Successful treatment with flupenthixol decanoate of a patient with both schizophrenia and alcoholism

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.

[Alcohol-induced psychotic disorder--a diagnostic entity of its own?]

Alcohol-induced psychotic disorders are relatively rare schizophrenia-like disorders characterized by key symptoms, such as auditory hallucinations, anxiety and delusions while disorders of consciousness and orientation are lacking. The diagnostic entity of this disorder has been questioned. Recent findings indicate a high risk for rehospitalization and relapse but compared to other drug-induced disorders a low risk of schizophrenia-like course of the illness (5 % compared to 40-50 % with other drugs). Pathophysiological, diagnostic and therapeutic aspects of alcohol-induced psychotic disorders are discussed.

The Potential Role of Long-acting Injectable Antipsychotics in People with Schizophrenia and Comorbid Substance Use

OBJECTIVE: Treatment of schizophrenia in patients with comorbid substance use (alcohol/illicit drug use, abuse or dependence) presents challenges for public health systems. Substance use in people with schizophrenia is up to four times greater than the general population and is associated with medication nonadherence and poor outcomes. Therefore, continuous antipsychotic treatment in this population may pose more of a challenge than for those with schizophrenia alone. Many clinical trials and treatment recommendations in schizophrenia do not take into consideration substance use as people with comorbid substance use have typically been excluded from most antipsychotic trials. Nonetheless, antipsychotic treatment appears to be as efficacious in this population, although treatment discontinuation remains high. The objective of this review was to highlight the importance and utility of considering long-acting injectable antipsychotics for patients with schizophrenia and comorbid substance use. METHODS: We did a literature search using PubMed with key words schizophrenia and substance use/abuse/dependence, nonadherence, antipsychotics, long acting injectables, relapse, and psychosocial interventions. We limited our search to human studies published in English and 4,971 articles were identified. We focused on clinical trials, case reports, case series, reviews and meta-analyses resulting in 125 articles from 1975-2011. RESULTS: Our review suggests the potential role of long-acting injectables for people with comorbid substance use and schizophrenia in leading to improvements in psychopathology, relapse prevention, fewer rehospitalizations, and better outcomes. CONCLUSIONS: While more research is needed, long-acting antipsychotics should be considered an important option in the management of people with schizophrenia and comorbid substance use.

Pharmacotherapy of schizophrenia with comorbid substance use disorder--reviewing the evidence and clinical recommendations

Substance use disorder is the most common psychiatric comorbidity in schizophrenic patients, with prevalence rates of up to 65%. Recommendations for antipsychotic pharmacotherapy in schizophrenia are based on studies that excluded patients with this dual diagnosis. In the present comprehensive systematic review, the pharmacological studies performed in this subgroup of patients are summarised and discussed from the standpoint of evidence-based medicine. Unfortunately, randomized controlled studies, providing a high evidence level, in patients with this dual diagnosis are rare. Data, mainly based on open studies or case series, suggest superior efficacy for second generation antipsychotic agents (SGAs) (aripiprazole, clozapine, olanzapine, quetiapine, risperidone) with regard to improvement of distinct psychopathological symptoms, reduced craving and greater reduction of substance use compared with orally administered conventional antipsychotics (FGAs). Tricyclic antidepressants given adjunctive to antipsychotic maintenance therapy showed efficacy in reducing substance use and craving. The administration of anti-craving agents (naltrexone) led to a decrease of drug intake. Unfortunately, there is no clinical experience with acamprosate in schizophrenic patients with comorbid alcoholism. In conclusion, there are more theoretically based arguments for the preferential use of SGAs in schizophrenic patients with comorbid substance use disorder while the empirical evidence is weak. The early initiation of treatment with antidepressants, depending on the patient's psychopathology, as well as add-on medication with anti-craving agents should be considered.

Pharmakotherapie bei Schizophrenie und komorbider Substanzstörung

Substance use disorder is the most common psychiatric comorbidity in patients with schizophrenia, revealing prevalence rates of up to 65%. Recommendations of antipsychotic pharmacotherapy in schizophrenia are based on studies excluding patients with this double diagnosis. In this systematic review the available pharmacological studies in this subgroup of patients are summarised and discussed with regard to evidence-based medicine. Most available studies concern small sample sizes, and the level of evidence in those studies was low. Data suggest efficacy for second-generation antipsychotics (SGAs) (aripiprazole, clozapine, olanzapine, quetiapine, and risperidone) superior to orally administered conventional antipsychotics. Treatment with SGAs revealed superior improvement of distinct psychopathological symptoms, similarly to those studies excluding patients with comorbid substance abuse. In some studies reduced craving and increased reduction of substance abuse could be demonstrated. Tricyclic antidepressants (TCAs) added to antipsychotic maintenance therapy showed efficacy in reducing substance abuse and craving, whereas studies with other antidepressive agents (e.g. selective serotonin reuptake inhibitors) are lacking. Administration of the anti-craving agents naltrexone and disulfiram led to a decrease of drug intake in a few studies. Unfortunately no studies are available using acamprosate in patients with schizophrenia and comorbid alcoholism. In conclusion the preferential use of SGAs in patients with schizophrenia and comorbid substance use disorder is suggested, and the early initiation of concomitant treatment with TCAs (depending on current psychopathological status) and anti-craving agents has to be considered.

Antipsychotic drug treatment of schizophrenic patients with substance abuse disorders

BACKGROUND/AIM

In recent years, there has been a growing interest in developing adequate treatments for patients with a diagnosis of schizophrenia and a comorbid substance use disorder (SUD). In the present paper we aim to critically review published reports on the use of conventional and second-generation antipsychotics in the treatment of patients with schizophrenia and comorbid SUD, to provide clinicians with a clearer view of the pharmacological treatment of this highly prevalent dual diagnosis based upon the evidence arising from the scientific literature.

METHODS

A search of the relevant literature from Medline, PsycLIT and EMBASE databases, included in the Science Citation Index, and available up to November 2006 was conducted using the terms: 'schizophrenia', 'substance use disorder' and 'antipsychotics'.

RESULTS

While research on the use of conventional antipsychotics has remained limited, the majority of studies suggest the effectiveness of second-generation antipsychotics, particularly clozapine, for patients with schizophrenia and a comorbid substance use disorder.

CONCLUSION

In the absence of randomized controlled trials that could provide more reliable information, clinical decisions may need to rely on indirect data provided by the increasing number of case reports, open trials and retrospective studies showing a decrease in cigarette smoking, alcohol, cocaine or cannabis use and an improvement of overall psychiatric symptoms.

Alcohol drinking of alcohol-preferring AA rats is differentially affected by clozapine and olanzapine

Clinical evidence suggests that atypical antipsychotic drugs might reduce alcohol drinking and help to maintain abstinence. This study aimed to compare the effects of two widely used atypical antipsychotic drugs clozapine and olanzapine on alcohol intake in alcohol-preferring AA (Alko, Alcohol) rats that were taught to drink 10% alcohol in a 4 h limited access paradigm. Effects of acute clozapine (0, 0.3, 1.0 and 5.0 mg/kg) and olanzapine (0, 0.1, 0.5 and 1.25 mg/kg) treatments on the limited access alcohol drinking were studied. In repeated treatment experiment, clozapine (1.0 mg/kg) or olanzapine (0.5 mg/kg) was administered once daily, before limited access alcohol drinking session, over 5 successive days. To reveal any effect of the drugs selective for alcohol drinking, alcohol was exchanged with 0.1% saccharin solution for the 4 h limited access, and acute treatments were repeated. Effects of the drugs on ambulatory locomotor activity were tested with doses that were used in the acute experiments. Acute clozapine treatment had no effect on either alcohol or saccharin drinking, but olanzapine significantly reduced 4 h alcohol drinking. Repeated olanzapine treatment significantly reduced 4 h alcohol drinking when compared with vehicle or clozapine, but a tolerance developed to this effect. Repeated clozapine treatment produced no significant effect compared with vehicle. Both drugs significantly reduced locomotor activity. In conclusion, the atypical antipsychotic olanzapine non-selectively reduced alcohol drinking, while clozapine failed to do so, even if both were administered at pharmacologically effective doses.

World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of schizophrenia, Part 1: acute treatment of schizophrenia

These guide lines for the biological treatment of schizophrenia were developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBO). The goal during the development of these guidelines was to review systematically all available evidence pertaining to the treatment of schizophrenia, and to reach a consensus on a series of practice recommendations that are clinically and scientifically meaningful based on the available evidence. These guidelines are intended for use by all physicians seeing and treating people with schizophrenia. The data used for developing these guidelines have been extracted primarily from various national treatment guidelines and panels for schizophrenia, as well as from meta-analyses, reviews and randomised clinical trials on the efficacy of pharmacological and other biological treatment interventions identified by a search of the MEDLINE database and Cochrane Library. The identified literature was evaluated with respect to the strength of evidence for its efficacy and then categorised into four levels of evidence (A-D). This first part of the guidelines covers disease definition, classification, epidemiology and course of schizophrenia, as well as the management of the acute phase treatment. These guidelines are primarily concerned with the biological treatment (including antipsychotic medication, other pharmacological treatment options, electroconvulsive therapy, adjunctive and novel therapeutic strategies) of adults suffering from schizophrenia.

