How schizophrenic patients change during 3 years' treatment with depot neuroleptics

Fluphenazine decanoate (depot) and enanthate for schizophrenia

BACKGROUND

Intramuscular injections (depot preparations) offer an advantage over oral medication for treating schizophrenia by reducing poor compliance. The benefits gained by long-acting preparations, however, may be offset by a higher incidence of adverse effects.

OBJECTIVES

To assess the effects of fluphenazine decanoate and enanthate versus oral anti-psychotics and other depot neuroleptic preparations for individuals with schizophrenia in terms of clinical, social and economic outcomes.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's Trials Register (February 2011 and October 16, 2013), which is based on regular searches of CINAHL, BIOSIS, AMED, EMBASE, PubMed, MEDLINE, PsycINFO, and registries of clinical trials.

SELECTION CRITERIA

We considered all relevant randomised controlled trials (RCTs) focusing on people with schizophrenia comparing fluphenazine decanoate or enanthate with placebo or oral anti-psychotics or other depot preparations.

DATA COLLECTION AND ANALYSIS

We reliably selected, assessed the quality, and extracted data of the included studies. For dichotomous data, we estimated risk ratio (RR) with 95% confidence intervals (CI). Analysis was by intention-to-treat. We used the mean difference (MD) for normal continuous data. We excluded continuous data if loss to follow-up was greater than 50%. Tests of heterogeneity and for publication bias were undertaken. We used a fixed-effect model for all analyses unless there was high heterogeneity. For this update. we assessed risk of bias of included studies and used the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach to create a 'Summary of findings' table.

MAIN RESULTS

This review now includes 73 randomised studies, with 4870 participants. Overall, the quality of the evidence is low to very low.Compared with placebo, use of fluphenazine decanoate does not result in any significant differences in death, nor does it reduce relapse over six months to one year, but one longer-term study found that relapse was significantly reduced in the fluphenazine arm (n = 54, 1 RCT, RR 0.35, CI 0.19 to 0.64, very low quality evidence). A very similar number of people left the medium-term studies (six months to one year) early in the fluphenazine decanoate (24%) and placebo (19%) groups, however, a two-year study significantly favoured fluphenazine decanoate (n = 54, 1 RCT, RR 0.47, CI 0.23 to 0.96, very low quality evidence). No significant differences were found in mental state measured on the Brief Psychiatric Rating Scale (BPRS) or in extrapyramidal adverse effects, although these outcomes were only reported in one small study each. No study comparing fluphenazine decanoate with placebo reported clinically significant changes in global state or hospital admissions.Fluphenazine decanoate does not reduce relapse more than oral neuroleptics in the medium term (n = 419, 6 RCTs, RR 1.46 CI 0.75 to 2.83, very low quality evidence). A small study found no difference in clinically significant changes in global state. No difference in the number of participants leaving the study early was found between fluphenazine decanoate (17%) and oral neuroleptics (18%), and no significant differences were found in mental state measured on the BPRS. Extrapyramidal adverse effects were significantly less for people receiving fluphenazine decanoate compared with oral neuroleptics (n = 259, 3 RCTs, RR 0.47 CI 0.24 to 0.91, very low quality evidence). No study comparing fluphenazine decanoate with oral neuroleptics reported death or hospital admissions.No significant difference in relapse rates in the medium term between fluphenazine decanoate and fluphenazine enanthate was found (n = 49, 1 RCT, RR 2.43, CI 0.71 to 8.32, very low quality evidence), immediate- and short-term studies were also equivocal. One small study reported the number of participants leaving the study early (29% versus 12%) and mental state measured on the BPRS and found no significant difference for either outcome. No significant difference was found in extrapyramidal adverse effects between fluphenazine decanoate and fluphenazine enanthate. No study comparing fluphenazine decanoate with fluphenazine enanthate reported death, clinically significant changes in global state or hospital admissions.

