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Mishra A, Maiti R, Mishra BR, Srinivasan A. Efficacy of pharmacological agents for the management of treatment-resistant schizophrenia: a network meta-analysis. Expert Rev Clin Pharmacol 2024; 17:293-302. [PMID: 38269529 DOI: 10.1080/17512433.2024.2310715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Accepted: 01/23/2024] [Indexed: 01/26/2024]
Abstract
OBJECTIVE The present network meta-analysis (NMA) was conducted to compare and generate evidence for the most efficacious treatment among available pharmacological interventions for treatment-resistant schizophrenia (TRS). METHODS Reviewers extracted data from 47 studies screened from PubMed/MEDLINE, Embase, Cochrane databases and clinical trial registries fulfilling the eligibility criteria. Random effects Bayesian NMA was done with non-informative priors. Network geometry was visualized, and node splitting was done for the closed triangles. Standardized mean difference and 95% credible interval(95%CrI) were reported for the reduction in symptom severity scores. The probability of each intervention for each rank was plotted. Meta-regression was done for the duration of the therapy. RESULTS Augmentation of antipsychotics with escitalopram (SMD: -1.7[95%CrI: -2.8, -0.70]), glycine (SMD: -1.2 [95%CrI: -2.2, -0.28]) and Yokukansan (SMD: -1.3 [95%CrI: -2.4, -0.24]) shows a statistically significant reduction in symptom severity when compared to clozapine. As per surface under cumulative ranking curve analysis, escitalopram in combination with antipsychotics appeared to be the best intervention with moderate certainty of evidence. There was no significant effect of the duration of therapy on the treatment effects. CONCLUSION Escitalopram augmentation of antipsychotics appears to be the most efficacious treatment with moderate certainty of evidence among the available pharmacological interventions. PROSPERO REGISTRATION CRD42022380292.
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Affiliation(s)
- Archana Mishra
- Department of Pharmacology, All India Institute of Medical Sciences (AIIMS), Bhubaneswar, India
| | - Rituparna Maiti
- Department of Pharmacology, All India Institute of Medical Sciences (AIIMS), Bhubaneswar, India
| | - Biswa Ranjan Mishra
- Department of Psychiatry, All India Institute of Medical Sciences (AIIMS), Bhubaneswar, India
| | - Anand Srinivasan
- Department of Pharmacology, All India Institute of Medical Sciences (AIIMS), Bhubaneswar, India
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Capuzzi E, Caldiroli A, Quitadamo C, Butturini F, Surace T, Clerici M, Buoli M. Novel pharmacotherapy targeting the positive symptoms of schizophrenia. Expert Opin Pharmacother 2023; 24:1623-1648. [PMID: 37401388 DOI: 10.1080/14656566.2023.2231346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 06/27/2023] [Indexed: 07/05/2023]
Abstract
INTRODUCTION The severity of positive symptoms in schizophrenia is associated with poor prognosis. About one-third of schizophrenia patients partially respond to treatment with available antipsychotics. The purpose of the present manuscript is to provide an updated overview of novel pharmacotherapy targeting positive symptoms in schizophrenia. AREAS COVERED A comprehensive research on the main database sources (PubMed, PsychINFO, Isi Web of Knowledge, MEDLINE, and EMBASE) was performed to obtain original articles published till 31st January 2023 about new pharmacological strategies for the treatment of positive symptoms in schizophrenia. EXPERT OPINION The most promising compounds include: lamotrigine, pro-cognitive-compounds (donepezil - in the short term, idazoxan and piracetam) and drugs acting partially or totally outside the Central Nervous System (CNS) (anti-inflammatory drugs: celecoxib, methotrexate; cardiovascular compounds: L-theanine, mononitrate isosorbide, propentofylline, sodium nitroprusside; metabolic regulators: diazoxide, allopurinol; others: bexarotene, raloxifene [in women]). The effectiveness of the latter compounds indicates that other biological systems, such as immunity or metabolism can be object of future research to identify pharmacological targets for positive symptoms of schizophrenia. Mirtazapine could be useful for treating negative symptoms without increasing the risk of a worsening of delusions/hallucinations. Nevertheless, the lack of replication of studies prevents to draw definitive conclusions and future studies are needed to confirm the findings presented in this overview.
