Ropinirole as an effective adjunctive treatment for clozapine-resistant negative symptoms in simple schizophrenia: a case report

Relative prevalence of 10 types of pharmacodynamic interactions in psychiatric treatment

OBJECTIVE

To assess the relative prevalence and factors affecting the prescription of medication combinations with a theoretical efficacy limiting pharmacodynamic interaction, defined as two medications with opposing indications and side effects or antagonistic action at the primary receptor of mechanism of action.

METHOD

One hundred sixteen combinations were identified for 10 types of pharmacodynamic interactions. PubMed was searched for each combination to assess the quality of evidence either supporting clinical use or verifying reduced efficacy. Micromedex was searched to determine the presence of warnings to prescribers of reduced efficacy. The prevalence in clinical practice was determined by computer review of the Genoa Healthcare database for all prescribers at 10 participating community mental health centers. The expected prevalence was calculated as the product of the probability of each medication prescribed alone and was compared with the actual prevalence of the combination using the test of proportions.

RESULTS

The frequency of prescription of eight combinations met the Bonferroni corrected level of significance of p < 0.001. Four were combinations of amphetamine and D2 antagonists and each were prescribed less often than chance, p = 0.0001 consistent with epidemiological studies and multiple animal studies verifying an efficacy limiting interaction. Despite epidemiological studies indicating increased risk of accidents, alprazolam and amphetamine were prescribed more often than chance, p = 0.0001. Micromedex generated warnings for efficacy limiting interactions for five other combinations, but with no subsequent change in prescription frequency.

CONCLUSIONS

Neither presence of medical evidence nor warnings from Micromedex consistently affect the prescription of combinations with pharmacodynamic efficacy limiting interactions.

Simple Schizophrenia: A Forgotten Diagnosis in Psychiatry

Clustering of symptoms to characterize simple schizophrenia is still debated, and support is needed for the characterization of simple schizophrenia as a syndrome. We conducted a systematic review to identify all cases of simple schizophrenia published until December 2017. We identified 42 cases of simple schizophrenia, 57% of which met all three diagnostic criteria (ICD-10, DSM-4 research criteria, and Black and Boffeli's criteria for simple schizophrenia). The mean age at first contact with clinical services was 30.1 (SD = 11.6) years, with a mean delay of 7.4 (SD = 6.8) years from symptom onset to first presentation. An insidious onset and negative symptoms were characteristic features in all cases. Social withdrawal, alogia, blunted affect, lack of initiative/interest, and functional impairment were found in more than 85% of cases. Our findings contribute to greater awareness and understanding of simple schizophrenia, and have the potential to reawaken interest in this clinically distinct subgroup.

Dementia praecox redux: a systematic review of the nicotinic receptor as a target for cognitive symptoms of schizophrenia

Most individuals with schizophrenia suffer some cognitive dysfunction: such deficits are predictive of longer-term functioning; and current dopamine-blocking antipsychotics have made little impact on this domain. There is a pressing need to develop novel pharmacological agents to tackle this insidious but most disabling of problems. The acetylcholinergic system is involved in cognitive and attentional processing, and its metabotropic and nicotinic receptors are widespread throughout the brain. Deficits in acetylcholinergic functioning occur in schizophrenia, and high rates of tobacco smoking have been posited to represent a form of self-medication. The nicotinic acetylcholine receptor (nAChR) has emerged as a putative target to improve cognitive deficits in schizophrenia, and this study systematically reviewed the emerging data. Nineteen studies were identified, covering three compound classes: agonists at the α7 and α 4β2 nAChRs, and positive allosteric modulators. Overall data are underwhelming: some studies showed significant improvements in cognition but as many studies had negative findings. It remains unclear if this represents drug limitations or nascent study methodology problems. The literature is particularly hindered by variability in inclusion of smokers, generally small sample sizes, and a lack of consensus on cognitive test batteries. Future work should evaluate longer-term outcomes, and, particularly, the effects of concomitant cognitive training.

Unheard voices: outcomes of tertiary care for treatment-refractory psychosis

Aims and method In up to a quarter of patients, schizophrenia is resistant to standard treatments. We undertook a naturalistic study of 153 patients treated in the tertiary referral in-patient unit of the National Psychosis Service based at the Maudsley Hospital in London. A retrospective analysis of symptoms on admission and discharge was undertaken using the OPCRIT tool, along with preliminary economic modelling of potential costs related to changes in accommodation.

Results In-patient treatment demonstrated statistically significant improvements in all symptom categories in patients already identified as having schizophrenia refractory to standard secondary care. The preliminary cost analysis showed net savings to referring authorities due to changes from pre- to post-discharge accommodation.

Clinical implications Despite the enormous clinical, personal and societal burden of refractory psychotic illnesses, there is insufficient information on the outcomes of specialised tertiary-level care. Our pilot data support its utility in all domains measured.

VNP: Interactive Visual Network Pharmacology of Diseases, Targets, and Drugs

In drug discovery, promiscuous targets, multifactorial diseases, and "dirty" drugs construct complex network relationships. Network pharmacology description and analysis not only give a systems-level understanding of drug action and disease complexity but can also help to improve the efficiency of target selection and drug design. Visual network pharmacology (VNP) is developed to visualize network pharmacology of targets, diseases, and drugs with a graph network by using disease, target or drug names, chemical structures, or protein sequence. To our knowledge, VNP is the first free interactive VNP server that should be very helpful for systems pharmacology research. VNP is freely available at http://cadd.whu.edu.cn/ditad/vnpsearch.