy studies.

STUDY DESIGN

Random-effect meta/regression analysis of trials that focused on predominant or prominent NS; and adopted a double-blind, randomized, placebo-controlled design. The final pooled meta-analytic database, based on the available add-on and monotherapy studies combined, included 24 publications containing data on a total of 25 studies (21 add-on, 4 monotherapy).

STUDY RESULTS

The pooled overall estimate for the placebo effect from the primary analysis for all included studies had a medium effect size, with a Cohen's d value of 0.6444 (SE = 0.091). The estimates were similar in the add-on and monotherapy studies. Meta-regression indicated that the high placebo response was significantly associated with clinical trial characteristics, including the high ratio of patients assigned to active vs. placebo treatment and short trial duration.

CONCLUSIONS

These results represent a major downward correction for a current effect size estimate of the placebo response in the negative symptoms of schizophrenia. Our findings also pinpoint certain clinical trial characteristics, which may serve as important predictors of the placebo response. The knowledge of these factors can have important implications for drug development and trial design for new drugs for negative symptoms of schizophrenia.

Place of the partial dopamine receptor agonist aripiprazole in the management of schizophrenia in adults: a Delphi consensus study

BACKGROUND

Aripiprazole is a second-generation antipsychotic, efficacious in patients with schizophrenia during acute episodes. Due to its pharmacological profile, aripiprazole may be of interest in patients with specific clinical profiles who have not been studied extensively in randomised clinical trials.

OBJECTIVES

To capture experience with aripiprazole in everyday psychiatric practice using the Delphi method in order to inform decision-making on the use of aripiprazole for the treatment of patients with schizophrenia in clinical situations where robust evidence from clinical trials is lacking.

METHODS

The scope of the survey was defined as the management of schizophrenia in adults. A systematic literature review was performed to identify the different clinical situations in which aripiprazole has been studied, and to describe the level of clinical evidence. Clinical profiles to include in the Delphi survey were selected if there was a clear interest in terms of medical need but uncertainty over the efficacy of aripiprazole. For each clinical profile retained, five to seven specific statements were generated and included in a questionnaire. The final 41-item questionnaire was proposed to a panel of 406 French psychiatrists with experience in the treatment of schizophrenia. Panellists rated their level of agreement using a Likert scale. A second round of voting on eleven items was organised to clarify points for which a consensus was not obtained in the first round.

RESULTS

Five clinical profiles were identified in the literature review (persistent negative symptoms, pregnancy, cognitive dysfunction, addictive comorbidity and clozapine resistance). Sixty-two psychiatrists participated in the first round of the Delphi survey and 33 in the second round. A consensus was obtained for 11 out of 41 items in the first round and for 9/11 items in the second round. According to the panellists' clinical experience, aripiprazole can be used as maintenance treatment for pregnant women, is relevant to preserve cognitive function and can be considered an option in patients with a comorbid addictive disorder or with persistent negative symptoms.

CONCLUSION

These findings may help physicians in choosing relevant ways to use aripiprazole and highlight areas where more research is needed to widen the evidence base.

Psychosocial interventions for community-dwelling individuals with schizophrenia: study protocol for a systematic review and meta-analysis

INTRODUCTION

Despite the recent global mental health movement of the transition from hospital-centred to integrated community-based services, comprehensive evidence of psychosocial interventions focusing on community-dwelling individuals with schizophrenia is still lacking. To overcome this gap in the current knowledge, we will conduct a systematic review and meta-analysis to assess the efficacy of all types of psychosocial interventions for community-dwelling (non-hospitalised) individuals with schizophrenia when compared with non-active control conditions (eg, treatment as usual).

METHODS AND ANALYSIS

This study protocol has been developed according to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines. By March 2022, the following sources will have been searched, without restrictions for language or publication period: Embase, PubMed, PsycINFO, CINAHL, the Cochrane Central Register of Controlled Trials, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform. We will also try to identify other potentially eligible studies by searching the reference lists of included studies, other relevant systematic reviews and grey literature. All relevant randomised controlled trials from both high-income and low-income to middle-income countries will be allowed. Two independent reviewers will conduct the selection/screening of studies, data extraction and methodological quality assessment of included studies. The primary outcomes are quality of life and psychiatric hospital admission. Standard pairwise meta-analyses with a random-effects model will be conducted. Subgroup and sensitivity analyses will be performed to assess the robustness of the findings. Risk of bias will be assessed with the Revised Cochrane Risk-of-Bias Tool for Randomised Trials. The Grades of Recommendation Assessment, Development and Evaluation approach will be used to assess the quality of evidence.

ETHICS AND DISSEMINATION

Ethics approval is not required for this study. The study findings will be disseminated through conference presentations as well as peer-reviewed publications.

PROSPERO REGISTRATION NUMBER

CRD42021266187.

Pimavanserin Exposure-Response Analyses in Patients With Schizophrenia: Results From the Phase 2 ADVANCE Study

PURPOSE/BACKGROUND

Pimavanserin is a selective serotonin 5-HT 2A receptor inverse agonist/antagonist being investigated in patients with negative symptoms of schizophrenia. This analysis aimed to characterize exposure-response relationships of pimavanserin in this population.

METHODS/PROCEDURES

Exposure-response models were developed using data from ADVANCE. Patients with negative symptoms of schizophrenia receiving background antipsychotics were randomized to pimavanserin 20 mg (adjusted to 34 or 10 mg between weeks 2-8 based on efficacy or tolerability) or placebo for 26 weeks. Time-varying pimavanserin exposure measures were predicted for each patient using a population pharmacokinetic model and individual empiric Bayesian parameter estimates. Response measures were the Negative Symptom Assessment 16 (NSA-16, primary end point), Personal and Social Performance scale, negative symptoms component of the Clinical Global Impression of Schizophrenia-Severity Scale, and adverse events.

FINDINGS/RESULTS

A higher pimavanserin exposure was associated with greater improvement in NSA-16 score. For a median area under the pimavanserin plasma concentration-time curve from time 0 to 24 hours of 1465 ng × h/mL for the 34-mg dose, the model predicted a 10.5-point reduction in NSA-16 score. This exposure-response relationship with NSA-16 scores was not influenced by covariates. Similar results were observed with Personal and Social Performance and Clinical Global Impression of Schizophrenia-Severity, but not to the extent as NSA-16. There was no significant exposure-response relationship with anxiety, headache, insomnia, or somnolence.

IMPLICATIONS/CONCLUSIONS

Increasing pimavanserin plasma concentration was associated with improved NSA-16 scores (primary end point) in patients with negative symptoms of schizophrenia. No exposure-response relationship with select adverse events was observed.

Efficacy and safety of cariprazine augmentation in patients treated with clozapine: a pilot study

BACKGROUND

Cariprazine, a novel antipsychotic drug, is a partial agonist of dopamine D2/D3 receptors with preferential binding to the D3 receptor. There has been an increasing interest in cariprazine augmentation to clozapine; however, the evidence thus far has been only limited to case reports and case series.

OBJECTIVES

To evaluate the efficacy and safety of the augmentation of clozapine with cariprazine in patients with sub-optimal treatment response.

METHODS

Demographic and clinical information of the study population were collected from the electronic records and PANSS scale administered at baseline and 3 months. Tolerability and discontinuation reasons where applicable were also recorded.

RESULTS

Ten patients (four men and six women) with a mean age of 36.5 years (range = 26-45) were included. Reasons for cariprazine initiation included inadequate treatment response, persistent negative symptoms and/or tolerability issues with clozapine or previous augmentation options. Two patients discontinued cariprazine within the first 6 weeks due to restlessness and poor response, respectively. There was a significant reduction in the median total PANSS score from baseline to 3 months (from 59 to 22.5, p < 0.05), median positive PANSS score (from 11.5 to 5.5, p < 0.05) and in the median negative PANSS score (from 15.5 to 3, p < 0.05) which correspond to a 48%, 33.8% and 65.8% mean score reduction, respectively.

CONCLUSION

This is the first pilot study evaluating the effectiveness of clozapine augmentation. The preliminary evidence suggests that this may be a safe and effective practice in patients failing to adequately respond to or tolerate clozapine and/or previous augmentation strategies.

Pimavanserin for negative symptoms of schizophrenia: results from the ADVANCE phase 2 randomised, placebo-controlled trial in North America and Europe

BACKGROUND

Negative symptoms of schizophrenia are associated with adverse clinical outcomes, but there are few effective treatments. We aimed to assess the effects of pimavanserin, a selective 5-HT_2A inverse agonist and antagonist, on negative symptoms of schizophrenia.