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Affiliation(s)
- Enrico Capuzzi
- Fondazione IRCCS, Department of Mental Health and Addiction, San Gerardo Dei Tintori, Monza, Italy
| | - Alice Caldiroli
- Fondazione IRCCS, Department of Mental Health and Addiction, San Gerardo Dei Tintori, Monza, Italy
| | - Cecilia Quitadamo
- Department of Medicine and Surgery, University of Milano Bicocca, Monza, MB, Italy
| | - Francesco Butturini
- Department of Medicine and Surgery, University of Milano Bicocca, Monza, MB, Italy
| | - Teresa Surace
- Fondazione IRCCS, Department of Mental Health and Addiction, San Gerardo Dei Tintori, Monza, Italy
| | - Massimo Clerici
- Fondazione IRCCS, Department of Mental Health and Addiction, San Gerardo Dei Tintori, Monza, Italy
- Department of Medicine and Surgery, University of Milano Bicocca, Monza, MB, Italy
| | - Massimiliano Buoli
- Department of Neurosciences and Mental Health, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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Seppälä A, Pylvänäinen J, Lehtiniemi H, Hirvonen N, Corripio I, Koponen H, Seppälä J, Ahmed A, Isohanni M, Miettunen J, Jääskeläinen E. Predictors of response to pharmacological treatments in treatment-resistant schizophrenia - A systematic review and meta-analysis. Schizophr Res 2021; 236:123-134. [PMID: 34496316 DOI: 10.1016/j.schres.2021.08.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 06/30/2021] [Accepted: 08/04/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND As the burden of treatment-resistant schizophrenia (TRS) on patients and society is high it is important to identify predictors of response to medications in TRS. The aim was to analyse whether baseline patient and study characteristics predict treatment response in TRS in drug trials. METHODS A comprehensive search strategy completed in PubMed, Cochrane and Web of Science helped identify relevant studies. The studies had to meet the following criteria: English language clinical trial of pharmacological treatment of TRS, clear definition of TRS and response, percentage of response reported, at least one baseline characteristic presented, and total sample size of at least 15. Meta-regression techniques served to explore whether baseline characteristics predict response to medication in TRS. RESULTS 77 articles were included in the systematic review. The overall sample included 7546 patients, of which 41% achieved response. Higher positive symptom score at baseline predicted higher response percentage. None of the other baseline patient or study characteristics achieved statistical significance at predicting response. When analysed in groups divided by antipsychotic drugs, studies of clozapine and other atypical antipsychotics produced the highest response rate. CONCLUSIONS This meta-analytic review identified surprisingly few baseline characteristics that predicted treatment response. However, higher positive symptoms and the use of atypical antipsychotics - particularly clozapine -was associated with the greatest likelihood of response. The difficulty involved in the prediction of medication response in TRS necessitates careful monitoring and personalised medication management. There is a need for more investigations of the predictors of treatment response in TRS.
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Affiliation(s)
- Annika Seppälä
- Center for Life Course Health Research, University of Oulu, Oulu, Finland; Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland.
| | - Jenni Pylvänäinen
- Center for Life Course Health Research, University of Oulu, Oulu, Finland; Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Heli Lehtiniemi
- Center for Life Course Health Research, University of Oulu, Oulu, Finland; Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland; Arctic Biobank, Infrastructure for Population Studies, Faculty of Medicine, University of Oulu, Oulu, Finland
| | - Noora Hirvonen
- Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland; Information Studies, Faculty of Humanities, University of Oulu, Oulu, Finland
| | - Iluminada Corripio
- Department of Psychiatry, Hospital de la Santa Creu i Sant Pau, CIBERSAM G21, U.A.B (Autonomous University of Barcelona), Barcelona, Spain
| | - Hannu Koponen
- University of Helsinki and Helsinki University Hospital, Psychiatry, Helsinki, Finland
| | - Jussi Seppälä
- Center for Life Course Health Research, University of Oulu, Oulu, Finland; Department of Mental Health and Substance Use Disorders, South Carelia Social and Health Care District, Lappeenranta, Finland
| | - Anthony Ahmed
- Department of Psychiatry, Weill Cornell Medicine, Cornell University, White Plains, USA
| | - Matti Isohanni
- Center for Life Course Health Research, University of Oulu, Oulu, Finland
| | - Jouko Miettunen
- Center for Life Course Health Research, University of Oulu, Oulu, Finland; Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Erika Jääskeläinen
- Center for Life Course Health Research, University of Oulu, Oulu, Finland; Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland; Department of Psychiatry, University Hospital of Oulu, Finland
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Japanese Society of Neuropsychopharmacology: "Guideline for Pharmacological Therapy of Schizophrenia". Neuropsychopharmacol Rep 2021; 41:266-324. [PMID: 34390232 PMCID: PMC8411321 DOI: 10.1002/npr2.12193] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 06/27/2021] [Indexed: 12/01/2022] Open
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Abstract
The objective in managing patients with schizophrenia is to provide effective control of symptoms and enable the patient to reintegrate into society. Pharmacotherapy should, therefore, aim to provide optimum symptom control with minimal side effects using a simple dosage regimen. Ideally, this would be achieved through the use of a single agent. Some patients are successfully managed with a single antipsychotic drug, but it is often necessary or thought to be necessary to use a combination of agents to provide effective treatment. One European survey reported that most patients receive two to three psychotropic agents on average, but at least 5-22% receive five or more agents [53]. Unfortunately, the addition of more agents increases the risk of drug interactions, adverse events and non-compliance. This is amplified by the paucity of evidence-based medicine currently available to guide physicians in the use of combinations of agents, and the tendency of polypharmaceutical practice to be mostly driven by personal preference, clinical experience and marketing. This article therefore briefly looks at the feasibility of using various drug classes as adjunctive therapy in patients with schizophrenia.