AUTHORS' CONCLUSIONS

There are more data for fluphenazine decanoate than for the enanthate ester. Both are effective antipsychotic preparations. Fluphenazine decanoate produced fewer movement disorder effects than other oral antipsychotics but data were of low quality, and overall, adverse effect data were equivocal. In the context of trials, there is little advantage of these depots over oral medications in terms of compliance but this is unlikely to be applicable to everyday clinical practice.

Do schizophrenics well adapted in the community need neuroleptics? A depot neuroleptic withdrawal study

Two depot neuroleptics (flupenthixol plamitate and clopenthixol decanoate) used for at least 15 months were withdrawn in 32 schizophrenic outpatients belonging to the most symptom-free and social cohort of a total patient population. They all had only slight schizophrenic symptoms, were well adapted in the community, and had been free from relapse for at least 2 years before the study. They were assessed by means of rating scales every month during the first six months and then after 9 and 12 months. After the one-year trial 26 patients had relapsed. Moreover, after the control period further 4 out of 6 patients relapsed during the following drug-free year. These results indicate the necessity of a long follow-up period after withdrawal of depot neuroleptics. Moreover, the results suggest that periodical drug-free periods of about 3 months are appropriate in symptom-poor patients during long-term treatment with long-acting antipsychotic drugs.

Depot fluphenazine decanoate and enanthate for schizophrenia

BACKGROUND

Intramuscular injections (depot preparations) offer an advantage over oral medication for treating schizophrenia by reducing poor compliance. The benefits gained by long acting preparations, however, may be offset by a higher incidence of adverse effects.

OBJECTIVES

To investigate the clinical effects of fluphenazine decanoate and enanthate.

SEARCH STRATEGY

For this update we searched the Cochrane Schizophrenia Group's Register (May 2002).

SELECTION CRITERIA

We considered all relevant randomised clinical controlled trials focusing on people with schizophrenia comparing fluphenazine decanoate or enanthate with placebo or oral anti-psychotics or other depot preparations.

DATA COLLECTION AND ANALYSIS

We reliably selected, quality rated and data extracted studies. For dichotomous data we estimated relative risk (RR) with 95% confidence intervals (CI), and, where possible, the number needed to treat/harm (NNT/H). Analysis was by intention-to-treat. We used the weighted mean difference (WMD) for normal continuous data. Tests of heterogeneity and for publication bias were undertaken.

MAIN RESULTS

This review now includes 70 randomised studies. Compared with placebo, fluphenazine decanoate did not reduce relapse over 6 months to 1 year, but one longer term study found that relapse was significantly reduced in the fluphenazine arm (n=54, RR 0.35, CI 0.2 to 0.6, NNT 2 CI 2 to 4). Fluphenazine decanoate does not reduce relapse more than oral neuroleptics (n=419, 6 RCTs, RR relapse 26-52 weeks 1.46 CI 0.8 to 2.8) or other depot antipsychotics (n=581, 11 RCTs, RR relapse 26-52 weeks 0.82 CI 0.6 to 1.2). Relapse rates over 6 months to 1 year were not significantly different between standard dosage of fluphenazine decanoate over a low dose group (n=523, 4 RCTs, RR 2.09 CI 0.6 to 7.1). Movement disorders were significantly less for people receiving fluphenazine decanoate compared with oral neuroleptics (n=259, 3 RCTs, RR 0.47 CI 0.2 to 0.9, NNT 14 CI 10 to 82). For fluphenazine enanthate there were limited data but no clear difference in global change (0 to 5 weeks) when compared with oral neuroleptics (n=31, 1 RCTs, RR 0.67 CI 0.3 to 1.7), and in relapse rates over 6-26 weeks between fluphenazine enanthate and other depots. Compared with placebo, giving the enanthate caused no more people to need need anticholinergic drugs (n=25, 1 RCT, RR 9.69 CI 0.6 to 163.0) and movement disorders, tardive dyskinesia, tremor, blurred vision and dry mouth were equally prevalent when enanthate was compared with other depot neuroleptics.

AUTHORS' CONCLUSIONS

There are more data for fluphenazine decanoate than for the enanthate ester. Both are effective antipsychotic preparations. In the context of trials, there is little advantage of these depots over oral medications in terms of compliance but this is unlikely to be applicable to everyday clinical practice.

Depot pipotiazine palmitate and undecylenate for schizophrenia

BACKGROUND

Antipsychotic drugs are usually given orally but compliance may be problematic. The development of depot injections in the 1960s gave rise to their extensive use as a means of long-term maintenance treatment. Pipotiazine palmitate is a depot from the phenothiazine family of antipsychotic drugs.

OBJECTIVES

To assess the clinical, social and economic effects of depot pipotiazine palmitate and undecylenate compared with placebo, oral antipsychotics and other depot antipsychotic preparations for people with schizophrenia.

SEARCH STRATEGY

For this update we searched the Cochrane Schizophrenia Group's Register (June 2003). We also inspected references of all identified trials for more studies and contacted relevant industries.

SELECTION CRITERIA

We included all randomised clinical trials comparing depot pipotiazine palmitate and undecylenate to oral antipsychotics or other depot preparations for people with schizophrenia.

DATA COLLECTION AND ANALYSIS

We reliably selected, quality rated and independently extracted data from relevant studies. We calculated the random effects relative risk (RR), the 95% confidence intervals (CI) and, where possible the number needed to treat (NNT) on an intention-to-treat basis. For continuous data, we calculated weighted mean differences (WMD). We only presented scale data for those tools that had attained pre-specified levels of quality.

MAIN RESULTS

When pipotiazine palmitate was compared with 'standard' oral antipsychotic no differences were found for outcomes of global impression (n=53, 1 RCT, RR 2.57, CI 0.8 to 8.6), relapse (n=124, 1 RCT, RR 1.55 CI 0.76 to 3.2), study attrition (n=219, 3 RCTs, RR 1.37 CI 0.8 to 2.4) and behaviour (n=124, 1 RCT, WMD 4.65, CI -1.1 to 10.4). There was also no reported difference in adverse effects such as tardive dyskinesia or the need for anticholinergic drugs. Sixteen studies compared pipotiazine palmitate with other depot preparations (n=1123). Pipotiazine palmitate was consistently equivalent to other depots in terms of a range of outcomes, including global impression (n=217, 4 RCTs, RR not improved 0.99 CI 0.91 to 1.07), relapse (n=239, 5 RCTs, RR relapse by 1 year 0.98 CI 0.55 to 1.75), and adverse effects (n=337, 5 RCTs, RR needing anticholinergic medication 0.98 CI 0.84 to 1.15).

REVIEWERS' CONCLUSIONS

Although well-conducted and reported randomised trials are still needed to fully inform practice (no trial data exists reporting hospital and services outcomes, satisfaction with care and economics) pipotiazine palmitate is a viable choice for both clinician and recipient of care.

Depot pipothiazine palmitate and undeclynate for schizophrenia

BACKGROUND

Anti-psychotic drugs are usually given orally but compliance with medication given by this route may be difficult to quantify. The development of depot injections in the 1960s gave rise to extensive use of depots as a means of long-term maintenance treatment. Pipothiazine palmitate is a depot from the phenothiazine family of antipsychotic drugs.

OBJECTIVES

To assess the effects of depot pipothiazine palmitate and undeclynate versus placebo, oral anti-psychotics and other depot antipsychotic preparations for people with schizophrenia in terms of clinical, social and economic outcomes.

SEARCH STRATEGY

Relevant trials were identified by searching Biological Abstracts (1982-1998), Cochrane Library (Issue 2, 1998), Cochrane Schizophrenia Group's Register (June 1998), EMBASE (1980-1998), MEDLINE (1966-1998) and PsycLIT (1974-1998). References of all identified trials were also inspected for more studies and industry contacted.