METHODS

The ADVANCE study was a phase 2, 26-week, randomised, double-blind, placebo-controlled study of pimavanserin in stable outpatients with schizophrenia aged 18-55 years with predominant negative symptoms. Patients were randomly assigned (1:1) across 83 sites (18 in North America and 65 in Europe) to receive pimavanserin or placebo daily, added to an ongoing antipsychotic medication, per a computer-generated schedule (stratification by geographical region). Eligible patients had a score of at least 20 on the sum of seven Positive and Negative Syndrome Scale (PANSS) Marder negative factor items (and scores of ≥4 on at least three or ≥5 on at least two of negative symptom items). The starting dosage of 20 mg of pimavanserin or placebo could be adjusted to 34 mg or 10 mg within the first 8 weeks of the study, after which dosage remained stable until the end of the study. Both pimavanserin and placebo were administered orally once daily as two individual tablets (pimavanserin tablets were either 10 mg or 17 mg). The primary endpoint was change in total score using the 16-item Negative Symptom Assessment (NSA-16) from baseline to week 26. Primary outcomes were analysed in patients who received at least one dose of the study drug and had NSA-16 assessments at baseline and at least once post-baseline (full analysis set). Safety outcomes were analysed in patients who had received at least one dose of the study drug. This trial is registered with ClinicalTrials.gov, NCT02970305, and is complete.

FINDINGS

Between Nov 4, 2016, and April 16, 2019, we randomly assigned 403 patients to pimavanserin (n=201; 131 [65%] male; 187 [93%] White) or placebo (n=202; 137 [68%] male, 186 (92%) White), of whom 400 were included in the efficacy analysis (199 in the pimavanserin group, 201 in the placebo group). Mean age was 37·7 years (SD 9·4) in the pimavanserin group and 36·7 (9·2) years in the placebo group. The change in total NSA-16 score from baseline to week 26 was significantly improved with pimavanserin (least squares mean -10·4 [SE 0·67]) versus placebo (least squares mean -8·5 [0·67]; p=0·043; effect size: 0·211). The number of patients with treatment-emergent adverse events (TEAEs) was similar between groups: 80 (40%) patients experienced TEAEs in the pimavanserin group and 71 (35%) in the placebo group. Most TEAEs were headache (6% [n=13] vs 5% [n=10]) and somnolence (5% [n=11] vs 5% [n=10]). One patient from the placebo group reported severe headache (0·5%), rhinorrhoea (0·5%), cough (0·5%), and influenza (0·5%). In the pimavanserin group, one patient reported severe toothache (0·5%), and two patients had worsening of schizophrenia (1%). Mean change in QTcF interval was higher with pimavanerin (4·5 ms [SD 18·0]) than with placebo (0·0 ms [16·0]).

INTERPRETATION

Stable patients with predominant negative symptoms of schizophrenia showed a reduction in negative symptoms after treatment with pimavanserin. However, given the small effect size, further investigation with optimised dosing is warranted to determine the clinical significance of this effect.

FUNDING

Acadia Pharmaceuticals.

Pimavanserin augments the efficacy of atypical antipsychotic drugs in a mouse model of treatment-refractory negative symptoms of schizophrenia

Negative symptoms are a core, pervasive, and often treatment-refractory phenotype of schizophrenia, one which contributes to poor functional outcome, ability to work, pursue educational goals, and quality of life, as well as caretaker burden. Improvement of negative symptoms in some patients with schizophrenia has been reported with some atypical antipsychotic drugs [AAPDs], but improvement is absent in many patients and partial in others. Therefore, more effective treatments are needed, and better preclinical models of negative symptoms are needed to identify them. Sub-chronic [sc] treatment of rodents with phencyclidine [PCP], a noncompetitive N-methyl-d-aspartate [NMDAR] antagonist, produces deficits in social interactions [SI] that have been widely studied as a model of negative symptoms in schizophrenia. Acute restraint stress [ARS] also provides a model of treatment-refractory negative symptoms [TRS] to AAPDs. By themselves, in sc-PCP mice, the AAPDs, risperidone, olanzapine, and aripiprazole, but not the selective 5-HT_2AR inverse agonist, pimavanserin [PIM], rescued the SI deficit in sc-PCP mice, as did the combination of PIM with sub-effective doses of each of these AAPDs. These three AAPDs alone did not rescue SI deficit in sc-PCP+2h-ARS mice, indicating these mice were treatment refractory. However, co-administration of PIM with any of the AAPDs significantly restored SI in these mice. PIM may be an effective adjunctive therapy for treating negative symptoms of schizophrenia in some patients who have failed to respond to AAPDs, but further studies are needed.

Developments in Biological Mechanisms and Treatments for Negative Symptoms and Cognitive Dysfunction of Schizophrenia

The causal mechanisms and treatment for the negative symptoms and cognitive dysfunction in schizophrenia are the main issues attracting the attention of psychiatrists over the last decade. The first part of this review summarizes the pathogenesis of schizophrenia, especially the negative symptoms and cognitive dysfunction from the perspectives of genetics and epigenetics. The second part describes the novel medications and several advanced physical therapies (e.g., transcranial magnetic stimulation and transcranial direct current stimulation) for the negative symptoms and cognitive dysfunction that will optimize the therapeutic strategy for patients with schizophrenia in future.

Cariprazine, A Broad-Spectrum Antipsychotic for the Treatment of Schizophrenia: Pharmacology, Efficacy, and Safety

Schizophrenia is characterized by positive, negative, cognitive, and affective symptoms. Antipsychotic medications, which work by blocking the dopamine D₂ receptor, are the foundation of pharmacotherapy for schizophrenia to control positive symptoms. Cariprazine is a dopamine D₃ receptor-preferring D₃/D₂ partial agonist antipsychotic that is approved for the treatment of schizophrenia (USA and European Union [EU]) and manic and depressive episodes associated with bipolar I disorder (USA). Partial agonist agents have a lower intrinsic activity at receptors than full agonists, so they act as either functional agonists or functional antagonists depending on the surrounding neurotransmitter environment. Beyond efficacy against positive symptoms, the unique D₃-preferring partial agonist pharmacology of cariprazine suggests potential advantages against negative symptoms, and cognitive and functional impairment, which are challenging to treat. The efficacy and safety of cariprazine in adult patients with schizophrenia have been demonstrated in four short-term randomized, double-blind, placebo-controlled clinical trials, two long-term open-label studies, one relapse prevention study, and one prospective negative symptom study versus the active comparator risperidone. Additional post hoc investigations have supported efficacy across individual symptoms and domains in schizophrenia, as well as in diverse areas of interest including cognition, functioning, negative symptoms, hostility, and global well-being. This comprehensive review of cariprazine summarizes its pharmacologic profile, clinical trial evidence, and post hoc investigations. Collective evidence suggests that the pharmacology of cariprazine may offer broad-spectrum efficacy advantages for patients with schizophrenia, including effects against difficult-to-treat negative and cognitive symptoms, as well as functional improvements. Cariprazine was generally safe and well tolerated in patients with short- and long-term exposure and no new safety concerns were associated with longer-duration treatment.

Trial registration ClinicalTrials.gov identifiers, NCT00404573, NCT00694707, NCT01104766, NCT01104779, NCT01412060, NCT00839852, NCT01104792.

Real world sedentary behavior and activity levels in patients with schizophrenia and controls: An ecological momentary assessment study

BACKGROUND

People with schizophrenia often experience poor health, leading to shortened lifespans. The health of people with schizophrenia may be further exacerbated by increased sedentary behavior, which independently predicts health risk in the general population. However, the prevalence and patterns of objectively measured sedentary behavior in schizophrenia have not been studied extensively on a momentary basis.

METHODS

Activity of 100 patients with schizophrenia was compared to that of healthy controls (HC; n=71) using ecological momentary assessment (EMA). EMA provides real-time, real-world monitoring of behavior. We sampled behavior seven times per day for seven days, quantifying active versus inactive behaviors and four different movement patterns (recumbent, seated, standing, and moving). Due to different employment rates between samples, we focused on surveys completed at home.

RESULTS

Four of the five most commonly reported activities for participants with schizophrenia involved sitting or lying down. When considering activity during the last hour, participants with schizophrenia were more likely to be sitting or pacing and less likely to be standing than HC. If participants with schizophrenia only did one thing in the last hour, it was more likely to involve sitting and less likely to involve standing compared to HC.

DISCUSSION

People with schizophrenia were significantly more likely to be seated and less likely to be standing or active during the past hour than HC, despite high frequencies of seated behaviors in the HC as well. The adverse health consequences of sitting for extended periods may be especially relevant for people with schizophrenia and likely contribute to premature mortality in this population.

[Transcranial electrical brain stimulation methods for treatment of negative symptoms in schizophrenia]

Über die letzten Jahre entwickelten sich Neuromodulationsverfahren zu einer dritten Säule neben Pharmakotherapie und Psychotherapie in der Behandlung psychischer Erkrankungen. Besonders in der Behandlung von Menschen mit einer Schizophrenie könnten Hirnstimulationsverfahren eine Alternative oder Ergänzung zu den etablierten Therapiestrategien darstellen. Die meist vorhandenen Positivsymptome können zumeist mit Antipsychotika adäquat behandelt werden. Gerade bei Patienten mit Schizophrenie besitzen jedoch Negativsymptome einen überdauernden Krankheitswert und beeinflussen den Verlauf durch globale Antriebsverarmung und beeinträchtigte Kognition im alltäglichen Leben negativ. Dieser Übersichtsartikel stellt eine Zusammenfassung über die verschiedenen nichtinvasiven Hirnstimulationsverfahren transkranielle Gleichstromstimulation (transcranial direct current stimulation, tDCS), Wechselstromstimulation (transcranial alternating current stimulation, tACS) sowie Rauschstromstimulation (transcranial random noise stimulation, tRNS) zur Behandlung der Negativsymptomatik bei Schizophrenie dar. Die neuen transkraniellen Hirnstimulationsverfahren könnten dabei helfen, gestörte neuronale Vernetzungen wieder herzustellen und die Konnektivität vor allem der dorsolateralen präfrontalen Anteile des Kortex zu verbessern. Einige Studien weisen auf eine Verbesserung der Negativsymptome durch Behandlung mit tDCS, tACS bzw. tRNS hin und könnten so neue Therapiemöglichkeiten in der Behandlung der Schizophrenie darstellen.

Cognitive Impairment and Diminished Neural Responses Constitute a Biomarker Signature of Negative Symptoms in Psychosis

The treatment of negative symptoms (NS) in psychosis represents an urgent unmet medical need given the significant functional impairment it contributes to psychosis syndromes. The lack of progress in treating NS is impacted by the lack of known pathophysiology or associated quantitative biomarkers, which could provide tools for research. This current analysis investigated potential associations between NS and an extensive battery of behavioral and brain-based biomarkers in 932 psychosis probands from the B-SNIP database. The current analyses examined associations between PANSS-defined NS and (1) cognition, (2) pro-/anti-saccades, (3) evoked and resting-state electroencephalography (EEG), (4) resting-state fMRI, and (5) tractography. Canonical correlation analyses yielded symptom-biomarker constructs separately for each biomarker modality. Biomarker modalities were integrated using canonical discriminant analysis to summarize the symptom-biomarker relationships into a "biomarker signature" for NS. Finally, distinct biomarker profiles for 2 NS domains ("diminished expression" vs "avolition/apathy") were computed using step-wise linear regression. NS were associated with cognitive impairment, diminished EEG response amplitudes, deviant resting-state activity, and oculomotor abnormalities. While a connection between NS and poor cognition has been established, association to neurophysiology is novel, suggesting directions for future mechanistic studies. Each biomarker modality was related to NS in distinct and complex ways, giving NS a rich, interconnected fingerprint and suggesting that any one biomarker modality may not adequately capture the full spectrum of symptomology.

Meta-analysis of randomized controlled trials of galantamine in schizophrenia: significant cognitive enhancement

Cognitive impairments are core features of schizophrenia and the best predictor of functional outcome. Cholinergic system and alpha-7 nicotinic acetylcholine (α7nACh) receptors are strongly implicated in the pathophysiologic mechanisms associated with cognitive impairments in schizophrenia. Galantamine is not only a reversible, competitive inhibitor of acetylcholinesterase but also a type I positive allosteric modulator of α7nACh receptors. The objective of this meta-analysis was to examine the efficacy of galantamine for cognitive symptoms of schizophrenia. In the meta-analysis that included six randomized controlled trials (RCTs, N=226), cognitive impairments significantly improved with galantamine compared to placebo, with a small Hedges' g effect size of 0.233. This finding is consistent with other RCTs in schizophrenia with medications with a similar mechanism of action. On the basis of the results from all the failed (although some efficacy has been shown) RCTs to date in schizophrenia, targeting only one pathophysiologic mechanism may be insufficient to detect a clinically meaningful signal. Nicotinergic medications, like any other add-on medications, are unlikely to be effective as stand-alone medications. Hence, these medications may have to be combined with other medications with complementary mechanisms such as glutamatergic/N-methyl-D-aspartate systems to detect a meaningful effect size for the three domains of psychopathology.

A systematic review of the effects of psychosocial interventions on social functioning for middle-aged and older-aged adults with severe mental illness

OBJECTIVES

The number of older adults with severe mental health problems such as schizophrenia is likely to double in the next 20 years. The needs of this patient group change across the life course, but difficulties with social functioning persist into older age. Poorer social functioning is associated with poorer outcomes and has been identified as a priority for intervention by patients themselves. This paper systematically reviews studies examining the effectiveness of psychosocial interventions on social functioning for people with severe mental health problems in later life.

METHODS

A systematic review of peer-reviewed journal articles was conducted and databases were searched from inception to December 2017. The review was limited to psychosocial interventions, for mid to older aged adults (≥40 years of age) with severe mental illness that included a validated measure of social functioning.

RESULTS

Fifteen studies (17 papers) met inclusion criteria. There was evidence to support skills training interventions that primarily focused on social skills training or integrated mental and physical health interventions. There was not sufficient evidence to recommend any other interventions.

CONCLUSIONS

The results highlight the limited nature of interventions designed specifically for older people with severe mental health problems that target social functioning and the need for more robust, large-scale studies in the area. Current evidence suggests that cognitive behaviour therapy can be effective in targeting social functioning in younger age groups, but, as yet, there is insufficient evidence to recommend this intervention for an older population.

Early-Onset Schizophrenia With Predominantly Negative Symptoms: A Case Study of a Drug-Naive Female Patient Treated With Cariprazine

Schizophrenia is a chronic and severe mental disorder characterized by positive, negative, and cognitive symptoms. Negative symptoms are usually present from the prodromal phase; early diagnosis and management of negative symptoms is a major health concern since an insidious onset dominated by negative symptoms is associated with a worse outcome. Antipsychotic medications, which are effective for treating positive symptoms, are generally ineffective for treating negative or cognitive symptoms. We present a 23-year-old woman showing severe symptoms at her first visit to our department. The patient's parents reported that their daughter had experienced several years of psychosocial decline and putative psychiatric symptoms, but no medical attention had been previously sought; as such, the diagnosis of schizophrenia with predominantly negative symptoms was very much delayed. Early onset of schizophrenia, longer duration of untreated psychosis, and severe negative symptoms, which have limited treatment options, suggested a poor prognosis. We initiated monotherapy with cariprazine, a novel antipsychotic that has recently been proven efficacious in treating schizophrenia with predominantly negative symptoms. This report describes a 52-week cariprazine treatment regimen and follows the patient's impressive clinical improvement confirmed by PANSS and CGI scores, and psychological tests.

[The peptide analogue of neurotensin with antipsychotic and pro-cognitive effects: results of the pilot clinical trial]

OBJECTIVE

To evaluate the psychotropic specific spectrum activity of the novel peptide drug dilept and to find its effective doses in patients with schizotypal disorder.

MATERIAL AND METHODS

The effects of dilept were studied in 25 patients (33.4±10.0 years old) with schizotypal disorder (F21.3) with predominance of obsessive-compulsive, hypochondriac, phobic symptoms, mild cognitive impairment and negative symptoms. Patients were treated with dilept 60, 120 and 200 mg daily for 14 days as monotherapy (with allowance of phenazepam up to 2 mg single doses for insomnia and anxiety) followed by combined treatment with phenazepam in the case of insufficient effectiveness of dilept monotherapy. The Positive and Negative Syndrome scale (PANSS), Psychopathological Symptom Severity scale, Clinical Global Impression scale (CGI) and Wechsler Adult Intelligence scale (WAIS-R) were used as outcome measures.

RESULTS AND CONCLUSION

Dilept demonstrated the unique spectrum of psychotropic activity: antipsychotic with stimulating action, favorable effect on negative symptoms and cognitive dysfunction. Treatment action was the most evident when dilept was used in the dose 200 mg/day. There was no evidence of any side-effects known to be typical for antipsychotics. The efficacy of dilept and phenazepam combination is dependent on dilept's antipsychotic and pro-cognitive effects, while benzodiazepine lacks these effects.

ASP2905, a specific inhibitor of the potassium channel Kv12.2 encoded by the Kcnh3 gene, is psychoactive in mice

Schizophrenia is a major psychiatric disorder associated with positive and negative symptoms and cognitive impairments. In this study, we used animal models of behavior to evaluate the antipsychotic activity of ASP2905, a potent and selective inhibitor of the potassium channel Kv12.2 encoded by the Kcnh3/BEC1 gene. ASP2905 inhibited hyperlocomotion induced by methamphetamine and by phencyclidine. In contrast, ASP2905 did not affect spontaneous locomotion, suggesting that ASP2905 selectively inhibits abnormal behaviors induced by stimulants. Chronic infusion of ASP2905 significantly ameliorated phencyclidine-induced prolongation of immobility time in mice subjected to the forced swimming test. These findings suggest that ASP2905 potentially mitigates symptoms of schizophrenia, such as apathy. The antipsychotic clozapine also reversed phencyclidine-induced prolonged immobility, while risperidone and haloperidol had no effect. Assessment of the effects of ASP2905 on latent learning deficits in mice treated with phencyclidine as neonates subjected to the water-finding task showed that ASP2905 significantly ameliorated phencyclidine-induced prolongation of finding latency, which reflects latent learning performance. These findings suggest that ASP2905 potentially mitigates cognitive impairments caused by schizophrenia, such as attention deficits. In contrast, administration of clozapine did not ameliorate phencyclidine-induced prolongation of finding latency. Therefore, ASP2905 may alleviate the broad spectrum of symptoms of schizophrenia, including positive and negative symptoms and cognitive impairments, which is in contrast to currently available antipsychotics, which are generally only partially effective for ameliorating these symptoms.