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The past and future of novel, non-dopamine-2 receptor therapeutics for schizophrenia: A critical and comprehensive review. J Psychiatr Res 2019; 108:57-83. [PMID: 30055853 DOI: 10.1016/j.jpsychires.2018.07.006] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 06/13/2018] [Accepted: 07/12/2018] [Indexed: 01/28/2023]
Abstract
Since the discovery of chlorpromazine in the 1950's, antipsychotic drugs have been the cornerstone of treatment of schizophrenia, and all attenuate dopamine transmission at the dopamine-2 receptor. Drug development for schizophrenia since that time has led to improvements in side effects and tolerability, and limited improvements in efficacy, with the exception of clozapine. However, the reasons for clozapine's greater efficacy remain unclear, despite the great efforts and resources invested therewith. We performed a comprehensive review of the literature to determine the fate of previously tested, non-dopamine-2 receptor experimental treatments. Overall we included 250 studies in the review from the period 1970 to 2017 including treatments with glutamatergic, serotonergic, cholinergic, neuropeptidergic, hormone-based, dopaminergic, metabolic, vitamin/naturopathic, histaminergic, infection/inflammation-based, and miscellaneous mechanisms. Despite there being several promising targets, such as allosteric modulation of the NMDA and α7 nicotinic receptors, we cannot confidently state that any of the mechanistically novel experimental treatments covered in this review are definitely effective for the treatment of schizophrenia and ready for clinical use. We discuss potential reasons for the relative lack of progress in developing non-dopamine-2 receptor treatments for schizophrenia and provide recommendations for future efforts pursuing novel drug development for schizophrenia.
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Zygmunt M, Hoinkis D, Hajto J, Piechota M, Skupień-Rabian B, Jankowska U, Kędracka-Krok S, Rodriguez Parkitna J, Korostyński M. Expression of alternatively spliced variants of the Dclk1 gene is regulated by psychotropic drugs. BMC Neurosci 2018; 19:55. [PMID: 30208879 PMCID: PMC6134793 DOI: 10.1186/s12868-018-0458-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 09/06/2018] [Indexed: 01/05/2023] Open
Abstract
Background The long-term effects of psychotropic drugs are associated with the reversal of disease-related alterations through the reorganization and normalization of neuronal connections. Molecular factors that trigger drug-induced brain plasticity remain only partly understood. Doublecortin-like kinase 1 (Dclk1) possesses microtubule-polymerizing activity during synaptic plasticity and neurogenesis. However, the Dclk1 gene shows a complex profile of transcriptional regulation, with two alternative promoters and exon splicing patterns that suggest the expression of multiple isoforms with different kinase activities. Results Here, we applied next-generation sequencing to analyze changes in the expression of Dclk1 gene isoforms in the brain in response to several psychoactive drugs with diverse pharmacological mechanisms of action. We used bioinformatics tools to define the range and levels of Dclk1 transcriptional regulation in the mouse nucleus accumbens and prefrontal cortex. We also sought to investigate the presence of DCLK1-derived peptides using mass spectrometry. We detected 15 transcripts expressed from the Dclk1 locus (FPKM > 1), including 2 drug-regulated variants (fold change > 2). Drugs that act on serotonin receptors (5-HT2A/C) regulate a subset of Dclk1 isoforms in a brain-region-specific manner. The strongest influence was observed for the mianserin-induced expression of an isoform with intron retention. The drug-activated expression of novel alternative Dclk1 isoforms was validated using qPCR. The drug-regulated isoform contains genetic variants of DCLK1 that have been previously associated with schizophrenia and hyperactivity disorder in humans. We identified a short peptide that might originate from the novel DCLK1 protein product. Moreover, protein domains encoded by the regulated variant indicate their potential involvement in the negative regulation of the canonical DCLK1 protein. Conclusions In summary, we identified novel isoforms of the neuroplasticity-related gene Dclk1 that are expressed in the brain in response to psychotropic drug treatments. Electronic supplementary material The online version of this article (10.1186/s12868-018-0458-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Magdalena Zygmunt
- Department of Molecular Neuropharmacology, Institute of Pharmacology of the Polish Academy of Sciences, Smetna 12, 31-343, Krakow, Poland
| | - Dżesika Hoinkis
- Department of Molecular Neuropharmacology, Institute of Pharmacology of the Polish Academy of Sciences, Smetna 12, 31-343, Krakow, Poland
| | - Jacek Hajto
- Department of Molecular Neuropharmacology, Institute of Pharmacology of the Polish Academy of Sciences, Smetna 12, 31-343, Krakow, Poland
| | - Marcin Piechota
- Department of Molecular Neuropharmacology, Institute of Pharmacology of the Polish Academy of Sciences, Smetna 12, 31-343, Krakow, Poland
| | - Bożena Skupień-Rabian
- Laboratory of Proteomics and Mass Spectrometry, Malopolska Centre of Biotechnology, Jagiellonian University, Krakow, Poland
| | - Urszula Jankowska
- Laboratory of Proteomics and Mass Spectrometry, Malopolska Centre of Biotechnology, Jagiellonian University, Krakow, Poland
| | - Sylwia Kędracka-Krok
- Department of Physical Biochemistry, Faculty of Biochemistry, Biophysics and Biotechnology, Jagiellonian University, Krakow, Poland
| | - Jan Rodriguez Parkitna
- Department of Molecular Neuropharmacology, Institute of Pharmacology of the Polish Academy of Sciences, Smetna 12, 31-343, Krakow, Poland
| | - Michał Korostyński
- Department of Molecular Neuropharmacology, Institute of Pharmacology of the Polish Academy of Sciences, Smetna 12, 31-343, Krakow, Poland.
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Galling B, Vernon JA, Pagsberg AK, Wadhwa A, Grudnikoff E, Seidman AJ, Tsoy-Podosenin M, Poyurovsky M, Kane JM, Correll CU. Efficacy and safety of antidepressant augmentation of continued antipsychotic treatment in patients with schizophrenia. Acta Psychiatr Scand 2018; 137:187-205. [PMID: 29431197 DOI: 10.1111/acps.12854] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/02/2018] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To evaluate the efficacy and safety of antidepressant augmentation of antipsychotics in schizophrenia. METHODS Systematic literature search (PubMed/MEDLINE/PsycINFO/Cochrane Library) from database inception until 10/10/2017 for randomized, double-blind, efficacy-focused trials comparing adjunctive antidepressants vs. placebo in schizophrenia. RESULTS In a random-effects meta-analysis (studies = 42, n = 1934, duration = 10.1 ± 8.1 weeks), antidepressant augmentation outperformed placebo regarding total symptom reduction [standardized mean difference (SMD) = -0.37, 95% confidence interval (CI) = -0.57 to -0.17, P < 0.001], driven by negative (SMD = -0.25, 95% CI = -0.44-0.06, P = 0.010), but not positive (P = 0.190) or general (P = 0.089) symptom reduction. Superiority regarding negative symptoms was confirmed in studies augmenting first-generation antipsychotics (FGAs) (SMD = -0.42, 95% CI = -0.77, -0.07, P = 0.019), but not second-generation antipsychotics (P = 0.144). Uniquely, superiority in total symptom reduction by NaSSAs (SMD = -0.71, 95% CI = -1.21, -0.20, P = 0.006) was not driven by negative (P = 0.438), but by positive symptom reduction (SMD = -0.43, 95% CI = -0.77, -0.09, P = 0.012). Antidepressants did not improve depressive symptoms more than placebo (P = 0.185). Except for more dry mouth [risk ratio (RR) = 1.57, 95% CI = 1.04-2.36, P = 0.03], antidepressant augmentation was not associated with more adverse events or all-cause/specific-cause discontinuation. CONCLUSIONS For schizophrenia patients on stable antipsychotic treatment, adjunctive antidepressants are effective for total and particularly negative symptom reduction. However, effects are small-to-medium, differ across antidepressants, and negative symptom improvement seems restricted to the augmentation of FGAs.
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Affiliation(s)
- B Galling
- Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin, Germany.,The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, NY, USA.,Hofstra Northwell School of Medicine, Hofstra University, Hempstead, NY, USA
| | - J A Vernon
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, NY, USA
| | - A K Pagsberg
- Child and Adolescent Mental Health Center, Mental Health Services, Capital Region of Denmark, Glostrup, Denmark.,Faculty of Health and Medical Sciences, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - A Wadhwa
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, NY, USA
| | | | - A J Seidman
- Department of Psychology, Iowa State University, Ames, IA, USA
| | - M Tsoy-Podosenin
- Department of Psychiatry, St John's Episcopal Hospital, New York, NY, USA
| | - M Poyurovsky
- Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel.,Tirat Carmel Mental Health Center, tirat Carmel, Israel
| | - J M Kane
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, NY, USA.,Hofstra Northwell School of Medicine, Hofstra University, Hempstead, NY, USA.,The Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - C U Correll
- Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin, Germany.,The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, NY, USA.,Hofstra Northwell School of Medicine, Hofstra University, Hempstead, NY, USA.,The Feinstein Institute for Medical Research, Manhasset, NY, USA
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Terevnikov V, Joffe G, Stenberg JH. Randomized Controlled Trials of Add-On Antidepressants in Schizophrenia. Int J Neuropsychopharmacol 2015; 18:pyv049. [PMID: 25991654 PMCID: PMC4576515 DOI: 10.1093/ijnp/pyv049] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Accepted: 04/27/2015] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Despite adequate treatment with antipsychotics, a substantial number of patients with schizophrenia demonstrate only suboptimal clinical outcome. To overcome this challenge, various psychopharmacological combination strategies have been used, including antidepressants added to antipsychotics. METHODS To analyze the efficacy of add-on antidepressants for the treatment of negative, positive, cognitive, depressive, and antipsychotic-induced extrapyramidal symptoms in schizophrenia, published randomized controlled trials assessing the efficacy of adjunctive antidepressants in schizophrenia were reviewed using the following parameters: baseline clinical characteristics and number of patients, their on-going antipsychotic treatment, dosage of the add-on antidepressants, duration of the trial, efficacy measures, and outcomes. RESULTS There were 36 randomized controlled trials reported in 41 journal publications (n=1582). The antidepressants used were the selective serotonin reuptake inhibitors, duloxetine, imipramine, mianserin, mirtazapine, nefazodone, reboxetin, trazodone, and bupropion. Mirtazapine and mianserin showed somewhat consistent efficacy for negative symptoms and both seemed to enhance neurocognition. Trazodone and nefazodone appeared to improve the antipsychotics-induced extrapyramidal symptoms. Imipramine and duloxetine tended to improve depressive symptoms. No clear evidence supporting selective serotonin reuptake inhibitors' efficacy on any clinical domain of schizophrenia was found. Add-on antidepressants did not worsen psychosis. CONCLUSIONS Despite a substantial number of randomized controlled trials, the overall efficacy of add-on antidepressants in schizophrenia remains uncertain mainly due to methodological issues. Some differences in efficacy on several schizophrenia domains seem, however, to exist and to vary by the antidepressant subgroups--plausibly due to differences in the mechanisms of action. Antidepressants may not worsen the course of psychosis. Better designed, larger, and longer randomized controlled trials are needed.
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Affiliation(s)
- Viacheslav Terevnikov
- Kellokoski Hospital, Kellokoski, Finland (Dr Terevnikov); Department of Psychiatry, Helsinki University Central Hospital, Hospital District of Helsinki and Uusimaa, Helsinki, Finland (Drs Joffe and Stenberg).
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Abstract
BACKGROUND Perphenazine is an old phenothiazine antipsychotic with a potency similar to haloperidol. It has been used for many years and is popular in the northern European countries and Japan. OBJECTIVES To examine the clinical effects and safety of perphenazine for those with schizophrenia and schizophrenia-like psychoses. SEARCH METHODS We updated our original search using the Cochrane Schizophrenia Group's register (September 2013), references of all included studies and contacted pharmaceutical companies and authors of included studies in order to identify further trials. SELECTION CRITERIA We included all randomised controlled trials that compared perphenazine with other treatments for people with schizophrenia and/or schizophrenia-like psychoses. We excluded trials of depot formulations of perphenazine. DATA COLLECTION AND ANALYSIS Two review authors independently inspected citations and, where possible, abstracts. We ordered papers, inspected and quality assessed them. We extracted data, again working independently. If loss to follow-up was greater than 50% we considered results as 'prone to bias'. For dichotomous data, we calculated risk ratios (RR) and for continuous data we calculated mean differences (MD), both with the 95% confidence intervals (CI). We assessed quality of data using the GRADE (Grading of Recommendations Assessment, Development and Evaluationtool) and assessed risk of bias for included studies. MAIN RESULTS Thirty-one studies fulfilled the inclusion criteria, with a total of 4662 participants (of which 4522 were receiving the drugs relevant to our comparison) and presented data that could be used for at least one comparison. The trial centres were located in Europe (especially Scandinavia), Japan and Northern America.When comparing perphenazine with placebo, for our primary outcome of clinical response, results favoured perphenazine with significantly more people receiving placebo rated as either 'no better or deterioration' for global state than people receiving perphenazine (1 RCT, n = 61 RR 0.32 CI 0.13 to 0.78, very low quality evidence). More people receiving placebo relapsed, although not a statistically significant number (1 RCT, n = 48, RR 0.14 CI 0.02 to 1.07, very low quality evidence). Death was not reported in the perphenazine versus placebo comparison. Experiences of dystonia were equivocal between groups (1 RCT, n = 48, RR 1.00 CI 0.07 to 15.08, very low quality evidence); other outcomes not reported in this comparison include serious adverse events, economic outcomes, and service use and hospitalisation.For the comparison of perphenazine versus any other antipsychotic drugs, no real differences in effect between the drugs were found. There was no significant difference between groups for those considered 'no better or deterioration' (17 RCTs, n = 1879, RR 1.04 CI 0.91 to 1.17, very low quality evidence). For mental state outcome of 'no effect' of the study drug, there was again no significant difference between groups (4 RCTs, n = 383, RR 1.24 CI 0.61 to 2.52, very low quality evidence). Death was not reported in any of the included studies. There was no significant difference in rates of dystonia with perphenazine versus any other antipsychotic drugs (4 RCTs, n = 416, RR 1.36 CI 0.23 to 8.16, very low quality evidence), nor was there a significant difference between groups for serious adverse events (2 RCTs, n = 1760, RR 0.98 CI 0.68 to 1.41, very low quality evidence). AUTHORS' CONCLUSIONS Although perphenazine has been used in randomised trials for more than 50 years, incomplete reporting and the variety of comparators used make it impossible to draw clear conclusions. All data for the main outcomes in this review were of very low quality evidence. At best we can say that perphenazine showed similar effects and adverse events as several of the other antipsychotic drugs. Since perphenazine is a relatively inexpensive and frequently used compound, further trials are justified to clarify the properties of this classical antipsychotic drug.
