Switching antipsychotics: an updated review with a focus on quetiapine

The dilemma of polypharmacy in psychosis: is it worth combining partial and full dopamine modulation?

Antipsychotic polypharmacy in psychotic disorders is widespread despite international guidelines favoring monotherapy. Previous evidence indicates the utility of low-dose partial dopamine agonist (PDAs) add-ons to mitigate antipsychotic-induced metabolic adverse effects or hyperprolactinemia. However, clinicians are often concerned about using PDAs combined with high-potency, full dopaminergic antagonists (FDAs) due to the risk of psychosis relapse. We, therefore, conducted a literature review to find studies investigating the effects of combined treatment with PDAs (i.e. aripiprazole, cariprazine and brexpiprazole) and FDAs having a strong D 2 receptor binding affinity. Twenty studies examining the combination aripiprazole - high-potency FDAs were included, while no study was available on combinations with cariprazine or brexpiprazole. Studies reporting clinical improvement suggested that this may require a relatively long time (~11 weeks), while studies that found symptom worsening observed this happening in a shorter timeframe (~3 weeks). Patients with longer illness duration who received add-on aripiprazole on ongoing FDA monotherapy may be at greater risk for symptomatologic worsening. Especially in these cases, close clinical monitoring is therefore recommended during the first few weeks of combined treatment. These indications may be beneficial to psychiatrists who consider using this treatment strategy. Well-powered randomized clinical trials are needed to derive more solid clinical recommendations.

Addressing Nonadherence in the Schizophrenic Population

Nonadherence within the schizophrenic population is a challenge for both the patient and the clinician. This problem not only causes an increase in health care use and cost but also places the patient at risk of relapse and dissatisfaction with medical care. Nonadherence is influenced by several factors including disease, treatment, and psychological and social factors. All of these factors must be addressed if the clinician hopes to reduce nonadherence within this patient population. This article will attempt to identify factors that contribute to nonadherence and review strategies that can be implemented to address each of these factors.

Reasons and clinical outcomes of antipsychotic treatment switch in outpatients with schizophrenia in real-life clinical settings: the ETOS observational study

BACKGROUND

Patients under antipsychotic treatment for schizophrenia commonly exhibit poor adherence to treatment, high rates of treatment discontinuation, and frequent treatment changes. The ETOS study aimed to identify the reasons leading physicians to decide to switch antipsychotic treatment in outpatients with schizophrenia and to evaluate the outcome of this switch.

METHODS

ETOS was an observational 18-week (four visits) study in outpatients 18 to 65 years old, diagnosed with schizophrenia according to Diagnostic and Statistical Manual of Mental Disorders - 4th edition criteria at least 6 months prior to enrolment, who were initiated on a new antipsychotic monotherapy treatment within the 2 weeks prior to enrollment. A total of 574 patients were recruited by 87 hospital- and office-based physicians. Ethical approval was obtained prior to study initiation (NCT00999895).

RESULTS

The final analysis included 568 patients, 39.0 ± 11.2 years old with mean disease duration of 11.7 years. The male-to-female ratio was 53:47. The main reason for switching antipsychotic treatment was lack of tolerability (n = 369, 65.0%), followed by lack of efficacy (n = 249, 43.8%). Following treatment switch, 87.9% of patients (n = 499) showed meaningful clinical benefit by achieving a Clinical Global Impression-Clinical Benefit score of ≤4 at the final visit. By the end of the study, total Positive and Negative Syndrome Scale, Clinical Global Impression-Improvement, Clinical Global Impression-Severity, and Simpson-Angus Scale scores demonstrated significant mean decreases of 31.69, 0.70, 1.14, and 11.30, respectively (all p < 0.0001). Treatment adherence remarkably improved.

CONCLUSION

In the ETOS study, switch of antipsychotic monotherapy for reasons relating to lack of efficacy and/or tolerability was associated with significantly improved clinical benefit and significant increase of patients' adherence to treatment.

A retrospective study of antipsychotic drug switching in a pediatric population

BACKGROUND

Antipsychotic drugs can be used to help treat a wide variety of psychiatric disorders. However, specific antipsychotic drugs for any particular patient may need to be changed for a number of different reasons, including a lack of therapeutic efficacy and / or intolerance to medication side-effects. Drug switching may occur through a limited number of established patterns. The nature of these changes is not well characterized in youth, despite their frequent occurrence.

METHODS

A retrospective analysis of antipsychotic drug switches was conducted on patients who had been admitted as inpatients to a tertiary care child and adolescent psychiatric institute. PharmaNet (a large, central administrative database) records of all medications prescribed in the 52 weeks prior to admission, and then between admission and discharge, were analyzed for switching patterns. Additional data regarding diagnoses were obtained from medical chart review.

RESULTS

Patients represented a diagnostically heterogeneous population, and almost all antipsychotic drugs were administered off-label. In the one year prior to and during admission to the hospital, a total of 31 out of 139 patients switched antipsychotic drugs. The frequency of switching increased closer to the time of admission, and the proportional rate of switching was even higher during hospital stay. The most common switch was from risperidone to quetiapine. Our analysis identified three main patterns of drug switching, all occurring with similar frequency: titrated drug switches, abrupt drug switches and concurrent drug administration.

CONCLUSIONS

The present study indicates that antipsychotic drug switching in youth may be relatively common, particularly in the year prior to hospitalization. No specific manner of drug switching predominates. This study also demonstrates the feasibility of using large administrative databases to characterise switching patterns in youth.

Switching to ziprasidone in the clinical practice setting: an open-label study

OBJECTIVE

This observational study evaluates the long-term outcome of switching to ziprasidone in patients with schizophrenia in the clinical practice setting.