Negative Symptoms in Schizophrenia: A Review and Clinical Guide for Recognition, Assessment, and Treatment

Schizophrenia is frequently a chronic and disabling disorder, characterized by heterogeneous positive and negative symptom constellations. The objective of this review was to provide information that may be useful for clinicians treating patients with negative symptoms of schizophrenia. Negative symptoms are a core component of schizophrenia that account for a large part of the long-term disability and poor functional outcomes in patients with the disorder. The term negative symptoms describes a lessening or absence of normal behaviors and functions related to motivation and interest, or verbal/emotional expression. The negative symptom domain consists of five key constructs: blunted affect, alogia (reduction in quantity of words spoken), avolition (reduced goal-directed activity due to decreased motivation), asociality, and anhedonia (reduced experience of pleasure). Negative symptoms are common in schizophrenia; up to 60% of patients may have prominent clinically relevant negative symptoms that require treatment. Negative symptoms can occur at any point in the course of illness, although they are reported as the most common first symptom of schizophrenia. Negative symptoms can be primary symptoms, which are intrinsic to the underlying pathophysiology of schizophrenia, or secondary symptoms that are related to psychiatric or medical comorbidities, adverse effects of treatment, or environmental factors. While secondary negative symptoms can improve as a consequence of treatment to improve symptoms in other domains (ie, positive symptoms, depressive symptoms or extrapyramidal symptoms), primary negative symptoms generally do not respond well to currently available antipsychotic treatment with dopamine D₂ antagonists or partial D₂ agonists. Since some patients may lack insight about the presence of negative symptoms, these are generally not the reason that patients seek clinical care, and clinicians should be especially vigilant for their presence. Negative symptoms clearly constitute an unmet medical need in schizophrenia, and new and effective treatments are urgently needed.

Computational Dissociation of Dopaminergic and Cholinergic Effects on Action Selection and Inhibitory Control

BACKGROUND

Patients with schizophrenia make more errors than healthy subjects in the antisaccade task. In this paradigm, participants are required to inhibit a reflexive saccade to a target and to select the correct action (a saccade in the opposite direction). While the precise origin of this deficit is not clear, it has been connected to aberrant dopaminergic and cholinergic neuromodulation.

METHODS

To study the impact of dopamine and acetylcholine on inhibitory control and action selection, we administered two selective drugs (levodopa 200 mg/galantamine 8 mg) to healthy volunteers (N = 100) performing the antisaccade task. The computational model SERIA (stochastic early reaction, inhibition, and late action) was employed to separate the contribution of inhibitory control and action selection to empirical reaction times and error rates.

RESULTS

Modeling suggested that levodopa improved action selection (at the cost of increased reaction times) but did not have a significant effect on inhibitory control. By contrast, according to our model, galantamine affected inhibitory control in a dose-dependent fashion, reducing inhibition failures at low doses and increasing them at higher levels. These effects were sufficiently specific that the computational analysis allowed for identifying the drug administered to an individual with 70% accuracy.

CONCLUSIONS

Our results do not support the hypothesis that elevated tonic dopamine strongly impairs inhibitory control. Rather, levodopa improved the ability to select correct actions. However, inhibitory control was modulated by cholinergic drugs. This approach may provide a starting point for future computational assays that differentiate neuromodulatory abnormalities in heterogeneous diseases like schizophrenia.

Predictors of remission during acute treatment of first-episode schizophrenia patients involuntarily hospitalized and treated with algorithm-based pharmacotherapy: Secondary analysis of an observational study

AIM

Early clinical response predicts symptomatic remission and recovery in the maintenance treatment phase of first-episode schizophrenia (FES). However, little is known about predictors of symptomatic remission during acute treatment of severely ill patients with FES. Here, we conducted a secondary analysis of our retrospective observational study, which examined response, remission and treatment-resistance rates in seriously ill patients with FES spectrum disorders involuntarily hospitalized and treated with algorithm-based pharmacotherapy.

METHODS

We performed a retrospective chart review of 131 involuntarily admitted patients with schizophrenia or schizoaffective disorder. Our algorithm aimed to delay olanzapine treatment, standardize medications and suggest initiation of clozapine after failure of third-line antipsychotic treatment. The duration of each adequate antipsychotic treatment at an optimal dosage was 4 weeks or more. Remission was defined using the symptom-severity component of consensus remission criteria. A logistic regression model was applied to identify significant predictors of remission at discharge.

RESULTS

Overall, 74 patients (56%) were in remission at discharge. Non-remitters were hampered from becoming remitters mainly by the presence of negative symptoms. There were no differences in first-line antipsychotics, dosage of antipsychotics at time of response and adherence rates to algorithm-based pharmacotherapy between remitters and non-remitters. Shorter duration of untreated psychosis, favourable early response and less negative symptoms at baseline were identified as independent predictors of remission at discharge.

CONCLUSIONS

The importance of early intervention and specific and adequate treatments of negative symptoms is highlighted.

A systematic review of the indirect costs of schizophrenia in Europe

Background

Schizophrenia is a chronic disease associated with significant and long-lasting effects on health, and it is also a social and financial burden, not only for patients but also for families, other caregivers, and the wider society. It is essential to conduct the assessment of indirect costs, to understand all the effects of the disease on society. Our aim is to gain a better understanding of the indirect costs of schizophrenia in Europe.

Methods

We conducted a comprehensive systematic literature review covering EMBASE, Medline, and PsycINFO as well as reviewing Health Technology Assessment databases from different countries. We used a qualitative research synthesis for presenting information, as most of the studies were methodologically diverse, a quantitative analysis would have been impractical.

Results

Indirect cost adjusted to inflation ranged vastly between studies included in the review from 119 Euros to 62, 034 Euros annually. The average proportion of indirect costs of total costs was 44%. Studies highlighted important cost drivers as age, gender, and disease severity, explaining the variation in costs between treatment and patient groups.

Conclusions

Regardless of the methodological heterogeneity of the reviewed studies, there was an agreement about the significance of indirect costs of schizophrenia on the society. Considering the relatively high prevalence of schizophrenia in Europe, a need for more cost of illness studies especially from Central Eastern and Southern Europe is suggested.

Clinical relevance of paliperidone palmitate 3-monthly in treating schizophrenia

Antipsychotics are the mainstay in schizophrenia management, and long-acting injectable (LAI) antipsychotics contribute to the successful maintenance of treatment by improving non-adherence and preventing relapses. Paliperidone palmitate 3-monthly (PP3M) formulation is the only available LAI antipsychotic that offers an extended 3-month window of stable plasma drug concentration, enabling only four injections per year. This paper summarizes clinically relevant endpoints from available evidence for PP3M to bridge translational research gaps and provide measurable outcomes that can be interpreted in clinical practice. Low number-needed-to-treat (NNT) for relapse prevention (NNT [95% CI] 6-month estimate: 4.8 [3.2; 10.0]; 12-month estimate: 3.4 [2.2; 7.0]), and high number-needed-to-harm (NNH [95% CI] akathisia, 27.1 [12.3; -667.1]; tremor, 80.0 [22.5; 67.3]; dyskinesia, -132.6 [44.5; -23.2]; parkinsonism, 160.0 [28.9; -49.8]) quantify the relative benefits and low propensity for adverse events with PP3M. Symptom remission and reductions in positive and negative symptoms indicate treatment stability. Additionally, meaningful functional remission, reduced dosing frequency, and freedom from daily negotiations favorably impact patient preference and attenuate burdensome aspects of caregiving, representing important healthcare determinants that enhance prospects of treatment continuity in schizophrenia. This information can potentially improve clinicians' judgment of treatment choices, clinical response, and patient selection in routine care. Taken together, PP3M is a valuable antipsychotic treatment option, meriting consideration for a broader role in the long-term management of schizophrenia; its utility should not be limited to patients with poor adherence or when oral antipsychotics have failed.

Potential Role of Antipsychotic-Galantamine-Memantine Combination in the Treatment of Positive, Cognitive, and Negative Symptoms of Schizophrenia

Schizophrenia is, in part, a cognitive illness. There are no approved medications for cognitive impairments associated with schizophrenia (CIAS) and primary negative symptoms. Cholinergic and glutamatergic systems, alpha-7 nicotinic acetylcholine (α-7nACh) and N-methyl-D-aspartate (NMDA) receptors, kynurenic acid (KYNA), and mismatch negativity have been implicated in the pathophysiology of CIAS and negative symptoms. Galantamine is an acetylcholinesterase inhibitor that is also a positive allosteric modulator at the α4β2 and α7nACh receptors. Memantine is a noncompetitive NMDA receptor antagonist. Galantamine and memantine alone and in combination were effective for cognition in animals and people with Alzheimer's disease. The objective of this article is to critically dissect the published randomized controlled trials with galantamine and memantine for CIAS to highlight the efficacy signal. These studies may have failed to detect a clinically meaningful efficacy signal due to limitations, methodological issues, and possible medication nonadherence. There is evidence from a small open-label study that the galantamine-memantine combination may be effective for CIAS with kynurenine pathway metabolites as biomarkers to detect the severity of cognitive impairments. Given that there are no available treatments for cognitive impairments and primary negative symptoms in schizophrenia, testing of this "five-pronged strategy" (quintuple hypotheses: dopamine, nicotinic-cholinergic, glutamatergic/NMDA, GABA, and KYNA) is a "low-risk high-gain" approach that could be a major breakthrough in the field. The galantamine-memantine combination has the potential to treat positive, cognitive, and negative symptoms, and targeting the quintuple hypotheses concurrently may lead to a major scientific advancement - from antipsychotic treatment to antischizophrenia treatment.

Latent Iron Deficiency as a Marker of Negative Symptoms in Patients with First-Episode Schizophrenia Spectrum Disorder

Iron deficiency may alter dopaminergic transmission in the brain. This study investigated whether iron metabolism is associated with negative symptoms in patients with first-episode psychosis. The study enrolled 121 patients with first-episode schizophrenia spectrum disorder, whose duration of treatment was 2 months or less. Negative symptoms were measured using the Positive and Negative Syndrome Scale (PANSS) and Clinician-Rated Dimensions of Psychosis Symptom Severity (Dimensional) scale of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Prominent negative symptoms were defined as moderate or severe negative symptoms on the Dimensional scale of the DSM-5. Iron deficiency was defined as a serum ferritin ≤ 20 ng/mL. Patients with iron deficiency were significantly more likely to have prominent negative symptoms (45.2 vs. 22.2%; p = 0.014) and a higher PANSS negative symptoms score (p = 0.046) than those with normal ferritin levels. Patients with prominent negative symptoms had significantly lower ferritin levels (p = 0.025). The significance of these results remained after controlling for the duration of illness and other confounding variables. Our finding of an independent association between iron deficiency and negative symptoms in patients at the very early stage of illness implies that iron dysregulation has an effect on negative symptoms in patients with schizophrenia. The possibility of therapeutic intervention with iron should be further investigated.

Cross Cultural Validation and Extension of the Clinical Assessment Interview for Negative Symptoms (CAINS) in the Chinese Context: Evidence from a Spectrum Perspective

The Clinical Assessment Interview for Negative Symptoms (CAINS) was designed in accordance with the recent theory and research in social affective neuroscience and to address the psychometric and conceptual limitations of other instruments assessing negative symptoms. The present study aimed to provide a large-scale validation of the CAINS in China and examine its applicability and validity evidence across the schizophrenia spectrum. Using confirmatory factor analysis, our results replicated the original findings in the US development samples that the CAINS possesses a stable 2-factor structure, namely "motivation/pleasure" and "expression". We also found significant correlations between the CAINS and other negative symptom measures. The CAINS demonstrated good discriminant validity in differentiating negative symptoms in people with schizophrenia, nonpsychotic first-degree relatives and people with social anhedonia. People with schizophrenia exhibited significantly higher CAINS subscale scores than first-degree relatives and healthy controls. In addition, first-degree relatives had higher "motivation/pleasure" scores than healthy controls. The "motivation/pleasure" subscale scores of individuals with social anhedonia were also significantly higher than healthy controls.

Long-term maintenance and effects of exercise in early psychosis

AIM

The aims of this study were to examine if people with first-episode psychosis (FEP) are able to continue adhering to exercise after a supervised intervention and to explore if the benefits of exercise can be sustained.

METHODS

Twenty-eight persons with FEP took part in a 10-week exercise intervention that provided each participant with twice-weekly accompaniment to exercise activities of their own choice, of whom 20 were re-assessed 6 months after the intervention. Long-term adherence to exercise was assessed, and measures of psychiatric symptoms, physical health, neurocognition and social functioning were administered at baseline, post-intervention and 6-month follow-up.

RESULTS

During the supervised intervention, participants achieved 124.4 min of moderate-to-vigorous exercise per week. After 6 months, physical activity levels had decreased significantly (P = 0.025) and only 55% of participants had continued to exercise weekly. Repeated-measures analysis of variance found that the significant improvements in psychiatric symptoms and social functioning observed immediately after the intervention were maintained at 6 months (P = 0.001). However, post hoc analyses showed that symptomatic reductions were only maintained for those who continued to exercise, whereas symptom scores increased among those who had ceased exercising. Previously observed improvements in waist circumference and verbal memory were lost by 6 months.

CONCLUSION

Long-term exercise participation is associated with significant benefits for symptoms, cognition and social functioning in FEP. However, adherence to unsupervised exercise is low. Future research should explore the effectiveness of 'step-down' support following supervised interventions, and aim to establish sustainable methods for maintaining regular exercise in order to facilitate functional recovery and maintain physical health.

Negative symptoms of schizophrenia: new developments and unanswered research questions

Negative symptoms of schizophrenia are associated with poor functional outcome and place a substantial burden on people with this disorder, their families, and health-care systems. We summarise the evolution of the conceptualisation of negative symptoms, the most important findings, and the remaining open questions. Several studies have shown that negative symptoms might be primary to schizophrenia or secondary to other factors, and that they cluster in the domains of avolition-apathy and expressive deficit. Failure to take this heterogeneity into account might hinder progress in research on neurobiological substrates and discoveries of treatments for primary or enduring negative symptoms. Improvement in recognition and routine assessment of negative symptoms is instrumental for correct management of secondary negative symptoms that are amenable to treatment. If substantial progress is to be made in the understanding and treatment of negative symptoms, then advances in concepts and assessment should be integrated into the design of future studies of these symptoms.

Disrupted salience processing involved in motivational deficits for real-life activities in patients with schizophrenia

Motivational deficits in patients with schizophrenia adversely affect various domains of daily living. This symptom in everyday life situations manifests in a complex behavioral pattern whose root cannot be simplified to an impaired reward-motivation scheme. This study aimed to identify impairment of the salience network that underlies motivational deficits seen in patients with schizophrenia in real-life situations. During the functional magnetic resonance imaging scan, 20 patients with schizophrenia and 20 normal controls performed a task mimicking real-life situations, in which an avatar proposed participation in a daily activity with either an intrinsic or extrinsic reward. Group and type-of-reward effects were evaluated with respect to brain activity. Further, psychophysiological interactions were analyzed for the dorsal anterior cingulate cortex (dACC) and insula, which are the key nodes of the salience network. The acceptance of the proposal was significantly higher for intrinsic than for extrinsic rewards in controls, whereas patients showed no difference. The imaging results showed a group effect in the dACC, right insula, thalamus, and lingual gyrus. The dACC showed negative contrast interaction with regions of the left dorsolateral prefrontal cortex, and the right insula showed positive contrast interaction with the occipital gyrus and precentral gyrus. These results suggest that patients exhibit no different participation behavior between activities with intrinsic and extrinsic rewards, which can be explained by the floor effect. Disrupted salience processing in schizophrenia including aberrant salience network and a disconnection of the salience and reward networks may account for the lack of motivation for daily activities.

Amisulpride augmentation in clozapine-unresponsive schizophrenia (AMICUS): a double-blind, placebo-controlled, randomised trial of clinical effectiveness and cost-effectiveness

BACKGROUND

When treatment-refractory schizophrenia shows an insufficient response to a trial of clozapine, clinicians commonly add a second antipsychotic, despite the lack of robust evidence to justify this practice.

OBJECTIVES

The main objectives of the study were to establish the clinical effectiveness and cost-effectiveness of augmentation of clozapine medication with a second antipsychotic, amisulpride, for the management of treatment-resistant schizophrenia.

DESIGN

The study was a multicentre, double-blind, individually randomised, placebo-controlled trial with follow-up at 12 weeks.

SETTINGS

The study was set in NHS multidisciplinary teams in adult psychiatry.

PARTICIPANTS

Eligible participants were people aged 18-65 years with treatment-resistant schizophrenia unresponsive, at a criterion level of persistent symptom severity and impaired social function, to an adequate trial of clozapine monotherapy.

INTERVENTIONS

Interventions comprised clozapine augmentation over 12 weeks with amisulpride or placebo. Participants received 400 mg of amisulpride or two matching placebo capsules for the first 4 weeks, after which there was a clinical option to titrate the dosage of amisulpride up to 800 mg or four matching placebo capsules for the remaining 8 weeks.

MAIN OUTCOME MEASURES

The primary outcome measure was the proportion of 'responders', using a criterion response threshold of a 20% reduction in total score on the Positive and Negative Syndrome Scale.

RESULTS

A total of 68 participants were randomised. Compared with the participants assigned to placebo, those receiving amisulpride had a greater chance of being a responder by the 12-week follow-up (odds ratio 1.17, 95% confidence interval 0.40 to 3.42) and a greater improvement in negative symptoms, although neither finding had been present at 6-week follow-up and neither was statistically significant. Amisulpride was associated with a greater side effect burden, including cardiac side effects. Economic analyses indicated that amisulpride augmentation has the potential to be cost-effective in the short term [net saving of between £329 and £2011; no difference in quality-adjusted life-years (QALYs)] and possibly in the longer term.

LIMITATIONS

The trial under-recruited and, therefore, the power of statistical analysis to detect significant differences between the active and placebo groups was limited. The economic analyses indicated high uncertainty because of the short duration and relatively small number of participants.

CONCLUSIONS

The risk-benefit of amisulpride augmentation of clozapine for schizophrenia that has shown an insufficient response to a trial of clozapine monotherapy is worthy of further investigation in larger studies. The size and extent of the side effect burden identified for the amisulpride-clozapine combination may partly reflect the comprehensive assessment of side effects in this study. The design of future trials of such a treatment strategy should take into account that a clinical response may be not be evident within the 4- to 6-week follow-up period usually considered adequate in studies of antipsychotic treatment of acute psychotic episodes. Economic evaluation indicated the need for larger, longer-term studies to address uncertainty about the extent of savings because of amisulpride and impact on QALYs. The extent and nature of the side effect burden identified for the amisulpride-clozapine combination has implications for the nature and frequency of safety and tolerability monitoring of clozapine augmentation with a second antipsychotic in both clinical and research settings.

TRIAL REGISTRATION

EudraCT number 2010-018963-40 and Current Controlled Trials ISRCTN68824876.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 49. See the NIHR Journals Library website for further project information.

Exercise as an intervention for first-episode psychosis: a feasibility study

AIM

Exercise can improve psychiatric symptoms, neurocognitive functioning and physical health in schizophrenia. However, the effects in early psychosis have not been explored. This study aimed to assess the feasibility of an exercise intervention for early psychosis and to determine if it was associated with changes in physical and mental health.

METHODS

Thirty-one patients with first-episode psychosis (FEP) were recruited from early intervention services to a 10-week exercise intervention. The intervention group received individualized training programmes, aiming to achieve ≥90 min of moderate-to-vigorous activity each week, using exercise programmes tailored to individual preferences and needs. A comparison FEP sample from the same services (n = 7) received treatment as usual.

RESULTS

Rates of consent and retention in the exercise group were 94% and 81%, respectively. Participants achieved an average of 107 min of moderate-to-vigorous exercise per week. Positive and Negative Syndrome Scale total scores reduced by 13.3 points after 10 weeks of exercise, which was significantly greater than the treatment as usual comparison group (P = 0.010). The greatest differences were observed in negative symptoms, which reduced by 33% in the intervention group (P = 0.013). Significant improvements were also observed in psychosocial functioning and verbal short-term memory. Increases in cardiovascular fitness and processing speed were positively associated with the amounts of exercise achieved by participants.

CONCLUSION

Individualized exercise training could provide a feasible treatment option for improving symptomatic, neurocognitive and metabolic outcomes in FEP.

Are negative symptoms in schizophrenia a distinct therapeutic target?

Background and aims

The relationship between negative symptoms and cognition in schizophrenia is not clear, inconsistent findings have been reported by multiple authors and meta analyses. The aim of this study was to investigate the relationship between cognition and primary negative symptoms.

Methods

67 outpatients diagnosed with schizophrenia were evaluated using PANSS and the NSA-16 scale. Correlation and regression analyses were used in the present study to investigate the relationship between the primary negative symptoms and cognition.

Results

No relationship was found between the PANSS Cognitive factor and Negative factor, but when investigating the relationship of the Cognitive PANSS factor with the negative symptoms evaluated with the NSA-16 scale, it was shown that there is a significant association between cognition and motor retardation.

Conclusions

Our study reveals the relative independence of cognitive factor from the global negative domain of the psychopathology, even though the association with motor retardation was clear. These findings also support the need of using appropriate assessment tools in order to gain a more refined understanding of the phenomenology of schizophrenia.

Use of Transcranial Direct Stimulation in the Treatment of Negative Symptoms of Schizophrenia

Schizophrenia is a debilitating disease that affects approximately 1% of the population. Negative symptoms are among the major determinants of the functional impairment and a significant proportion of patients with negative symptoms will continue to experience these symptoms despite antipsychotic medications. There are promising results in the application of brain stimulation, particularly transcranial direct current stimulation (tDCS), for the reduction of negative symptoms of schizophrenia. However, findings are still controversial. This is a selective review of the literature published between 2011 and 2017 on use of tDCS in treatment of negative symptoms of schizophrenia. We included only randomized controlled trials where schizophrenia and negative symptoms were assessed using any psychometrically validated scale (eg, Positive and Negative Symptoms Scale or Scale for the Assessment of Negative Symptoms). Studies of participants with neurological conditions were excluded, as were those that did not report any symptom outcome variables. Only 5 studies are included. Three studies showed a decrease of negative symptoms. The other studies did not show any therapeutic effects of tDCS in the severity of positive and negative symptoms compared to controls. Our findings suggest that negative symptoms in schizophrenia can be treated with tDCS over the dorsolateral prefrontal cortex, but results are affected by several factors, such as the electrode montage, the concomitant medication, the homogeneity of the sample, the intensity of the tDCS treatment. Further randomized, double-blinded, sham-controlled studies in large samples are still needed to establish the effectiveness of the tDCS in the treatment of negative symptoms in schizophrenia, but there is the potential for tDCS to become a useful complementary treatment option in this population.

Treatment of negative symptoms: Where do we stand, and where do we go?

Negative symptoms, e.g. social withdrawal, reduced initiative, anhedonia and affective flattening, are notoriously difficult to treat. In this review, we take stock of recent research into treatment of negative symptoms by summarizing psychosocial as well as pharmacological and other biological treatment strategies. Major psychosocial approaches concern social skills training, cognitive behavior therapy for psychosis, cognitive remediation and family intervention. Some positive findings have been reported, with the most robust improvements observed for social skills training. Although cognitive behavior therapy shows significant effects for negative symptoms as a secondary outcome measure, there is a lack of data to allow for definite conclusions of its effectiveness for patients with predominant negative symptoms. With regard to pharmacological interventions, antipsychotics have been shown to improve negative symptoms, but this seems to be limited to secondary negative symptoms in acute patients. It has also been suggested that antipsychotics may aggravate negative symptoms. Recent studies have investigated glutamatergic compounds, e.g. glycine receptor inhibitors and drugs that target the NMDA receptor or metabotropic glutamate 2/3 (mGlu2/3) receptor, but no consistent evidence of improvement of negative symptoms was found. Finally, some small studies have suggested improvement of negative symptoms after non-invasive electromagnetic neurostimulation, but this has only been partly replicated and it is still unclear whether these are robust improvements. We address methodological issues, in particular the heterogeneity of negative symptoms and treatment response, and suggest avenues for future research. There is a need for more detailed studies that focus on different dimensions of negative symptoms.

Primary and persistent negative symptoms: Concepts, assessments and neurobiological bases

Primary and persistent negative symptoms (PPNS) represent an unmet need in the care of people with schizophrenia. They have an unfavourable impact on real-life functioning and do not respond to available treatments. Underlying etiopathogenetic mechanisms of PPNS are still unknown. The presence of primary and enduring negative symptoms characterizes deficit schizophrenia (DS), proposed as a separate disease entity with respect to non-deficit schizophrenia (NDS). More recently, to reduce the heterogeneity of negative symptoms by using criteria easily applicable in the context of clinical trials, the concept of persistent negative symptoms (PNS) was developed. Both PNS and DS constructs include enduring negative symptoms (at least 6months for PNS and 12months for DS) that do not respond to available treatments. PNS exclude secondary negative symptoms based on a cross-sectional evaluation of severity thresholds on commonly used rating scales for positive symptoms, depression and extrapyramidal side effects; the DS diagnosis, instead, excludes all potential sources of secondary negative symptoms based on a clinical longitudinal assessment. In this paper we review the evolution of concepts and assessment modalities relevant to PPNS, data on prevalence of DS and PNS, as well as studies on clinical, neuropsychological, brain imaging electrophysiological and psychosocial functioning aspects of DS and PNS.

Bitopertin in Negative Symptoms of Schizophrenia-Results From the Phase III FlashLyte and DayLyte Studies

BACKGROUND

There is currently no standard of care for treatment of negative symptoms of schizophrenia, although some previous results with glutamatergic agonists have been promising.