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Affiliation(s)
- Benno Hartung
- University Hospital DüsseldorfInstitute for Legal MedicineMoorenstr. 5DüsseldorfNorth Rhine WestphaliaGermany40225
| | - Stephanie Sampson
- The University of NottinghamInstitute of Mental HealthUniversity of Nottingham Innovation Park, Jubilee CampusNottinghamUKNG7 2TU
| | - Stefan Leucht
- Technische Universität München Klinikum rechts der IsarKlinik und Poliklinik für Psychiatrie und PsychotherapieIsmaninger Straße 22MünchenGermany81675
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Meta-analysis of noradrenergic and specific serotonergic antidepressant use in schizophrenia. Int J Neuropsychopharmacol 2014; 17:343-54. [PMID: 23823741 DOI: 10.1017/s1461145713000667] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
We examined whether noradrenergic and specific serotonergic antidepressants (NaSSAs: mirtazapine and mianserin), as augmentation therapy, have therapeutic potential for schizophrenia treatment. A systematic review was conducted of PubMed, Cochrane Library and PsycINFO in December 2012 and meta-analyses of double-blind, randomized placebo-controlled trials were performed. Standardized mean difference (SMD), risk ratio (RR), number-needed-to-treat (NNT), number-needed-to-harm (NNH) and 95% confidence intervals (CI) were calculated. Results were across 12 studies and 362 patients were included (mirtazapine: seven trials and 221 patients; mianserin: five trials and 141 patients). NaSSA augmentation therapy was superior to placebo in overall symptoms (S.M.D. = -0.75, CI -1.24 to -0.26, p = 0.003, N = 11, n = 301), negative symptoms (S.M.D. = -0.88, CI -1.41 to -0.34, p = 0.001, N = 9, n = 240) and response rate (RR = 0.71, CI 0.57-0.88, p = 0.002, NNT = 4, p<0.00001, N = 6, n = 163). There was no significant difference in positive symptoms, depressive symptoms or discontinuation rate between NaSSAs and placebo treatments. In addition, no patients who received NaSSAs developed worsening psychosis during the study. For individual NaSSAs, mirtazapine was superior to placebo in overall symptoms (S.M.D. = 0.98, CI = -1.74 to -0.22, p = 0.01, N = 7, n = 194), negative symptoms (S.M.D. = -1.25, CI -1.88 to -0.62, p = 0.0001, N = 6, n = 172) and response rate (RR = 0.70, p = 0.04, NNT = 4, p = 0.0004, N = 4, n = 119). Moreover, NaSSAs were associated with reduced akathisia score (p < 0.00001) and extrapyramidal symptom scales (p = 0.01). However, NaSSAs caused drowsiness/sedation/somnolence compared with placebo (RR = 3.52, p = 0.002, NNT = 6, p = 0.01, N = 8, n = 209). Our results indicate that NaSSA (especially mirtazapine) augmentation therapy improved overall and negative symptoms in patients with schizophrenia. Because the included studies were small, the results should be treated with caution.
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Frånberg O, Marcus MM, Svensson TH. Involvement of 5-HT2A receptor and α2-adrenoceptor blockade in the asenapine-induced elevation of prefrontal cortical monoamine outflow. Synapse 2012; 66:650-60. [DOI: 10.1002/syn.21551] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2011] [Accepted: 02/14/2012] [Indexed: 12/30/2022]
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Hecht EM, Landy DC. Alpha-2 receptor antagonist add-on therapy in the treatment of schizophrenia; a meta-analysis. Schizophr Res 2012; 134:202-6. [PMID: 22169246 DOI: 10.1016/j.schres.2011.11.030] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2011] [Revised: 11/20/2011] [Accepted: 11/28/2011] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Reduced dopaminergic activity in the pre-frontal cortex may partially explain the negative symptoms of schizophrenia. Animal models have shown that adding an alpha-2 adrenergic receptor antagonist to a D2 antagonist can efflux dopamine into the frontal cortex increasing dopaminergic activity. Trials of alpha-2 antagonist add-on therapy in humans have been limited by small sample sizes. Therefore, a meta-analysis was conducted to determine if adding an alpha-2 antagonist to a D2 antagonist improves schizophrenia treatment by reducing negative symptoms. METHODS Randomized, placebo-controlled trials of the addition of an alpha-2 antagonist to a D2 antagonist were identified through a PubMed search. Treatment effects were measured using schizophrenia rating scales and meta-analyzed as standardized mean differences using random effects models. RESULTS Eight unique studies were identified, each including 18 to 41 patients and lasting four to eight weeks. The overall effect size of add-on alpha-2 therapy across the eight trials was an improvement of 0.16 (95% C.I., -.30 to 0.62) for positive symptoms, 0.84 (95% C.I., .17 to 1.51) for negative symptoms, 0.28 (95% C.I., -.08 to 0.64) for general symptoms, and .80 (95% C.I., .15 to 1.46) for symptoms overall. Negative symptom improvements were independent of improvements in depressive symptoms, measured using the Hamilton depression rating scale, for 3 of the 5 studies. CONCLUSIONS Add-on agents with alpha-2 antagonist activity appear to improve the efficacy of D2 antagonists for the treatment of schizophrenia by reducing negative symptoms. These results support conducting a more definitive confirmatory clinical trial.
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Citrome L. Treatment-refractory schizophrenia: what is it and what has been done about it? ACTA ACUST UNITED AC 2011. [DOI: 10.2217/npy.11.35] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Singh SP, Singh V, Kar N, Chan K. Efficacy of antidepressants in treating the negative symptoms of chronic schizophrenia: meta-analysis. Br J Psychiatry 2010; 197:174-9. [PMID: 20807960 DOI: 10.1192/bjp.bp.109.067710] [Citation(s) in RCA: 140] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Treatment of negative symptoms in chronic schizophrenia continues to be a major clinical issue. AIMS To analyse the efficacy of add-on antidepressants for the treatment of negative symptoms of chronic schizophrenia. METHOD Systematic review and meta-analysis of randomised controlled trials comparing the effect of antidepressants and placebo on the negative symptoms of chronic schizophrenia, measured through standardised rating scales. Outcome was measured as standardised mean difference between end-of-trial and baseline scores of negative symptoms. RESULTS There were 23 trials from 22 publications (n = 819). The antidepressants involved were selective serotonin reuptake inhibitors, mirtazapine, reboxetine, mianserin, trazodone and ritanserin; trials on other antidepressants were not available. The overall standardised mean difference was moderate (-0.48) in favour of antidepressants and subgroup analysis revealed significant responses for fluoxetine, trazodone and ritanserin. CONCLUSIONS Antidepressants along with antipsychotics are more effective in treating the negative symptoms of schizophrenia than antipsychotics alone.