METHODS

Patients (208) with schizophrenia who had been switched to ziprasidone monotherapy due to partial response or tolerability problems were followed for 1 year. Efficacy was assessed at baseline and months 1, 3, and 12 with Brief Psychiatric Rating Scale (BPRS), Clinical Global Impression-severity (CGI-S), and CGI-improvement. Quality of life, functionality, and safety measures, including metabolic parameters, were also assessed; 195 subjects comprised the per protocol analysis population.

RESULTS

A reduction > or = 30% in BPRS total score was observed in 42.5% of the subjects. Mean scores of the BPRS (global and positive and negative clusters), CGI-S and CGI-I significantly decreased at endpoint (p < 0.001). Ziprasidone treatment was also associated with statistically significant improvements in the GAF, WHO-DAS-II, and SF-12. After 1-year follow-up, a mean weight decrease of -1.6 kg (p < 0.05) was observed. Mean levels of LDL cholesterol and triglycerides also decreased (p < 0.01) while HDL cholesterol levels increased (p < 0.05) at endpoint. No significant changes in mean glucose levels at study end were detected.

CONCLUSION

These findings suggest that switching to ziprasidone is effective and well tolerated in patients with schizophrenia requiring a change in antipsychotic medication.

Effectiveness studies: advantages and disadvantages

In recent years, so-called “effectiveness studies,” also called “real-world studies” or “pragmatic trials, ” have gained increasing importance in the context of evidencebased medicine. These studies follow less restrictive methodological standards than phase III studies in terms of patient selection, comedication, and other design issues, and their results should therefore be better generalizable than those of phase III trials. Effectiveness studies, like other types of phase IV studies, can therefore contribute to knowledge about medications and supply relevant information in addition to that gained from phase III trials. However, the less restrictive design and inherent methodological problems of phase IV studies have to be carefully considered. For example, the greater variance caused by the different kinds of confounders as well as problematic design issues, such as insensitive primary outcome criteria, unblinded treatment conditions, inclusion of chronic refractory patients, etc, can lead to wrong conclusions. Due to these methodological problems, effectiveness studies are on a principally lower level of evidence, adding only a complementary view to the results of phase III trials without falsifying their results.

Predictors of switching antipsychotic medications in the treatment of schizophrenia

BACKGROUND

To identify patient characteristics and early changes in patients' clinical status that best predict subsequent switching of antipsychotic agents in the long-term treatment of schizophrenia.

METHODS

This post-hoc analysis used data from a one-year randomized, open-label, multisite study of antipsychotics in the treatment of schizophrenia. The study protocol permitted switching of antipsychotics when clinically warranted after the first eight weeks. Baseline patient characteristics were assessed using standard psychiatric measures and reviews of medical records. The prediction model included baseline sociodemographics, comorbid psychiatric and non-psychiatric conditions, body weight, clinical and functional variables, as well as change scores on standard efficacy and tolerability measures during the first two weeks of treatment. Cox proportional hazards modeling was used to identify the best predictors of switching from the initially assigned antipsychotic medication.

RESULTS

About one-third of patients (29.5%, 191/648) switched antipsychotics before the end of the one-year study. There were six variables identified as the best predictors of switching: lack of antipsychotic use in the prior year, pre-existing depression, female gender, lack of substance use disorder, worsening of akathisia (as measured by the Barnes Akathisia Scale), and worsening of symptoms of depression/anxiety (subscale score on the Positive and Negative Syndrome Scale) during the first two weeks of antipsychotic therapy.

CONCLUSIONS

Switching antipsychotics appears to be prevalent in the naturalistic treatment of schizophrenia and can be predicted by a small and distinct set of variables. Interestingly, worsening of anxiety and depressive symptoms and of akathisia following two weeks of treatment were among the more robust predictors of subsequent switching of antipsychotics.

Combined antipsychotic use in a community rehabilitation psychiatric service

OBJECTIVES

Despite the clinical guidelines regarding the use of combined antipsychotics and the limited evidence for its benefits, use remains high in psychiatric practice. The aim of this study was to examine prescribing practices and investigate reasons for initiating and continuing combined antipsychotics in stable psychiatric illnesses.

METHOD

A cross-sectional case record survey of antipsychotic prescribing practices in a community psychiatric rehabilitation service. A total sample (n = 75) of patients with chronic and enduring psychiatric illnesses was studied. The age, gender, diagnosis and prescribed antipsychotics were examined. The proportional prevalence and documented reasons for combined antipsychotic prescribing were analysed.

RESULTS

Seventy-three of the 75 patients were prescribed antipsychotic mediations. Of these, 44 (60%) received a combination of two or more antipsychotics. The most common reason for combined prescribing was a switch of antipsychotic (n = 18; 41%). No reason was documented in 19 cases (43%).

CONCLUSIONS

In this study, slow cross-tapering or incomplete switch process of antipsychotics contributed to the prolonged period of combined antipsychotics treatment. Adequate documentation regarding indication and review of medications cannot be overemphasized.

Antipsychotic adherence, switching, and health care service utilization among Medicaid recipients with schizophrenia

OBJECTIVE

To evaluate health care resource utilization in patients with schizophrenia who continued newly prescribed antipsychotic medications, compared with those switching to different treatments.

METHODS

Adults with schizophrenia in the California Medicaid (MediCal) database who initiated treatment with index medications in 1998-2001, were classified as having: 1) abandoned antipsychotic medications; 2) switched to another medication; or 3) continued with the index antipsychotic, for up to 6 months after the index date.

RESULTS

Of 2300 patients meeting eligibility criteria, 1382 (60.1%) continued index medications, 480 (20.9%) switched, and 438 (19.0%) abandoned antipsychotic treatment. