Optimizing early prediction for antipsychotic response in schizophrenia

Association of serum brain-derived neurotrophic factor level and early response to antipsychotic drug in first-episode patients with schizophrenia

OBJECTIVES

To investigate the role of Brain derived neurotrophic factor (BDNF) in the psychotic symptoms in first-episode patients with schizophrenia and whether BDNF levels were associated with the improvement of psychotic symptoms after risperidone treatment.

METHODS

89 schizophrenia patients and 90 healthy controls were recruited, the schizophrenia patients were assigned into early response or early non-response groups at 2 weeks based on improvement in the positive and negative symptoms scale (PANSS) total score. All patients were treated with risperidone for 2 weeks, their serum BDNF levels were compared at baseline and after 2 weeks treatment.

RESULTS

We found that patients had lower BDNF levels, compared to controls at baseline. After 2 weeks of treatment of risperidone, BDNF levels were significantly increased and psychotic symptoms were decreased in early response group. Correlation analysis showed that the change of BDNF levels after treatment was correlated with the change of PANSS total score. Further regression analysis showed that the change in BDNF levels was an independent predictor for the improvement in psychotic symptoms.

CONCLUSIONS

Our findings reveal that the level of BDNF was lower in first-episode schizophrenic patients, moreover, the changes in serum BDNF levels may have a predictive effect on the early improvement in psychotic symptoms in the first 2 weeks.

Early non-response as a predictor of later non-response to antipsychotics in schizophrenia: a randomized trial

BACKGROUND

It remains a challenge to predict the long-term response to antipsychotics in patients with schizophrenia who do not respond at an early stage. This study aimed to investigate the optimal predictive cut-off value for early non-response that would better predict later non-response to antipsychotics in patients with schizophrenia.

METHODS

This multicenter, 8-week, open-label, randomized trial was conducted at 19 psychiatric centers throughout China. All enrolled participants were assigned to olanzapine, risperidone, amisulpride, or aripiprazole monotherapy for 8 weeks. The positive and negative syndrome scale (PANSS) was evaluated at baseline, week 2, week 4, and week 8. The main outcome was the prediction of nonresponse. Nonresponse is defined as a < 20% reduction in the total scores of PANSS from baseline to endpoint. Severity ratings of mild, moderate, and severe illness corresponded to baseline PANSS total scores of 58, 75, and 95, respectively.

RESULTS

At week 2, a reduction of < 5% in the PANSS total score showed the highest total accuracy in the severe and mild schizophrenia patients (total accuracy, 75.0% and 80.8%, respectively), and patients who were treated with the risperidone and amisulpride groups (total accuracy, 82.4%, and 78.2%, respectively). A 10% decrease exhibited the best overall accuracy in the moderate schizophrenia patients (total accuracy, 84.0%), olanzapine (total accuracy, 79.2%), and aripiprazole group (total accuracy, 77.4%). At week 4, the best predictive cut-off value was < 20%, regardless of the antipsychotic or severity of illness (total accuracy ranging from 89.8 to 92.1%).

CONCLUSIONS

Symptom reduction at week 2 has acceptable discrimination in predicting later non-response to antipsychotics in schizophrenia, and a more accurate predictive cut-off value should be determined according to the medication regimen and baseline illness severity. The response to treatment during the next 2 weeks after week 2 could be further assessed to determine whether there is a need to change antipsychotic medication during the first four weeks.

TRIAL REGISTRATION

This study was registered on Clinicaltrials.gov (NCT03451734).

Early Efficacy of Antipsychotic Medications at Week 2 Predicts Subsequent Responses at Week 6 in a Large-scale Randomized Controlled Trial

BACKGROUND

Since the early clinical efficacy of antipsychotics has not yet been well perceived, this study sought to decide whether the efficacy of antipsychotics at week 2 can predict subsequent responses at week 6 and identify how such predictive capacities vary among different antipsychotics and psychotic symptoms.

METHODS

A total of 3010 patients with schizophrenia enrolled in a randomized controlled trial (RCT) and received a 6-week treatment with one antipsychotic drug randomly chosen from five atypical antipsychotics (risperidone 2-6 mg/d, olanzapine 5-20 mg/d, quetiapine 400-750 mg/d, aripiprazole 10-30 mg/d, and ziprasidone 80-160 mg/d) and two typical antipsychotics (perphenazine 20-60 mg/d and haloperidol 6-20 mg/d). Early efficacy was defined as the reduction rate using the Positive and Negative Syndrome Scale (PANSS) total score at week 2. With cut-offs at 50% reduction, logistic regression, receiver operating characteristic (ROC) and random forests were adopted.

RESULTS

The reduction rate of PANSS total score and improvement of psychotic symptoms at week 2 enabled subsequent responses to 7 antipsychotics to be predicted, in which improvements in delusions, lack of judgment and insight, unusual thought content, and suspiciousness/ persecution were endowed with the greatest weight.

CONCLUSION

It is robust enough to clinically predict treatment responses to antipsychotics at week 6 using the reduction rate of PANSS total score and symptom relief at week 2. Psychiatric clinicians had better determine whether to switch the treatment plan by the first 2 weeks.

Early Antipsychotic Nonresponse as a Predictor of Nonresponse and Nonremission in Adolescents With Psychosis Treated With Aripiprazole or Quetiapine: Results From the TEA Trial

OBJECTIVE

To evaluate 1) whether early nonresponse to antipsychotics predicts nonresponse and nonremission, 2) patient and illness characteristics as outcome predictors, and 3) response prediction of 30-item Positive and Negative Syndrome Scale (PANSS-30) compared with 6-item PANSS (PANSS-6) and Clinical Global Impressions-Improvement Scale (CGI-I) in youths with first-episode psychosis.

METHOD

Post hoc analysis from a 12-week, double-blinded, randomized trial of aripiprazole vs extended-release quetiapine in adolescents (age 12-17 years) with first-episode psychosis was performed. Early nonresponse (week 2 or week 4) was defined as <20% symptom reduction (PANSS-30) (or <20% symptom reduction [PANSS-6] or CGI-I score 4-7 [less than "minimally improved"]). Nonresponse (week 12) was defined as <50% symptom reduction (PANSS-30). Nonremission (week 12) was defined as a score of >3 on 8 selected PANSS-items. Positive/negative predictive values (PPV/NPV) and receiver operating characteristics, binary logistic regression models, and PPV/NPV using PANSS-6 and CGI-I were analyzed.

RESULTS

Of 113 randomized patients, 84 were included in post hoc analysis (mean [SD] age = 15.7 [1.3] years; 28.6% male). The 12-week symptom decrease was 31.9% [27.9%], most pronounced within the first 2 weeks (61.1% of total PANSS reduction). Response (27.4%) and remission (22.6%) rates were low. Results indicated that early nonresponse reliably predicted 12-week nonresponse (PPV: week 2, 82.2%; week 4, 90.0%) and nonremission (PPV: week 2, 80.0%; week 4, 90.0%); early nonresponse at week 4 was a statistically significant baseline predictor for 12-week nonresponse; and PANSS-6 had similar predictive significance as PANSS-30. However, outcomes were heterogeneous using CGI-I.

CONCLUSION

In youths with first-episode psychosis showing early nonresponse to aripiprazole or extended-release quetiapine, switching antipsychotic drug should be considered. PANSS-6 is a feasible and clinically relevant alternative to PANSS-30 to predict 12-week nonresponse/nonremission.

CLINICAL TRIAL REGISTRATION INFORMATION

Tolerance and Effect of Antipsychotics in Children and Adolescents With Psychosis; https://www.

CLINICALTRIALS

gov/; NCT01119014.

Proposing and Validating the Diagnosis Scale for Internet Gaming Disorder in Taiwanese ADHD Adolescents: Likert Scale Method Based on the DSM-5

The paper aims to adjust the Taiwanese version of Internet gaming disorder-short form Likert scale with Likert (IGD-SF-T-L) based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria to a Likert scale model and test its psychometric property among children and adolescents with Attention Deficit Hyperactivity Disorder (ADHD). Confirmatory factor analysis (CFA) was conducted for validity and the Cronbach’s α for reliability of IGD-SF-T-L. The ROC (receiver operating curves) was used to propose the cut-off point for assessing the instrument’s psychometric properties and its corresponding indices for the diagnostic accuracy. In total, 102 children and adolescents with ADHD were recruited. The construct validity of IGD-SF-T by CFA was model well fitted with excellent reliability (Cronbach’s α = 0.918). The ROC using the Chen’s CIAS > 56 as the state variable for IGD diagnosis showed the AUC (areas under the curves) was 0.918. The cut-off point proposed for IGD-SF-T-L to indicate a diagnosis of IGD was ≥ 10. The corresponding indices of accuracy: sensitivity, specificity, LR (likelihood ratio) +, LR-, and AUC were 0.893, 0.826, 5.134, 0.130, and 0.859, respectively. The proposed IGD-SF-T-L is an adequate, standardized psychometrical measurement for diagnosing IGD among Taiwanese adolescents with ADHD. More attention should be paid toward recent ADHD youth with Internet gaming disorder and their family.

Association of End Point Definition and Randomized Clinical Trial Duration in Clinical Trials of Schizophrenia Medications

IMPORTANCE

Facilitating the development of safe and effective medications for schizophrenia is a public health imperative.

OBJECTIVES

To evaluate the association of shortening randomized clinical trial (RCT) duration with the modification of the Positive and Negative Syndrome Scale (PANSS) for the design of RCTs of medications for schizophrenia and to offer perspective on an alternative regulatory pathway to the historically accepted trial duration and response assessment.

DATA SOURCES

A database was created consisting of clinical trial data from 32 placebo-controlled RCTs of 8 atypical antipsychotic drugs approved by the US Food and Drug Administration (FDA) between January 1, 2001, and December 31, 2015. The database included information on total and individual PANSS item ratings, demographic characteristics, disposition, and adverse events (AEs).

STUDY SELECTION

All clinical trials submitted to 8 new drug applications of atypical antipsychotic drugs were selected.

DATA EXTRACTION AND SYNTHESIS

Quality control checks were performed to ensure that the collected data were consistent with the reported results of each trial. Data were collected from March 15, 2015, to September 30, 2015. Data analysis was conducted from October 1, 2015, to June 20, 2016.

MAIN OUTCOMES AND MEASURES

The following analyses were performed: (1) longitudinal assessment of mean change from baseline in total PANSS score, (2) correlation analyses between change from baseline in total PANSS score at week 6 and earlier time points, (3) concordance analyses of outcomes across trials between week 6 and earlier time points using total PANSS and modified PANSS, and (4) analyses of time course of treatment-emergent AEs.

RESULTS

The final database contained data from 14 219 participants enrolled in 32 drug trials; 9805 of 14 219 participants (69.0%) were male and were either white (7183 [50.5%]) or black (4346 [30.6%]) individuals. The mean (SD) age during treatment was 38.9 (10.9) years, and the mean (SD) age at schizophrenia diagnosis was 25 (8.5) years. Statistically significant separation between treatment response and placebo response was observed after 1 week of treatment. The overall concordance rate across treatment groups steadily increased from week 1 to week 4 (68.0% for week 1, 74.0% for week 2, 83.0% for week 3, and 93.0% for week 4). Trends in AE occurrence were evident by week 1 and percentage of AEs were similar across weeks 3, 4, and 6. The overall concordance rate between change from baseline in the modified PANSS score and change from baseline in the total PANSS score was 93.0% (80 of 86 treatment groups) at week 4 and 97.7% (84 of 86 treatment groups) at week 6. Shortening the trial duration to 4 weeks increased the required sample size to 502 participants. Using the modified PANSS as the end point, the sample size for a 4-week trial was 402 participants and 296 participants for a 6-week trial.

CONCLUSIONS AND RELEVANCE

Findings from this analysis suggest that there is the potential to streamline the design of schizophrenia drug clinical trials. Trial sponsors may consider incorporating these strategies and are encouraged to consult with the FDA early in the drug development process.

Early improvement as a predictor of remission and response in schizophrenia: Results from a naturalistic study

Objective

To examine the predictive validity of early improvement in a naturalistic sample of inpatients and to identify the criterion that best defines early improvement.

Methods

Two hundred and forty-seven inpatients who fulfilled ICD-10 criteria for schizophrenia were assessed with the Positive And Negative Syndrome Scale (PANSS) at admission and at biweekly intervals until discharge from hospital. Remission was defined according to the recently proposed consensus criteria, response as a reduction of at least 40% in the PANNS total score from admission to discharge.

Results

Receiver operating characteristic (ROC) analyses showed that early improvement (reduction of the PANSS total score within the first 2 weeks of treatment) predicts remission (AUC = 0.659) and response (AUC = 0.737) at discharge. A 20% reduction in the PANSS total score within the first 2 weeks was the most accurate cut-off for the prediction of remission (total accuracy: 65%; sensitivity: 53%; specificity: 76%), and a 30% reduction the most accurate cut-off for the prediction of response (total accuracy: 76%; sensitivity: 47%; specificity: 90%).

Conclusion

The findings of clinical drug trials that early improvement is a predictor of subsequent treatment response were replicated in a naturalistic sample. Further studies should examine whether patients without early improvement benefit from an early change of antipsychotic medication.

Early predictors of poor treatment response in patients with schizophrenia treated with atypical antipsychotics

BACKGROUND

The aims of this study were to explore the relationship between early reduction in psychotic symptoms and the ultimate response in patients with schizophrenia treated by atypical antipsychotics, and to determine the best time to switch or maitain the regimen. We also explore the possible predictors for the clinical response.

METHODS

One hundred eleven inpatients with acutely exacerbated schizophrenia were randomized to give optimal therapy of olanzapine, risperidone, and paliperidone in one-week run-in period and 12 weeks' intervention. All participants were assessed using Positive and Negative Syndrome Scale (PANSS). Early Response, defined as reduction of 25% in PANSS score, was examined at weeks 1, 2, 3, 4 and 8, and these ratings were used to predict ultimate response (25% PANSS reduction) at week 12. We hypothesized that early treatment response at Week 1 or 2 could predict Week 12's treatment outcome.

RESULTS

The early treatment response at Week 2 had a greater negative prediction value (NPV, 93.6%) than did the response at Week 1 (NPV, 69.7%), Week 3 (NPV, 91.5%), Week 4 (NPV, 90.7%) and Week 8 (NPV, 87.2%). The positive predictive value became more acceptable (65%) until Week 4. There was no any other potential predictors, including types of antipsychotics medication and treatment dosage, were associated with ultimate response in this study.

CONCLUSION

The treatment non-response at Week 2 optimally predicted the ultimate (Week 12) non-response, in terms of negative predictive value (NPV). These finding suggests that the revision of treatment strategy should be considered t if patients with schizophrenia was not responsive to them after 2 weeks' treatment, and for those who are responders at Week 2, another two weeks are needed to further evaluate whether they will be continuously responsive.

TRIAL REGISTRATION

NCT03730857 at ClinicalTrial.gov . Date of registration: 30/Oct/2018.

Psychometric Testing of Two Chinese-Version Scales on Attitudes Toward and Caregiving Behaviors for End-of-Life Patients and Families

The study purpose was to examine the validities and reliabilities of the Chinese-versions Frommelt Attitudes Toward Care of the Dying Scale (Attitudes Scale) and Caregiving Behaviors Scale for End-of-Life Patients and Families (Behaviors Scale). The scales were tested in a convenience sample of 318 nurses with ≥6 months work experience at three hospitals. Cronbach’s alphas of the Attitudes and Behaviors Scales were .90 and .96, respectively. Each scale had Kaiser–Meyer–Olkin index >.85 and Bartlett’s test of sphericity >4000 ( p < .001). Attitudes Scale loaded on three factors: respecting and caring for dying patients and families, avoiding care of the dying, and involving patients and families in end-of-life care. The Behaviors Scale loaded on two factors: supporting dying patients and families, and helping families cope with grief. Factor loadings for both scales were ≥.49. Both Attitudes and Behaviors Scales are reliable and valid for evaluating nurses’ attitudes and caregiving behaviors for the dying.

Early response or nonresponse at week 2 and week 3 predict ultimate response or nonresponse in adolescents with schizophrenia treated with olanzapine: results from a 6-week randomized, placebo-controlled trial

In adults with schizophrenia, early response/non-response (ER/ENR) to antipsychotics at 2 weeks robustly predicts ultimate response/non-response (UR/UNR). However, less data about the predictive value of ER/ENR exist in adolescents with schizophrenia. Post hoc analysis of a 6-week trial in adolescents aged 13-17 with schizophrenia were randomized 2:1 to olanzapine or placebo. ER was defined as ≥20 % reduction in Brief Psychiatric Rating Scale-children (BPRS-C) total score at week 2 (ER2) or 3 (ER3); UR was defined with increasing stringency as total BPRS-C score reduction ≥20, ≥30, ≥40 or ≥50 %; remission was defined cross-sectionally using Andreasen et al. (2005) criteria. By week 2 (n = 69) and 3 (n = 66), olanzapine-treated youth achieved 73.3 and 85.5 % of their overall BPRS-C score reduction at 6 weeks last observation carried forward. ER and ENR patients did not differ significantly regarding baseline demographic, illness and treatment variables. ER 2 (frequency = 68.1 %) and ER 3 (frequency = 65.2 %) significantly predicted UR and remission (p = 0.0044-p < 0.0001), with ER3 having more predictive power. A ≥ 20 % BPRS-C reduction threshold for ER had best predictive validity (area under the curve = 0.88-0.92). At 6 weeks, patients with ER had significantly greater improvements in BPRS-C, Clinical Global Impressions Improvement and Severity scores, greater cross-sectional remission and less all-cause discontinuation (p = 0.047-p < 0.0001). Adverse event profiles were similar in the ER and ENR groups. Adolescents with schizophrenia experienced the majority of symptomatic improvement early during olanzapine treatment. ER predicted UR and remission, with ER3 having best predictive power. A ≥ 20 % improvement threshold for defining ER was confirmed as a robust outcome indicator.

Early treatment response predicted subsequent clinical response in patients with schizophrenia taking paliperidone extended-release

This 6-week open-labeled study investigated whether early treatment response in patients receiving paliperidone extended-release (paliperidone ER) can facilitate prediction of responses at Week 6. Patients with schizophrenia or schizoaffective disorder were administered 9mg/day of paliperidone ER during the first 2 weeks, after which the dose was adjusted clinically. They were assessed on Days 0, 4, 7, 14, 28, and 42 by the Positive and Negative Syndrome Scale (PANSS). The serum concentrations of 9-hydroxyrisperidone were examined on Days 14 and 42. Among the 41 patients enrolled, 26 were classified as responders (≧50% improvement on total PANSS scores at Week 6). In the receiver-operator curves (ROC) analyses, the changes in total PANSS scores at Week 2 appeared to show more accurate predictability compared to Day 4 and Day 7. At Week 6, no significant correlation was observed between blood 9-hydroxyrisperidone concentration and the total score or changes of PANSS scores. The results suggest that early treatment response to paliperidone ER, particularly at Week 2, can serve as a suitable outcome predictor at Week 6. Using 9mg/day paliperidone ER as an initial dose for schizophrenia treatment exhibited relatively favorable tolerability and feasibility.

Practical pharmacotherapy for acute schizophrenia patients

Well-organized clinical guidelines of pharmacotherapy for schizophrenia are not necessarily applicable to emergency and acute-phase situations. Thus, practical pharmacotherapy for acute schizophrenia patients should be based on data from real clinical practice and be independent of pharmaceutical companies. This study investigated the current guidelines being used to determine the initially preferred antipsychotics, durations required before an antipsychotic is viewed as being ineffective, and the strategies utilized for early non-responders that include switching, high dose, and augmentation. In patients who develop side-effects to the preferred antipsychotic drug, continued use may depend on the specific characteristics of the side-effects. For acute-phase patients, antipsychotics with high efficacy and effectiveness may be chosen based on meta-analysis findings for not only double-blinded but also rater-blinded randomized controlled trials. Many previous studies have reported being able to make an early prediction at 2 weeks regarding the later response. These predictions were supported by the findings of a recent meta-analysis of 34 studies that examined 9975 participants. In early non-responders to the initial antipsychotic, the effectiveness of the switching strategy appears to depend on the initial antipsychotic administered and the antipsychotic the patient is subsequently switched to. Furthermore, the effectiveness of the strategy between switching and augmentation might also depend on the initial antipsychotic administered. The current findings might serve as the basis for the use of dosing above the licensed range versus continuing the use of conventional dosing in non-responders, provided there is close monitoring of the side-effects. Further research is required before any modifications of routine practices are undertaken regarding the direction of new potential treatments.

Clozapine: a review of clinical practice guidelines and prescribing trends

BACKGROUND

Clozapine effectiveness in the treatment of refractory schizophrenia has been sustained by published evidence in the last two decades, despite the introduction of safer options.

DISCUSSION

Current clinical practice guidelines have strongly recommended the use of clozapine in treatment-resistant schizophrenia, but prescribing trends do not appear to have followed such recommendations. Clozapine is still underutilized especially in patients at risk of suicide. It seems that physicians are hesitant in prescribing clozapine due to concerns about serious adverse effects. Recent reports have highlighted the need to inform health professionals about the benefits of treating patients with clozapine and have voiced concerns about the underutilization of clozapine especially in patients at risk of suicide.

SUMMARY

Guidelines and prescribing patterns reported in various countries worldwide are discussed. Suggestions on how to optimize clozapine utilization have been published but more efforts are needed to properly inform and support prescribers' practices.

Early improvement as a predictor of treatment response and remission in patients with schizophrenia: a pooled, post-hoc analysis from the asenapine development program

OBJECTIVE

The purpose of this study was to assess whether early symptom improvement predicts later treatment outcome in patients with schizophrenia.

METHODS

Data were pooled from intent-to-treat (ITT) populations of three six-week randomized controlled studies with fixed doses of asenapine (ASE; n=470), olanzapine (OLA; n=95), risperidone (RIS; n=56), haloperidol (HAL; n=112), or placebo (PLA; n=275). Early improvement was defined as a 20% reduction of Positive and Negative Syndrome Scale (PANSS) total score at week 2, compared to baseline (primary criterion). Treatment outcome at week 6 was defined as response (PANSS: ≥50% score reduction) or remission (PANSS item score ≤3 on selected items at week 6). Odds ratios (ORs) and predictive performance statistics were calculated.

RESULTS

Statistically significant associations between early improvement (at week 2) and treatment outcome (at week 6) were observed for all treatment groups except OLA; as evidenced by increased ORs for response. Analysis of associations between early improvement and remission, as defined by Andreasen et al. (2005), revealed a statistically significant relationship for ASE and PLA-treated patients only. Predictive performance statistics revealed higher negative predictive value (NPV) and sensitivity rates, and comparably lower positive predictive value (PPV) and specificity rates across treatment groups for both response and remission.

CONCLUSION

It is suggested that absence of improvement within two weeks of treatment may predict the unlikely success of subsequent pharmacological intervention.

Treatment of acute schizophrenia with paliperidone ER: predictors for treatment response and benzodiazepine use

The Paliperidone ER Treatment in Acute Intervention (PERTAIN) study was designed to explore treatment response, tolerability, and safety of flexible doses of paliperidone ER in patients with schizophrenia admitted for an acute exacerbation. This paper addresses a secondary analysis of PERTAIN data designed to explore predictors for treatment response, flexible dosing, and concomitant benzodiazepine use. This prospective, multicenter, phase 3b, open-label, single-arm, 6-week study used flexible doses of paliperidone ER (3 to 12mg once daily) to treat patients hospitalized for an acute exacerbation of schizophrenia, reflecting more closely daily clinical practice. Predictive models were evaluated for paliperidone ER flexible dosing, treatment response, and concomitant treatment with benzodiazepines as distinct independent variables. For the analysis of explanatory variables, a stepwise logistic regression was used, taking into account patient age, gender, body mass index, diagnosis and duration of schizophrenia, number of prior hospitalizations, psychotic symptoms (PANSS), disease severity (CGI-S), and patient functioning (PSP) at baseline. Early response (defined as response within 2weeks of treatment initiation) was also used as a predictor. Clinical response (defined as ≥30% decrease in PANSS total score and ≥1 point decrease in CGI-S from baseline to endpoint) was predicted by early clinical response (p<0.001) and there was a trend for the diagnosis of paranoid schizophrenia vs. other types of schizophrenia to predict clinical response (p=0.0525). High response (defined as ≥50% decrease in PANSS total score and ≥2 points decrease in CGI-S from baseline to endpoint) was predicted by early high response, higher baseline CGI-S, or female gender. More severely ill patients with a higher baseline CGI-S were twice likely to be treated concomitantly with a benzodiazepine.

Influencing Factors and Predictors of Early Response in Schizophrenia Patients Receiving the Paliperidone Extended-Release Tablets (Paliperidone ER)

OBJECTIVE

Paliperidone extended-release tablet (paliperidone ER) is a new oral psychotropic agent developed for schizophrenia treatment. There have been some studies about paliperidone's good efficacy and tolerability. Clinicians appear to change the antipsychotic medication to paliperidone ER. However, it is not known what patients are favorable responsive to paliperidone ER. The aim of this study was to evaluate the characteristics of early responders and investigate predictors of acute response when the medications changed to paliperidone ER.

METHODS

Data were analyzed from schizophrenic patients who participated in a multi-center, open-label, non-comparative clinical trial. Total 320 patients were examined in this study. Sociodemographic, psychopathology, social function and metabolic data were evaluated. Unpaired t-test for continuous and χ(2) for categorical data, respectively, were used to compare early responder and non-responders. Logistic regression analysis was used to establish a prediction model.

RESULTS

38.7% of study subjects (124 of 320) responded to paliperidone ER treatment. Logistic regression analysis showed that a good paliperidone ER response was more likely when patients were social drinkers, when patients had started medication at inpatient, when negative symptoms were less severe, and when patients' social relationship and self-care were better.

CONCLUSION

Early response to paliperidone ER treatment is associated with less negative symptoms and good social relationships and self-care. Strategies to reduce these symptoms may contribute to early response to paliperidone ER.

Early antipsychotic response to aripiprazole in adolescents with schizophrenia: predictive value for clinical outcomes

OBJECTIVE

In adults with chronic schizophrenia, most symptom decreases occur in the first few weeks of antipsychotic treatment, and nonresponse at week 2 predicts a later nonresponse. The trajectory of antipsychotic response and the predictive value of early antipsychotic effects were investigated for ultimate outcome in adolescent schizophrenia, where such data are still lacking.

METHOD

This post hoc analysis of a 6-week, randomized, double-blinded trial of aripiprazole (n = 196) versus placebo (n = 98) evaluated if adolescents 13 to 17 years old with schizophrenia exhibited substantial symptomatic improvement to aripiprazole in the first few treatment weeks and whether early response (ER) versus early nonresponse (ENR) predicted clinically relevant outcomes. ER decreased at least 20% and ENR decreased less than 20% in Positive and Negative Syndrome Scale (PANSS) total score at week 2 (ER2/ENR2) or 3 (ER3/ENR3). Ultimate response decreased at least 40% in PANSS score.

RESULTS

Nearly 50% of the PANSS decrease was achieved by week 2 and up to 75% by week 3. ER2/ER3 subjects showed significantly greater improvement than ENR subjects in PANSS total score, PANSS positive and negative subscale scores, and functionally relevant outcomes. In general, ER3 had better sensitivity, specificity, and positive and negative predictive values than ER2 for predicting ultimate response. ER2 subjects were 8.8 times (95% confidence interval 4.0-19.4) and ER3 subjects were 8.6 times (95% confidence interval 4.5-16.6) more likely to achieve remission at week 6 (p < .0001) than ENR2 and ENR3 subjects, respectively, although adverse events were similar.

CONCLUSIONS

Like adults with chronic schizophrenia, adolescents with early-phase schizophrenia exhibited most symptomatic improvement early during aripiprazole treatment, with week 3 improvements having the best predictive power. Although requiring extension, these results may inform clinical decision making. Clinical trial registration information-Aripiprazole in Adolescents with Schizophrenia, http://clinicaltrials.gov/, NCT00102063.

Should early improvement be re-defined to better predict the maintenance of response in first-episode schizophrenia patients?

OBJECTIVE

To evaluate the predictive validity of early response in first-episode schizophrenia within a 1-year follow-up trial and to compare the resulting cutoff to the currently proposed early response definition (20% improvement by week 2).

METHOD

Receiver operator characteristic (ROC) analyses were used to identify the predictive validity of the psychopathological improvement of treatment from week 1 to week 8, regarding the maintenance of response until week 52 as well as to define the most reasonable cutoff in 132 first-episode patients. The Youden Index (maximum of sensitivity and specificity) was used to compare the newly developed and the commonly used early response definition.

RESULTS

Starting with week 6, a reasonable validity to predict the maintenance of response was found (area under the curve = 0.721) with the best fitting cutoff being a 51.6% PANSS total score improvement. Using this cutoff 74 patients (56%) were correctly identified to become responder and maintain response during follow-up (sensitivity: 0.747). The Youden Index was higher applying the newly developed early response cutoff featuring higher specificity compared to the commonly used early response definition.

CONCLUSION

Regarding long-term treatment, it seems more appropriate to base predictions of the patient's maintenance of response not before 6 weeks of treatment.

Influencing factors and predictors of early improvement in the acute treatment of schizophrenia and schizophrenia spectrum disorder

BACKGROUND

To examine the influencing factors and predictors of early improvement in schizophrenia patients.

METHODS

370 patients suffering from a schizophrenia spectrum disorder were examined within a naturalistic multicenter study. Early improvement was defined as a ≥30% PANSS total score reduction within the first two treatment weeks, response as a ≥50% improvement of the PANSS total score from admission to discharge and remission according to the consensus remission criteria. Baseline and course-related variables such as positive, negative and depressive symptoms, side effects, functioning and subjective well-being were examined regarding their explanatory value for early improvement.

RESULTS

46% of the patients were identified to be early improvers. Of these, 77% became treatment responder at discharge and 74% achieved the consensus remission criteria. Amongst others, early improvers were significantly more often first-episode patients (p = 0.009), with a significantly shorter duration of current episode (p = 0.024) and a shorter duration of the illness (p = 0.0094). A higher PANSS positive subscore (p = 0.0089), a higher score in the Strauss-Carpenter-Prognostic Scale (SCPS) (p < 0.0001), less extrapyramidal side effects (p = 0.0004) at admission and the development of less extrapyramidal side effects within the first two treatment weeks (p = 0.0013) as well as a duration of current episode of ≤6 months (p = 0.0373) were identified to be significant predictors of early improvement.

CONCLUSION

Early improvement is associated with less illness chronicity and seems to be independent of the type of antipsychotic and the antipsychotic dosage applied. The SCPS was found to be a valuable tool to detect early improvers already at the initiation of antipsychotic treatment.

Randomized controlled trials in schizophrenia: opportunities, limitations, and trial design alternatives

State-of-the art clinical trial design and methodology are enormously important for the advancement of the field. In contrast, the critical relevance of trial conduct and implementation have only more recently been the focus of discussion and research. Although randomized controlled trials are generally considered the gold standard for the assessment of pharmacologic and nonpharmacologic interventions in medicine, trials are vulnerable to complications and influences that can seriously compromise their success, Like interventions, trial design and conduct are also contextual. They need to be individualized and adapted to a number of relevant variables, such as setting, population, illness phase, interventions, patient and rater expectations and biases, and the overall aims of the investigation. While this means that there is no unified approach possible, certain general principles and guidelines require careful consideration. Knowledge of basic solutions and alternatives, and the recognition of the complex challenges that need to be addressed proactively can help to minimize unwanted outcomes, including trial failure and uninformative or falsely negative outcomes. Moreover, novel design alternatives need to be explored that target sample enrichment according to the study question and enhancement of precision in the measurement of relevant outcomes. We propose two novel design strategies that take advantage of the recently validated early antipsychotic response paradigm (that has also been observed with antidepressants and mood stabilizers). In the “early responder randomized discontinuation design” all patients are assigned to the active drug, and only those who had at least a minimal response at 2 weeks are enrolled in a double-blind, placebo-controlled discontinuation trial, enriching the placebo controlled trial portion with true drug responders. In the mirror image “early nonresponder randomized dose increase or augmentation design,” early nonresponders at 2 weeks are assigned to staying on the medication or going either to a higher dose or an augmentation agent. It is hoped that through increased attention to the issues raised in this article and further refinement of trial methodology and conduct, the field will make much needed additional progress in the prevention and treatment of schizophrenia.

Early improvement on antipsychotic treatment as a predictor of subsequent response in schizophrenia: analyses from ziprasidone clinical studies

OBJECTIVE

We examine data from short-term placebo-controlled and comparator-controlled clinical trials of ziprasidone in schizophrenia to confirm the predictive capacity of early symptom changes for response. We pose the question of how early is too early to consider "stay or switch" and evaluate the predictive capability of a clinical measure in this regard.

METHODS

We presented two separate pooled analyses of (i) two placebo-controlled and (ii) two active comparator (risperidone and olanzapine) randomized trials of ziprasidone in schizophrenia. Relationship between early changes in Positive and Negative Syndrome Scale (PANSS) total, Brief Psychiatric Rating Scale (BPRS), and Clinical Global Impression-Improvement (CGI-I) scores and treatment outcome was evaluated.

RESULTS

Week 2 improvement was more reliably predictive of subsequent outcome than week 1 improvement using PANSS and BPRS scores with high sensitivity and specificity, whereas CGI-I had much lower specificity. Overall, non-improvement at week 1 or week 2 was highly predictive of non-response using BPRS scores and PANSS but not CGI-I.

CONCLUSIONS

These data, independent of antipsychotic used, confirm prior research showing that early improvement in symptoms is predictive of response. There appears to be an important window of time, beyond week 1, during which important clinical decisions to stay or switch medication may be made.

Evidence-based guidelines for the pharmacological treatment of schizophrenia: recommendations from the British Association for Psychopharmacology

These guidelines from the British Association for Psychopharmacology address the scope and targets of pharmacological treatment for schizophrenia. A consensus meeting, involving experts in schizophrenia and its treatment, reviewed key areas and considered the strength of evidence and clinical implications. The guidelines were drawn up after extensive feedback from the participants and interested parties, and cover the pharmacological management and treatment of schizophrenia across the various stages of the illness, including first-episode, relapse prevention, and illness that has proved refractory to standard treatment. The practice recommendations presented are based on the available evidence to date, and seek to clarify which interventions are of proven benefit. It is hoped that the recommendations will help to inform clinical decision making for practitioners, and perhaps also serve as a source of information for patients and carers. They are accompanied by a more detailed qualitative review of the available evidence. The strength of supporting evidence for each recommendation is rated.

Evidence-based pharmacotherapy of schizophrenia

We describe the pharmacological treatment of schizophrenia and have arranged the manuscript as a simple algorithm which starts from the choice of an antipsychotic drug for an acutely ill patient and concludes with the most important questions about maintenance treatment. In acutely ill patients the choice of drug is mainly based on pragmatic criteria. Among many strategies used for agitated patients, haloperidol plus promethazine is the best examined one. In case of persistent depression or negative symptoms treatment includes antidepressants, and some second-generation antipsychotic drugs (SGAs) have been found somewhat superior to first-generation antipsychotic drugs (FGAs) in these domains. If an antipsychotic is suspected to be ineffective, several factors need to be checked before action is taken. Few trials have addressed strategies such as switching the drug or increasing the dose in case of non-response. Clozapine remains the gold-standard for treatment-refractory patients, while none of the numerous augmentation strategies that have been examined by randomized controlled trials can be generally recommended. Maintenance treatment with antipsychotic drugs effectively reduces relapse rates. Small, not definitive, studies have shown that withdrawing antipsychotics from patients who have been stable for up to 6 yr leads to more relapses than continuing medication. In effect, continuous treatment is more effective than intermittent strategies. The identification of optimum doses for relapse prevention with FGAs has proven difficult, and there is little randomized data on SGAs. Although the randomized evidence on a superiority of depot compared to oral treatment is not ideal, this approach suggests obvious advantages in assuring compliance.

Pharmacologic treatment of schizophrenia

Despite pharmacologic advances, the treatment of schizophrenia remains a challenge, and suboptimal outcomes are still all too frequent. Although treatment goals of response, remission, and recovery have been defined more uniformly, a good “effectiveness” measure mapping onto functional outcomes is still lacking. Moreover, the field has to advance in transferring measurement-based approaches from research to clinical practice. There is an ongoing debate whether, and which, first- or second-generation antipsychotics should be used. However, an individualized treatment approach needs to consider current symptoms, comorbid conditions, past therapeutic response, and adverse effects, as well as patient choice and expectations. Moreover, acute and long-term goals and effects of medication treatment need to be balanced. While the acute response to appropriately dosed first-generation antipsychotics may not differ much from second-generation antipsychotics, advantages of lower rates of extrapyramidal side effects, tardive dyskinesia, and, possibly, relapse may favor second-generation antipsychotics. However, when considering individual adverse effect prof iles, the differentiation into first- and second-generation antipsychotics as unified classes can not be upheld, and a more differentiated view and treatment selection is required. To date, clozapine is the only evidence-based treatment for refractory patients, and the role of antipsychotic polypharmacy and other augmentation strategies remains unclear, at best. To improve the treatment outcomes in schizophrenia, research efforts are needed that elucidate biomarkers of the illness and of treatment response (both therapeutic and adverse effects). Moreover, new treatment options are needed that affect nondopaminergic targets with relevance for symptom reduction, relapse prevention, enhanced efficacy for nonresponders, and reduced key adverse effects.

Past and present progress in the pharmacologic treatment of schizophrenia

Despite treatment advances over the past decades, schizophrenia remains one of the most severe psychiatric disorders that is associated with a chronic relapsing course and marked functional impairment in a substantial proportion of patients. In this article, a historical overview of the pharmacologic advances in the treatment of schizophrenia over the past 50 years is presented. This is followed by a review of the current developments in optimizing the treatment and outcomes in patients with schizophrenia. Methodological challenges, potential solutions, and areas of particular need for further research are highlighted. Although treatment goals of response, remission, and recovery have been defined more uniformly, a good "effectiveness" measure mapping onto functional outcomes is still lacking. Moreover, the field must advance in transferring measurement-based approaches from research to clinical practice. There is an ongoing debate regarding whether and which first- or second-generation antipsychotics should be used. However, especially when considering individual adverse effect profiles, the differentiation into first- and second-generation antipsychotics as unified classes cannot be upheld, and a more differentiated view and treatment selection are required. The desired, individualized treatment approach needs to consider current symptoms, comorbid conditions, past therapeutic response, and adverse effects, as well as patient choice and expectations. Acute and long-term goals and effects of medication treatment should be balanced. To date, clozapine is the only evidence-based treatment for refractory patients, and the role of antipsychotic polypharmacy and other augmentation strategies remains unclear, at best. To discover novel treatments with enhanced/broader efficacy and improved tolerability, and to enable personalized treatment, the mechanisms underlying illness development and progression, symptomatic improvement, and side effect development need to be elucidated.

Clinical predictors of response to olanzapine or risperidone during acute episode of schizophrenia

The study attempted to identify clinical variables which could predict the response to a second-generation antipsychotic treatment during acute episodes among schizophrenic patients. Socio-demographic, premorbid and clinical variables were studied in a population of 95 diagnosed with schizophrenia, as defined in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSMIV), during an acute treated phase, in a multicentre prospective study. Patients were assigned to olanzapine or risperidone treatment in an open design. Clinical evaluations were performed at D0, D42 and D180. Good response to treatment was defined as a Positive and Negative Syndrome Scale (PANSS) reduction greater than 20% and a Brief Psychiatric Rating Scale (BPRS) score lower than 35. Univariate analysis revealed earlier age at onset of schizophrenia and earlier age at first prescription of antipsychotic among non-responders compared with good responders at D42. Non-responders also had a clinical profile at the onset of antipsychotic treatment characterised by more severe forms of the acute episode as shown by higher scores at the positive, general and overall PANSS scale and on CGI-S and BPRS scores. With a multivariate logistic regression model, age at onset and overall duration of illness remained the only clinical criteria identified as predictors of response to antipsychotic treatment at D42. Clinical variables do not clearly appear to be good predictors of treatment efficacy.

An early improvement threshold to predict response and remission in first-episode schizophrenia

BACKGROUND

Early improvement with treatment is thought to be important in patients with first-episode schizophrenia, yet a valid definition is still outstanding.

AIMS

To develop a valid definition of early improvement and test its predictive validity regarding response and remission.

METHOD

We examined 188 in-patients with first-episode schizophrenia. Early improvement was defined as improvement in Positive and Negative Syndrome Scale (PANSS) total score at week 2, response as a 40% PANSS total score improvement at end-point, and remission according to consensus criteria.

RESULTS

Reasonable predictive validity of early improvement was found for a 46% PANSS total score improvement at week 2 and a 50% improvement for remission (area under the curve: response 0.707, remission 0.692). Estimated confidence intervals ranged from 26 to 62% PANSS reduction for response and remission.

CONCLUSIONS

Patients with a first episode of schizophrenia should improve by at least 30% in PANSS total score at week 2 to achieve response and remission.

Interaction of haloperidol plasma level and antipsychotic effect in early phases of acute psychosis treatment

The definition of the best combination of "when" and "how much" of haloperidol dosing during acute psychotic illness still represents a challenge. Randomized controlled trials can hardly account for the high variability of dose x timing of dose increase strategies that can be applied in everyday practice. We conducted an observational study in order to study and evaluate the naturalistic strategies of haloperidol oral administration in a sample of 101 acutely ill psychotic patients. Out of this sample, 82 patients had complete data on PANSS scores and 50 patients had data on the haloperidol plasma levels. In accordance with previous evidence, we found that improvement during the first two weeks of treatment was a significant predictor of response (t=6.94, p=2.11E-08). On this note, increasing the haloperidol doses over 6.64+/-2.08 mg/day on average from the second to the third week of treatment in those patients who did not respond to treatment during the first two weeks of treatment was of no use for further amelioration. This cutoff was associated with treatment efficacy but not with the incidence of side effects. In conclusion a moderate dose of haloperidol is suggested in the first two weeks, in case of non response a dose increase is of no further benefit. This finding could contribute to tailor more individualized treatment and highlights the need for early detection of non-responders.

Antipsychotic drug treatment in first-episode psychosis: should patients be switched to a different antipsychotic drug after 2, 4, or 6 weeks of nonresponse?

Patients with schizophrenia show symptom reduction early after the initiation of drug treatment, but no consensus has been reached on the number of weeks after which a nonresponding patient should be switched to an alternative treatment. We aimed to test whether patients should be switched to an alternative treatment at 2, 4, or 6 weeks from treatment initiation. Remission within 12 months was assessed in 299 first-episode patients who completed the full 12-month European First-Episode Schizophrenia Trial. Logistic regression analyses were used to test whether the prediction of remission was improved by including assessments obtained 4 or 6 weeks from treatment initiation compared with a prediction based on baseline and 2-week measures only. Based on baseline and 2-week assessments, remission status was correctly predicted in 61% of the patients (positive and negative predictive power, 0.61 and 0.58, respectively; sensitivity, 0.94; and specificity, 0.12). This percentage increased to 63% (positive and negative predictive power, 0.67 and 0.55, respectively; sensitivity, 0.73; and specificity, 0.47) and 68% (positive and negative predictive power, 0.73 and 0.61, respectively; sensitivity, 0.73; and specificity, 0.60) by the inclusion of 4- and 6-week assessments, respectively. Although we confirmed earlier findings that 2-week measures of response are associated with remission, the prediction of remission is significantly improved by the inclusion of 4- and 6-week assessments. However, as the increase in prediction accuracy is modest, it is uncertain whether this improvement is clinically relevant.

FDG-PET and MRI imaging of the effects of sertindole and haloperidol in the prefrontal lobe in schizophrenia

Sertindole, a 2nd generation antipsychotic with low movement disorder side effects, was compared with haloperidol in a 6-week crossover study. Fifteen patients with schizophrenia (mean age=42.6, range=22-59, 11 men and 4 women) received sertindole (12-24 mg) or haloperidol (4-16 mg) for 6 weeks and then received a FDG-PET scan and an anatomical MRI. Patients were then crossed to the other treatment and received a second set of scans at week 12. Dose was adjusted by a physician blind to the medication type. Brodmann areas were identified stereotaxically using individual MRI templates applied to the coregistered FDG-PET image. Sertindole administration was associated with higher dorsolateral prefrontal cortex metabolic rates than haloperidol and lower orbitofrontal metabolic rates than haloperidol. This effect was greatest for gray matter of the dorsolateral Brodmann areas 8, 9, 10, 44, 45, and 46. Patients were further contrasted with an approximately age and sex-matched group of 33 unmedicated patients with schizophrenia and with a group of 55 normal volunteers. Sertindole administration was associated with greater change toward normal values and away from the values found in the unmedicated comparison group for dorsolateral prefrontal cortex gray matter and white matter underlying medial prefrontal and cingulate cortex. These results are consistent with the low motor side-effect profile of sertindole, greater improvement on prefrontal cognitive tasks with sertindole than haloperidol, and with the tendency of 2nd generation antipsychotic drugs to have greater frontal activation than haloperidol.

Antipsychotic Drug Treatment for Patients with Schizophrenia: Theoretical Background, Clinical Considerations and Patient Preferences

The cornerstone in treatment of psychosis is antipsychotic drugs. Treatment options have increased over the years; newer antipsychotic drugs with a proposed increased efficacy regarding negative and cognitive symptoms, but also a shift in side-effects from neurological side-effects to metabolic side-effects have arisen as the new challenge. The basis of successful pharmacological treatment is a fundamental understanding of the mechanisms of action, the desired effects and side-effects of antipsychotic drugs, a good relationship with the patient and a thorough monitoring of the patient before and during treatment. The clinically relevant aspects of antipsychotic drug treatment are reviewed; mechanism of antipsychotic drug action, clinical considerations in treatment, switching antipsychotic drugs, polypharmacy, safety and patient preference.

Clinical, functional, and economic ramifications of early nonresponse to antipsychotics in the naturalistic treatment of schizophrenia

OBJECTIVE

Early nonresponse to antipsychotics appears to predict subsequent nonresponse to treatment when assessed in randomized controlled trials of predominately acute inpatients treated for schizophrenia. This study assessed the predictive accuracy of early nonresponse to treatment and its clinical, functional, and economic ramifications in the naturalistic treatment of predominately chronic outpatients treated for schizophrenia.

METHODS

This post hoc analysis used data from a 1-year, randomized, open-label study of olanzapine, risperidone, and typical antipsychotics in the treatment of schizophrenia. If clinically warranted, patients could switch antipsychotics following 8 weeks of treatment. Patients completing 8 weeks of treatment (n = 443 of 664 enrollees) were included. Patients with early response (> or = 20% improvement from baseline on the Positive and Negative Syndrome Scale at 2 weeks) were compared with early nonresponders on symptom remission, functionality, perceptions of medication influence, and total health care costs at 8 weeks.

RESULTS

Early response/nonresponse at 2 weeks predicted subsequent response/nonresponse at 8 weeks with a high level of accuracy (72%) and specificity (89%). After 8 weeks, early nonresponders were less likely to achieve symptom remission (P < .001), improved less on functional domains (P < .05), perceived medication as less beneficial (P = .004), and incurred total heath care costs over twice that of early responders ($4349 vs $2102, P = .010).

CONCLUSIONS

In the usual care of schizophrenia patients, early nonresponse appears to reliably predict subsequent nonresponse to continued treatment with the same medication to be associated with poorer outcomes and higher health care costs. Identifying early nonresponders may minimize prolonging exposure to suboptimal or ineffective treatment strategies.

Predicting antipsychotic drug response - replication and extension to six weeks in an international olanzapine study

OBJECTIVE

To use the degree of response after 2 weeks of treatment to predict non-response at 4 to 6 weeks.

METHOD

Post-hoc re-analysis of a large multi-centered double-blind trial including 1996 patients with schizophrenia using receiver-operator curves and logistic regression analyses to predict non-response at 4 weeks and at 4-6 weeks from the percentage BPRS change at weeks 1 and 2. The primary non-response criterion was a less than 25% BPRS reduction from baseline.

RESULTS

A 0% BPRS reduction at 2 weeks predicted non-response at 4 weeks with a positive predictive value of 77.1%; and sustained non-response at weeks 4, 5 and 6 with a positive predictive value of 75.8%. In a secondary last-observation-carried forward-analysis a less stringent cutoff of < or =15% BPRS reduction was associated with an acceptable positive predictive value (75%), with even higher sensitivity (76%).

CONCLUSIONS

Those patients who showed little to no reduction of symptoms at week 2 were unlikely to show even minimal response at weeks 4 to 6. There is increasing evidence that such patients may benefit from a change in treatment.

Feasibility of reducing the duration of placebo-controlled trials in schizophrenia research

Use of placebo-controlled trials in medical and psychiatric research has been controversial, although a consensus is emerging about conditions under which placebo-controlled trials are ethical. In schizophrenia research, the paradigm of slow onset of antipsychotic effects has led to a model in which placebo-controlled trials of 6-8 weeks duration have been used to demonstrate efficacy. Recent evidence that the largest symptom reductions are typically seen in the first weeks of treatment suggests that shorter placebo-controlled studies to demonstrate antipsychotic efficacy are possible. In a pilot study of the feasibility of shortening placebo-controlled studies, we reanalyzed data from placebo-controlled registry trials of olanzapine and risperidone and found that trials as short as 4 weeks could have similar power to longer term 6-8 week studies, given the estimated time course of treatment effects. Although fuller evaluation is required, the results suggest future antipsychotic trials could be shortened from 6-8 weeks to 3-4 weeks with a relatively low increase in sample size requirements. Shortening placebo-controlled trials would reduce patient burden and ethical objections to prolonged administration of placebo and reduce potential bias due to high dropout rates in longer clinical trials.

Could HTR2A T102C and DRD3 Ser9Gly predict clinical improvement in patients with acutely exacerbated schizophrenia? Results from treatment responses to risperidone in a naturalistic setting

OBJECTIVE

This study seeks to replicate previous results indicating that T102C in the serotonin 2A receptor (HTR2A) and Ser9Gly in the dopamine D3 receptor (DRD3) were associated with a risperidone response to acutely exacerbated schizophrenia, and to determine whether possession of these alleles predicts clinical improvement in a naturalistic setting.

METHODS

We consecutively recruited 100 schizophrenia patients and assessed clinical improvement after 4 weeks of risperidone treatment.

RESULTS

The patients with T/T in the HTR2A gene showed less clinical improvement than did those with T/C or C/C (p = 0.044). In the case of the DRD3 gene, we did not find statically significant association with clinical improvement (p = 0.061). When patients were categorized into responders and nonresponders, the C allele was more frequent in responders (OR = 2.28, 95%CI = 1.06-4.91, p = 0.039). When combinations of the two polymorphisms were considered, patients who had T/T in the HTR2A gene and encoded Ser/Ser or Ser/Gly from DRD3 gene had a higher propensity to non-responsiveness compared to other subjects (OR = 3.57, 95%CI = 1.10-11.62, p = 0.039).

CONCLUSIONS

Our findings suggest that the HTR2A T102C could be a potential indicator of clinical improvement after risperidone treatment.