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Affiliation(s)
- Surendra P Singh
- University of Wolverhampton and Step to Health, Wolverhampton City Primary Care Trust, UK.
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Terevnikov V, Stenberg JH, Joffe M, Tiihonen J, Burkin M, Tchoukhine E, Joffe G. More evidence on additive antipsychotic effect of adjunctive mirtazapine in schizophrenia: an extension phase of a randomized controlled trial. Hum Psychopharmacol 2010; 25:431-8. [PMID: 20737516 DOI: 10.1002/hup.1137] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Adjunctive mirtazapine improved negative symptoms of schizophrenia in several studies. Recently, we found an improvement also in positive symptoms when mirtazapine was added to first generation antipsychotics (FGAs) in a 6 week randomized controlled trial (RCT). The short duration of that trial was its limitation. This study aimed to explore whether longer treatment is worthwhile. METHOD Completers of the RCT (n = 39) received open-label add-on mirtazapine for additional 6 weeks. The Positive and Negative Syndrome Scale (PANSS) total score (primary outcome) and several other clinical parameters were measured prospectively. RESULTS During the open-label phase, significant improvement was achieved in all parameters, with an effect size of 0.94 (CI 95% = 0.45-1.43) on the primary outcome and an impressive additive antipsychotic effect. Patients who received mirtazapine during both phases demonstrated greater improvement in positive symptoms (29.6% versus 21.2%, p = 0.027) than those who received mirtazapine during open-label extension phase only. CONCLUSIONS These findings support our previous data on the additive antipsychotic effect of mirtazapine in FGAs-treated schizophrenia. Mirtazapine may be effective in other symptom domains, too. Longer duration of mirtazapine treatment may yield additional benefits. If these results will be confirmed in larger studies, add-on mirtazapine may become a feasible option in difficult-to-treat schizophrenia.
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Berk M, Gama CS, Sundram S, Hustig H, Koopowitz L, D'Souza R, Malloy H, Rowland C, Monkhouse A, Monkhouse A, Bole F, Sathiyamoorthy S, Piskulic D, Dodd S. Mirtazapine add-on therapy in the treatment of schizophrenia with atypical antipsychotics: a double-blind, randomised, placebo-controlled clinical trial. Hum Psychopharmacol 2009; 24:233-8. [PMID: 19330802 DOI: 10.1002/hup.1017] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Schizophrenia is a multifaceted illness with positive, negative and cognitive symptom domains. Standard treatments often focus on positive symptoms and may not adequately relieve other symptoms. Previous studies have suggested a role for mirtazapine in schizophrenia, particularly in negative symptoms. This study investigates the efficacy of adding mirtazapine to treatment as usual to alleviate the negative symptoms of schizophrenia. METHODS In a 6 week, double-blind clinical trial, participants with a diagnosis of schizophrenia and currently being treated with atypical antipsychotic medication were randomised to adjunctive treatment with mirtazapine (30 mg/day) or placebo. The primary outcome measure was improvement in the Positive and Negative Syndrome Scale (PANSS). Measures of cognition, collected at baseline and week 6 only, were analysed using an Analysis of Covariance (ANCOVA) model. All other outcome measures were analysed using a linear mixed model. RESULTS Forty participants were recruited to the study with equal numbers randomised to each treatment arm. There was no significant difference between mirtazapine and placebo treated participants for improvement in PANSS scores or any of the secondary outcome measures at any stage during the 6-week trial. CONCLUSIONS This trial does not confirm previous research supporting the use of mirtazapine adjunctive to atypical antipsychotic treatment for schizophrenia.
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Affiliation(s)
- Michael Berk
- Department of Clinical and Biomedical Sciences: Barwon Health, The University of Melbourne, Geelong, Australia
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Abstract
BACKGROUND Negative symptoms are common in people with schizophrenia and are often difficult to treat with antipsychotic drugs. Treatment often involves the use of various add-on medications such as antidepressants. OBJECTIVES To review the effects of the combination of antipsychotic and antidepressant drug treatment for management of negative symptoms in schizophrenia and schizophrenia-like psychoses. SEARCH STRATEGY We searched the Cochrane Schizophrenia Group's register (January 2004). We also contacted authors of included studies in order to identify further trials. SELECTION CRITERIA We included all randomised controlled trials comparing antipsychotic and antidepressant combinations with antipsychotics alone for the treatment of prominent negative symptoms in schizophrenia and/or schizophrenia-like psychoses. DATA COLLECTION AND ANALYSIS Working independently, we selected and critically appraised studies, extracted data and analysed on an intention-to-treat basis. Where possible and appropriate we calculated the relative risk RR) and their 95% confidence intervals (CI), with the number needed to treat (NNT). MAIN RESULTS We included five studies (all short-term, total N=190). We found no significant difference for 'leaving the study early for any reason' between the antipsychotic plus antidepressant combination and the control group (n=90, 3 RCTs, RR 3.0 CI 0.35 to 26.04). Leaving early due to adverse events (n=64, 2 RCTs, RR 5.0 CI 0.26 to 97.0) and leaving the study early due to inefficacy (n=34, 1 RCT, RR 3.0 CI 0.13 to 68.84) also showed no significant difference between the two treatment groups. In terms of clinical response, participants treated with the antipsychotic plus antidepressant medications showed a statistically significant greater improvement (n=30, 1 RCT, WMD -1.0 CI -1.61 to -0.39) and showed a significantly lower severity at endpoint (n=30, 1 RCT, WMD -0.9 CI -1.55 to -0.25) on the Clinical Global Impression Scale than those treated with antipsychotics alone. More people allocated to combination therapy had a clinically significant improvement in negative symptoms compared with those given antipsychotics and placebo (n=60, 2 RCTs, RR 0.56 CI 0.32 to 0.97, NNT 3 CI 3 to 34). Significant differences in favour of the combination therapy were seen in different aspects of negative symptoms: 'affective flattening' (n=30, 1 RCT, WMD -7.0 CI -10.37 to -3.63), 'alogia' (n=26, 1 RCT, WMD -3.00 CI -5.14 to -0.86) and 'avolition' (n=30, 1 RCT, WMD -3.0 CI -5.04 to -0.96). No statistically significant difference was found between treatment groups in regards to the outcome 'at least one adverse event' (n=84, 2 RCTs, RR 1.80 CI 0.66 to 4.90). For movement disorders and other adverse effects, no statistically significant differences were found in any of the studies that provided usable data on these outcomes. There are no data at all on outcomes such as compliance, cost, social and cognitive functioning, relapse, recurrence of negative symptoms, rehospitalisation or quality of life. There are no medium or long term data. AUTHORS' CONCLUSIONS The combination of antipsychotics and antidepressants may be effective in treating negative symptoms of schizophrenia, but the amount of information is currently too limited to allow any firm conclusions. Large, pragmatic, well-designed and reported long term trials are justified.
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Affiliation(s)
- C Rummel
- Klinikum rechts der Isar, Klinik und Poliklinik für Psychiatrie und Psychotherapie der Technischen Universität München, Möhlstr. 26, Munich, Germany 81675.
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Rummel C, Kissling W, Leucht S. Antidepressants as add-on treatment to antipsychotics for people with schizophrenia and pronounced negative symptoms: a systematic review of randomized trials. Schizophr Res 2005; 80:85-97. [PMID: 16183258 DOI: 10.1016/j.schres.2005.07.035] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2005] [Revised: 07/25/2005] [Accepted: 07/29/2005] [Indexed: 10/25/2022]
Abstract
The aim of our meta-analysis was to review the evidence base for the efficacy and safety of antipsychotic and antidepressant combinations in the treatment of the negative symptoms of schizophrenia and schizophrenia-like psychoses. Randomized controlled trials comparing the combination of antidepressants and antipsychotics with antipsychotics alone for patients with pronounced negative symptoms in schizophrenia were searched for by accessing the register of randomized controlled trials of the Cochrane Schizophrenia group. The studies identified were independently inspected and their quality assessed by two reviewers. The principal outcome of interest was the reduction of negative symptoms. Dichotomous data were analyzed using the relative risk and continuous data were analyzed using standardized mean differences, both specified with 95% confidence intervals. It was possible to include seven trials (n = 202) examining antidepressants as add-on to antipsychotics in this review. Except for one study, all included studies used first generation antipsychotics. While there was often merely a trend in favour of augmentation of antipsychotics with antidepressants in the small single studies, the meta-analytic combination resulted in a statistically significant superiority in the outcome reduction of negative symptoms as a whole. Statistically significant differences between groups in terms of specific subscores of the SANS were found, but the results were inconsistent. The combination of antipsychotics and antidepressants may be more effective in treating negative symptoms of schizophrenia than antipsychotics alone, but this finding needs to be corroborated by further large trials.
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Affiliation(s)
- Christine Rummel
- Department of Psychiatry and Psychotherapy, Klinikum rechts der Isar der Technischen Universität München, Möhlstr. 26, 81675 München, Germany.
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Shiloh R, Gutnik I, Weizman A, Munitz H. Substantial increase in number and dosage of antipsychotics in non-responsive vs. responsive schizophrenia inpatients. Int J Psychiatry Clin Pract 2003; 7:53-7. [PMID: 24937243 DOI: 10.1080/1365150031001086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Current clinical guidelines recommend the use of a single antipsychotic drug for acute schizophrenic exacerbation. We examined whether this approach is also employed in non-responsive schizophrenia inpatients. METHODS Forty-one consecutively admitted schizophrenic inpatients were assigned into a study group [n=22; non-responsive (ΔBPRS<10%) to two consecutive trials of antipsychotics prior to and following 24 weeks of hospitalization] and a comparison group [n=19; partial-to-good (ΔBPRS=10-27%) responders under similar settings]. RESULTS The number and dosage of antipsychotics were increased by 34% and 40% (P=0.016 and P=0.062, respectively) in the study group compared to the comparison subjects following 24 weeks of hospitalization. In the study group, a significant correlation was found between the number of antipsychotics administered and their dose (r=0.22, n=88, P=0.04). CONCLUSION Clinicians do not comply with evidence-based algorithms, and treat non-responsive schizophrenia inpatients with a combination of antipsychotics and at substantially higher doses compared to partial-to-good responders. Our findings discourage such practice.
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Affiliation(s)
- Roni Shiloh
- Geha Psychiatric Hospital, Beilinson Campus, Petah Tikva Felsenstein Medical Research Center, Tel Aviv University Tel Aviv
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