SELECTION CRITERIA

All clinical randomised trials focusing on people with schizophrenia where depot pipothiazine palmitate and undeclynate, oral anti-psychotics or other depot preparations were compared.

DATA COLLECTION AND ANALYSIS

Studies were reliably selected, quality rated and data extracted. For dichotomous data Peto odds ratios (OR) with the 95% confidence intervals (CI) were estimated. Where possible, the number needed to treat statistic (NNT) was calculated. Analysis was by intention-to-treat. Normal continuous data were summated using the weighted mean difference (WMD). Scale data were presented only for those tools that had attained pre-specified levels of quality.

MAIN RESULTS

Fourteen studies were included. When pipothiazine palmitate was compared to 'standard' oral antipsychotics no differences were found for outcomes of mental state, study attrition, behaviour and adverse effects (total randomised = 166). Pipothiazine palmitate was compared to other depot preparations in nine studies (n=455). Again no differences were identified for outcomes of global improvement, mental state, study attrition, behaviour and adverse effects.

REVIEWER'S CONCLUSIONS

Although well-conducted and reported randomised trials are still needed to inform practice (no trial data exists reporting hospital and services outcomes, satisfaction with care and economics) pipothiazine palmitate is a viable choice for clinician and recipient of care. Data suggests it is not different to other depot antipsychotics.

A controlled study of 5 years' treatment with psychotherapy in combination with depot neuroleptics in schizophrenia. II. Personality changes measured by ten selected Rorschach variables

Fourteen chronic schizophrenics (experimental group) were matched with 13 schizophrenics (control group), with respect to sex, age, and time of first admission for the disease. The patients in the experimental group were treated with depot neuroleptics in combination with psychotherapy in a 5 year treatment programme. The control group were mainly treated with broad-spectrum neuroleptics and no structured psychotherapy. The main aim of this study was to investigate personality changes in these groups after 5 years' treatment, as measured by ten selected Rorschach (Ro) variables. Five control patients refused to be tested before the study. At the evaluation 5 years later, 3 had committed suicide and one had moved to another town and could not be tested. In the experimental group 1 patient committed suicide. Compared to the results before treatment, the experimental group's mean total scores on the 10 Ro variables after 5 years' treatment were significantly changed in a direction indicative of improvement (p less than 0.001). The control patients changed significantly in a direction indicative of deterioration (p less than 0.02). The differences in mean total scores between the 2 groups were statistically significant (p less than 0.001), in favour of the experimental group. This study has shown improved intellectual capacity, ego-strength and better ability for reality testing when psychotherapy was combined with depot neuroleptics, compared to schizophrenics treated with neuroleptics but no structured psychotherapy.

Personality changes in chronic schizophrenic patients during five years' treatment with intensive psychotherapy in combination with depot neuroleptics I. Analysis of changes as measured by the Holtzman Inkblot Technique

Twelve schizophrenic inpatients (experimental group) from one department of psychiatry were treated in an integrated programme lasting for at least 5 years (1967--1972). Two more patients participated during the last 4 years of the study. The treatment included depot neuroleptics in combination with individual and group psychotherapy. During the first 3 years of the investigation, the patients of the experimental group were urged to participate in individual and group psychotherapy twice a week. During the last 2 years patients were only offered group psychotherapy once a week. A matched sample of 13 schizophrenics (control group) was selected from other departments at the hospital. The main aim of this study was to describe and measure personality changes after this treatment programme as measured by the Holtzman Inkblot Technique. During the first 3 years of the investigation, a stable and continuously improved intellectual capacity and less disordered through processes were found, as measured by the Holtzman test. After a further 2 years a slight decrease in variables measuring intellectual capacity and more disordered thinking was found. Compared to the control group not receiving psychotherapy, the experimental group spent more days outside hospital during the observation period 1968--1975. The difference was not statistically significant, however. After 2 years of treatment the experimental group's of patients Activities of Daily Living (ADL performance) was increased -- at 5% level of statistical significance -- and it remained at about the same level throughout this investigation. The level of work performance, however, was not changed in this study. The patients in the experimental group were compared with two American reference groups; average adults and schizophrenics. After 3 years' treatment the experimental group had become more similar to the average adults than to the schizophrenics. Two years later a slight deterioration was found. Although psychotherapy seemed to have had additive positive effects in chronic schizophrenia, measures to prevent relapse must be considered.

Integrated rehabilitation in schizophrenia. Development of treatment methods and presentation of some results

The embryo to our integrated treatment programme was "combination treatment in schizophrenia". This combination treatment included behavioural therapy, psychotropic drugs and dynamic psychotherapy. It was also integrated with work therapy and sociotherapy. A number of prospective and retrospective studies for the development work are exemplified. The method of development and method descriptions for above all the psychotherapeutic work are presented. During the years most of the patients have been treated either by D. Lindberg (psychologist) or U. Malm (physician) under the medical responsibility of the head of the department (S.J. Dencker, M.D.). The resulting "integrated treatment programme" is described. The treatment comprises depot neuroleptics in combination with psychosocial measures during a time of two years. During this period the contributions of a head therapist, usually a specially trained psychologist or physician, are coordinated. After a diagnostic phase, including international rating scales and special record keeping, comprising 1--2 weeks, a medical adjustment time and a contact establishing period follows for about 1 month. When the patient is able to stay in an open ward a three months integrated treatment programme in hospital is started. In hospital the patients are either offered group psychotherapy 4 times a week (the "country model") or once a week (the "big city model") in combination with depot neuroleptics and other planned psychosocial methods. Our experiences from a treatment with integrated treatment programme point at the fact that patients with some form of schizophrenic state can live in the society "with a good quality of life". Methods and evaluations of the continued rehabilitation measures are proceeded and like Hogarty et al. (1976) we are looking for new roads.

Clopenthixol and flupenthixol depot preparations in outpatient schizophrenics. I. A one year double-blind study of clopenthixol decanoate and flupenthixol palmitate

Clopenthixol decanoate and flupenthixol palmitate, both depot neuroleptics belonging to the thioxanthene group, were studied during double-blind conditions for 12 months using four week intervals between injections. The 60 patients included in the study were chronic schizophrenics and treated as outpatients after earlier admission to hospital and rehabilitation training periods. They had all been treated with depot neuroleptics in the last three years and they had been free from relapse for at least 15 months. The main aim with this trial was to study the two depot drugs during maintenance treatment conditions in an outpatient setting. Ten patients dropped out, 7 because of unsatisfactory effect, mainly because only limited dose levels were accepted according to the design. In spite of the earlier long lasting neuroleptic treatment and the good social adaptation in this schizophrenic subgroup there was observed a symptom decrease in all the rating scales even in these symptom poor patients. This improvement in psychopathology with optimal results after half a year seems to be a combined result of the efficient neuroleptics tested and careful monitoring of the drug.

Three years' maintenance neuroleptic treatment in schizophrenia--before and beyond

A group of patients with schizophrenia, initially 67 patients, was studied over a period of 3 years. After three years 36 out of 67 patients were still on the same depot neuroleptic. The main aim was to describe and compare maintenance neuroleptic therapy using two depot neuroleptics, fluphenazine decanoate and pipotiazine palmitate, given monthly. Before the outpatient care the patients had participated in the department's comprehensive hospital treatment including depot neuroleptic medication. After a 1-year clinical trial with frequent assessments of the patients, significant symptom reductions were found on all rating scales. During the last 2 years of the study only drug therapy was given. Improvement concerning social function in the community and work level as well as the low-rated psychopathology noted at the start of study also persisted at the 3-year follow-up. The side effects were low in frequency and quality. These results show the clinical value of long-term maintenance treatment with depot neuroleptics. The results also confirm that the favourable effects of the hospital treatment demonstrated before the start of the clinical trial could be maintained. The possibilities of further improving aftercare and outpatient treatment beyond medication alone are discussed.