METHODS

Three (SunLyte [WN25308], DayLyte [WN25309], and FlashLyte [NN25310]) phase III, multicenter, randomized, 24-week, double-blind, parallel-group, placebo-controlled studies evaluated the efficacy and safety of adjunctive bitopertin in stable patients with persistent predominant negative symptoms of schizophrenia treated with antipsychotics. SunLyte met the prespecified criteria for lack of efficacy and was declared futile. Key inclusion criteria were age ≥18 years, DSM-IV-TR diagnosis of schizophrenia, score ≥40 on the sum of the 14 Positive and Negative Syndrome Scale negative symptoms and disorganized thought factors, unaltered antipsychotic treatment, and clinical stability. Following a 4-week prospective stabilization period, patients were randomly assigned 1:1:1 to bitopertin (5 mg and 10 mg [DayLyte] and 10 mg and 20 mg [FlashLyte]) or placebo once daily for 24 weeks. The primary efficacy end point was mean change from baseline in Positive and Negative Syndrome Scale negative symptom factor score at week 24.

RESULTS

The intent-to-treat population in DayLyte and FlashLyte included 605 and 594 patients, respectively. At week 24, mean change from baseline showed improvement in all treatment arms but no statistically significant separation from placebo in Positive and Negative Syndrome Scale negative symptom factor score and all other end points. Bitopertin was well tolerated.

CONCLUSIONS

These studies provide no evidence for superior efficacy of adjunctive bitopertin in any of the doses tested over placebo in patients with persistent predominant negative symptoms of schizophrenia.

Psychological and psychosocial interventions for negative symptoms in psychosis: systematic review and meta-analysis

BackgroundNegative symptoms observed in patients with psychotic disorders undermine quality of life and functioning. Antipsychotic medications have a limited impact. Psychological and psychosocial interventions, with medication, are recommended. However, evidence for the effectiveness of specific non-biological interventions warrants detailed examination.AimsTo conduct a meta-analytic and systematic review of the literature on the effectiveness of non-biological treatments for negative symptoms in psychotic disorders.MethodWe searched for randomised controlled studies of psychological and psychosocial interventions in psychotic disorders that reported outcome on negative symptoms. Standardised mean differences (SMDs) in values of negative symptoms at the end of treatment were calculated across study domains as the main outcome measure.ResultsA total of 95 studies met our criteria and 72 had complete quantitative data. Compared with treatment as usual cognitive-behavioural therapy (pooled SMD -0.34, 95% CI -0.55 to -0.12), skills-based training (pooled SMD -0.44, 95% CI -0.77 to -0.10), exercise (pooled SMD -0.36, 95% CI -0.71 to -0.01), and music treatments (pooled SMD -0.58, 95% CI -0.82 to -0.33) provide significant benefit. Integrated treatment models are effective for early psychosis (SMD -0.38, 95% CI -0.53 to -0.22) as long as the patients remain in treatment. Overall quality of evidence was moderate with a high level of heterogeneity.ConclusionsSpecific psychological and psychosocial interventions have utility in ameliorating negative symptoms in psychosis and should be included in the treatment of negative symptoms. However, more effective treatments for negative symptoms need to be developed.

Managing Negative Symptoms of Schizophrenia: How Far Have We Come?

The specific efficacy of antipsychotics on negative symptoms is questionable, suggesting an urgent need for specific treatments for negative symptoms. This review includes studies published since 2014 with a primary or secondary focus on treating negative symptoms in schizophrenia. Special emphasis is given to recently published meta-analyses. Topics include novel pharmacological approaches, including glutamatergic-based and nicotinic-acetylcholinergic treatments, treatments approved for other indications by the US FDA (or other regulatory bodies) (antipsychotics, antidepressants, and mood stabilizers), brain stimulation, and behavioral- and activity-based approaches, including physical exercise. Potential complications regarding the design of current negative symptom trials are discussed and include inconsistent placebo effects, lack of reliable biomarkers, negative symptom scale and inclusion criteria variability, attempts to distinguish between primary and secondary negative symptoms, lack of focus on early psychosis, and the potential iatrogenic bias of clinical trials.

Cariprazine versus risperidone monotherapy for treatment of predominant negative symptoms in patients with schizophrenia: a randomised, double-blind, controlled trial

BACKGROUND

Although predominant negative symptoms of schizophrenia can be severe enough to cause persistent impairment, effective treatment options are lacking. We aimed to assess the new generation antipsychotic cariprazine in adult patients with predominant negative symptoms.

METHODS

In this randomised, double-blind, phase 3b trial, we enrolled adults aged 18-65 years with long-term (>2 year), stable schizophrenia and predominant negative symptoms (>6 months) at 66 study centres (mainly hospitals and university clinics, with a small number of private practices) in 11 European countries. Patients were randomly assigned (1:1) by an interactive web response system to 26 weeks of monotherapy with fixed-dose oral cariprazine (3 mg, 4·5 mg [target dose], or 6 mg per day) or risperidone (3 mg, 4 mg [target dose], or 6 mg per day); previous medication was discontinued over 2 weeks. The primary outcome was change from baseline to week 26 or end of treatment on the Positive and Negative Syndrome Scale factor score for negative symptoms (PANSS-FSNS) analysed in a modified intention-to-treat population of patients who had follow-up assessments within 5 days after last receipt of study drugs with a mixed-effects model for repeated measures. Safety was assessed in all patients who received at least one dose of study drug. This study is registered with EudraCT, number 2012-005485-36.

FINDINGS

Between May 27, 2013, and Nov 17, 2014, 533 patients were screened and 461 (86%) patients were randomised to treatment (230 for cariprazine and 231 for risperidone); 460 were included in the safety population (one patient discontinued before study drug intake). 227 (99%) of 230 patients in the cariprazine group and 229 (99%) of 230 patients in the risperidone group were included in the modified intention-to-treat population (178 [77%] in each group completed 26 weeks of treatment). Mean daily doses were 4·2 mg (SD 0·6) for cariprazine and 3·8 mg (0·4) for risperidone. Treatment-emergent adverse events (eg, insomnia, akathisia, worsening of schizophrenia, headache, anxiety) were reported in 123 (54%) patients treated with cariprazine and 131 (57%) patients treated with risperidone. Use of cariprazine led to a greater least squares mean change in PANSS-FSNS from baseline to week 26 than did risperidone (-8·90 points for cariprazine vs -7·44 points for risperidone; least squares mean difference -1·46, 95% CI -2·39 to -0·53; p=0·0022; effect size 0·31). One patient in the risperidone group died of a cause regarded as unrelated to treatment.

INTERPRETATION

Our results support the efficacy of cariprazine in the treatment of predominant negative symptoms of schizophrenia.

FUNDING

Gedeon Richter Plc.

[The German research network for mental disorders]

Mental disorders are among the greatest medical and social challenges facing us. They can occur at all stages of life and are among the most important commonly occurring diseases. In Germany 28 % of the population suffer from a mental disorder every year, while the lifetime risk of suffering from a mental disorder is almost 50 %. Mental disorders cause great suffering for those affected and their social network. Quantitatively speaking, they can be considered to be among those diseases creating the greatest burden for society due to reduced productivity, absence from work and premature retirement. The Federal Ministry of Education and Research is funding a new research network from 2015 to 2019 with up to 35 million euros to investigate mental disorders in order to devise and develop better therapeutic measures and strategies for this population by means of basic and translational clinical research. This is the result of a competitive call for research proposals entitled research network for mental diseases. It is a nationwide network of nine consortia with up to ten psychiatric and clinical psychology partner institutions from largely university-based research facilities for adults and/or children and adolescents. Furthermore, three cross-consortia platform projects will seek to identify shared causes of diseases and new diagnostic modalities for anxiety disorders, attention deficit hyperactivity disorders (ADHS), autism, bipolar disorders, depression, schizophrenia and psychotic disorders as well as substance-related and addictive disorders. The spectrum of therapeutic approaches to be examined ranges from innovative pharmacological and psychotherapeutic treatment to novel brain stimulation procedures. In light of the enormous burden such diseases represent for society as a whole, a sustainable improvement in the financial support for those researching mental disorders seems essential. This network aims to become a nucleus for long overdue and sustained support for a German center for mental disorders.

A systematic review of physical activity policy recommendations and interventions for people with mental health problems in Sub-Saharan African countries

Introduction

There is a need for interventions to address the escalating mental health burden in Sub-Saharan Africa (SSA). Implementation of physical activity (PA) within the rehabilitation of people with mental health problems (PMHP) could reduce the burden and facilitate recovery. The objective of the current review was to explore (1) the role of PA within mental health policies of SSA countries, and (2) the current research evidence for PA to improve mental health in SSA.

Methods

We screened the Mental Health Atlas and MiNDbank for mental health policies in SSA countries and searched PubMed for relevant studies on PA in PMHP in SSA.

Results

Sixty-nine percent (=33/48) of SSA countries have a dedicated mental health policy. Two of 22 screened mental health policies included broad physical activity recommendations. There is clear evidence for the role of PA in the prevention and rehabilitation of depression in SSA.

Conclusion

Despite the existing evidence, PA is largely a neglected rehabilitation modality in the mental health care systems of SSA. Continued education of existing staff, training of specialized professionals and integration of PA for mental health in public health awareness programs are needed to initiate and improve PA programs within the mental health care systems of SSA.

Motivating factors and barriers towards exercise in severe mental illness: a systematic review and meta-analysis

Exercise can improve clinical outcomes in people with severe mental illness (SMI). However, this population typically engages in low levels of physical activity with poor adherence to exercise interventions. Understanding the motivating factors and barriers towards exercise for people with SMI would help to maximize exercise participation. A search of major electronic databases was conducted from inception until May 2016. Quantitative studies providing proportional data on the motivating factors and/or barriers towards exercise among patients with SMI were eligible. Random-effects meta-analyses were undertaken to calculate proportional data and 95% confidence intervals (CI) for motivating factors and barriers toward exercise. From 1468 studies, 12 independent studies of 6431 psychiatric patients were eligible for inclusion. Meta-analyses showed that 91% of people with SMI endorsed 'improving health' as a reason for exercise (N = 6, n = 790, 95% CI 80-94). Among specific aspects of health and well-being, the most common motivations were 'losing weight' (83% of patients), 'improving mood' (81%) and 'reducing stress' (78%). However, low mood and stress were also identified as the most prevalent barriers towards exercise (61% of patients), followed by 'lack of support' (50%). Many of the desirable outcomes of exercise for people with SMI, such as mood improvement, stress reduction and increased energy, are inversely related to the barriers of depression, stress and fatigue which frequently restrict their participation in exercise. Providing patients with professional support to identify and achieve their exercise goals may enable them to overcome psychological barriers, and maintain motivation towards regular physical activity.

Indian psychiatric society multicentric study: Correlates of prescription patterns of psychotropics in India

BACKGROUND

There is a lack of information on the clinical and sociodemographic correlates of prescription of psychotropics by psychiatrists.

AIM AND OBJECTIVE

This study aimed to evaluate the relationship of prescription patterns with various clinical and sociodemographic variables.

METHODOLOGY

Data of prescription patterns, psychiatric diagnosis, sociodemographic variables, and comorbid physical illnesses were collected for 4480 patients, across 11 centers.

RESULTS

Females are more often prescribed escitalopram, sertraline, amitriptyline, amisulpride, nonlithium mood stabilizers, and benzodiazepines, whereas males are more often prescribed fluoxetine, olanzapine, two antipsychotics concurrently, typical antipsychotics, valproate, lithium, and more than one benzodiazepine. Elderly (>65 years) participants are more often prescribed sertraline when compared to adolescents. In addition, elderly more often receive quetiapine and less often are prescribed benzodiazepines. Those with comorbid neurological disorders are commonly prescribed antipsychotics, amitriptyline, and more than one antidepressant and are less commonly prescribed lithium, combination of two mood stabilizers, and benzodiazepines. Those with cardiac ailments are more commonly prescribed sertraline, quetiapine, and lithium and less frequently prescribed amitriptyline, fluoxetine, olanzapine, risperidone, and typical antipsychotics. Those with diabetes mellitus more often received escitalopram and quetiapine. Presence of more than one psychiatric diagnosis was associated with the use of more number of medications. Further, diagnosis of affective disorders was associated with the use of a higher number of medications.

CONCLUSION

Findings of the present study suggest that sociodemographic variables and physical and psychiatric comorbidity influence the prescription patterns of psychotropics.

Chinese version of the Schizotypal Personality Questionnaire: Factor structure replication and invariance across sex

INTRODUCTION

The Schizotypal Personality Questionnaire (SPQ) is a self-report measure assessing symptoms of schizotypy. The SPQ has been used in both normative and clinical samples and has much theoretical and empirical support. A three-factor structure of the SPQ, derived on the basis of work in schizophrenia, consisting of Cognitive-Perceptual, Interpersonal, and Disorganized factors, has been well replicated. The present study aimed to (i) validate this three-factor structure in the Chinese version of the SPQ in a sample of individuals of Chinese ethnicity, and (ii) test for invariance across sex.

METHODS

A total of 209 (99 males) undergraduate university students (Mage  = 19.5, SD = 1.6) were administered the SPQ.

RESULTS

Confirmatory factor analysis indicated a better fit between the data and the three-factor model compared with a one-factor model. Multigroup confirmatory factor analysis also found strong measurement invariance across sex.

DISCUSSION

The current results add to a growing body of literature evidencing cross-cultural validity of the SPQ and its invariance across sex. Research and clinical implications of the current results are discussed.

Improvement of ketamine-induced social withdrawal in rats: the role of 5-HT7 receptors

Social withdrawal, one of the core negative symptoms of schizophrenia, can be modelled in the social interaction (SI) test in rats using N-methyl-D-aspartate receptor glutamate receptor antagonists. We have recently shown that amisulpride, an antipsychotic with a high affinity for serotonin 5-HT7 receptors, reversed ketamine-induced SI deficits in rats. The aim of the present study was to further elucidate the potential involvement of 5-HT7 receptors in the prosocial action of amisulpride. Acute administration of amisulpride (3 mg/kg) and SB-269970 (1 mg/kg), a 5-HT7 receptor antagonist, reversed ketamine-induced social withdrawal, whereas sulpiride (20 or 30 mg/kg) and haloperidol (0.2 mg/kg) were ineffective. The 5-HT7 receptor agonist AS19 (10 mg/kg) abolished the prosocial efficacy of amisulpride (3 mg/kg). The coadministration of an inactive dose of SB-269970 (0.2 mg/kg) showed the prosocial effects of inactive doses of amisulpride (1 mg/kg) and sulpiride (20 mg/kg). The anxiolytic chlordiazepoxide (2.5 mg/kg) and the antidepressant fluoxetine (2.5 mg/kg) were ineffective in reversing ketamine-induced SI deficits. The present study suggests that the antagonism of 5-HT7 receptors may contribute towards the mechanisms underlying the prosocial action of amisulpride. These results may have therapeutic implications for the treatment of negative symptoms in schizophrenia and other disorders characterized by social withdrawal.

Negative symptoms in schizophrenia

The negative symptoms have been described in association with schizophrenia since the early days of it being recognized as an entity. However, their elusive nature kept them unacknowledged until there was a revival of interest in them following the development of specific quantifying measures. Over the past three decades, there has been a tremendous surge in research on their types, measurements, status in the present classificatory system, and their implications. The developments in modern investigatory methods have provided the researchers with fresh insights into the underlying mechanisms, and a distributed functioning of the neuronal networks has emerged as the major abnormality. Accordingly, a variety of pharmacological and other treatment modalities have been developed which go beyond the traditional. Nevertheless, a lot remain unanswered. The present paper summarizes important concepts with regard to negative symptoms in schizophrenia.

Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the management of schizophrenia and related disorders

OBJECTIVES

This guideline provides recommendations for the clinical management of schizophrenia and related disorders for health professionals working in Australia and New Zealand. It aims to encourage all clinicians to adopt best practice principles. The recommendations represent the consensus of a group of Australian and New Zealand experts in the management of schizophrenia and related disorders. This guideline includes the management of ultra-high risk syndromes, first-episode psychoses and prolonged psychoses, including psychoses associated with substance use. It takes a holistic approach, addressing all aspects of the care of people with schizophrenia and related disorders, not only correct diagnosis and symptom relief but also optimal recovery of social function.

METHODS

The writing group planned the scope and individual members drafted sections according to their area of interest and expertise, with reference to existing systematic reviews and informal literature reviews undertaken for this guideline. In addition, experts in specific areas contributed to the relevant sections. All members of the writing group reviewed the entire document. The writing group also considered relevant international clinical practice guidelines. Evidence-based recommendations were formulated when the writing group judged that there was sufficient evidence on a topic. Where evidence was weak or lacking, consensus-based recommendations were formulated. Consensus-based recommendations are based on the consensus of a group of experts in the field and are informed by their agreement as a group, according to their collective clinical and research knowledge and experience. Key considerations were selected and reviewed by the writing group. To encourage wide community participation, the Royal Australian and New Zealand College of Psychiatrists invited review by its committees and members, an expert advisory committee and key stakeholders including professional bodies and special interest groups.

RESULTS

The clinical practice guideline for the management of schizophrenia and related disorders reflects an increasing emphasis on early intervention, physical health, psychosocial treatments, cultural considerations and improving vocational outcomes. The guideline uses a clinical staging model as a framework for recommendations regarding assessment, treatment and ongoing care. This guideline also refers its readers to selected published guidelines or statements directly relevant to Australian and New Zealand practice.

CONCLUSIONS

This clinical practice guideline for the management of schizophrenia and related disorders aims to improve care for people with these disorders living in Australia and New Zealand. It advocates a respectful, collaborative approach; optimal evidence-based treatment; and consideration of the specific needs of those in adverse circumstances or facing additional challenges.