Clozapine, quetiapine and olanzapine among addicted schizophrenic patients: towards testable hypotheses

Although life prevalence of substance use disorders among patients with schizophrenia is close to 50%, few studies have been carried out to date to identify an integrated pharmacological treatment for this comorbidity. So far, the most promising results, that we report here, have been obtained with clozapine. To a lesser extent, quetiapine and olanzapine, both clozapine analogues, have also shown promising results. Further to these observations, the present paper critically reviews the advantages associated with clozapine, quetiapine and olanzapine, and their relevance to the treatment of addiction among schizophrenic patients. Six characteristics seem to distinguish clozapine, quetiapine and olanzapine from the first-generation antipsychotics: (1) acting preferentially on the reward system, these second-generation antipsychotics (mainly clozapine and quetiapine) induce almost no extrapyramidal symptoms; (2) quickly dissociating from D(2), theses drugs (mainly clozapine and quetiapine) seem not to induce dysphoria, unlike conventional antipsychotics like haloperidol;(3) these drugs (mainly clozapine) seem more effective in the treatment of negative symptoms than conventional antipsychotics; (4) because of a diversified activity on several serotoninergic and noradrenergic receptors, these drugs positively alter mood, which does not seem to be the case with conventional antipsychotics, except for flupenthixol; (5) these drugs have a positive impact on cognition, which is not the case with the first-generation antipsychotics; (6) unlike conventional antipsychotics, these drugs seem to have a moderate affinity for 5-HT(3), the receptor on which ondansetron, an anti-craving medication, acts.

Flupenthixol as a potential pharmacotreatment of alcohol and cocaine abuse/dependence

Preclinical and clinical studies suggest that the mesolimbic dopamine system plays a major role in mediating the reinforcing effects of drugs of abuse, including alcohol and psychostimulants, and that pharmacological blockade of dopamine D1 and/or D2 receptors may reduce intake of these drugs, as well as relapse rates. The neuroleptic flupenthixol, which has dopamine D1 and D2 receptor antagonist properties and which may be given intramuscularly in order to improve compliance, has been studied as a possible anti-craving drug in substance abuse disorders. Flupenthixol has been shown to attenuate the discriminative stimulus effects of psychostimulants, as well as their intake in animal models of drug abuse. In addition, the compound was found to reduce alcohol intake in a rat model of alcoholism, but the 'anti-alcohol' effect appeared to be only weakly selective and nonspecific. Clinically, the drug has been studied in alcoholics, cocaine addicts and in patients with comorbid psychiatric disorders. Although the data base is still limited and a number of recent trials have not been completely analyzed, these studies suggest that flupenthixol may be useful in decreasing cocaine consumption. Recent studies in alcoholism, however, have shown disappointing results. A number of pilot studies suggest that probably the most promising area may be the treatment of substance abuse/dependence in patients with comorbid psychiatric disorders. Future studies should focus on dosing issues, the differentiation between short- and long-term effects and the identification of subgroups of patients with particular psychopathology.

Cost-effectiveness of mental health services for persons with a dual diagnosis: a literature review and the CCMHCP. The Cost-Effectiveness of Community Mental Health Care for Single and Dually Diagnosed Project

People suffering from comorbid mental illness and substance abuse disorders (the dually diagnosed) are thought to constitute large portions of clients treated as outpatients by public-sector community-based mental health providers. These providers dispense units of ambulatory mental health services and treatments incrementally to maintain clients in the community and out of psychiatric hospitals. Community maintenance is one step, albeit critical, toward quitting drugs and eventual abstinence. Thus, there is a need for information that compares the effectiveness and cost of such services on dually diagnosed clients to identify appropriate low-cost high-yield treatment and service options and packages. This article provides a review of the literature on the effectiveness of ambulatory mental health services and recent emergent reports of cost-effectiveness of programs for the dually diagnosed, paying special attention to the gray areas and gaps. This article also describes a new project; an inexpensive add-on to an existing community mental health center. The project will be examining over 4 years of data to compare influence and cost of different ambulatory mental health services and treatments delivered to a matched pair group of clients with dual disorders and those with only mental illness. The intention of this project is not only to address gray areas and gaps in the literature, but also to inform a more rational deployment of mental health services.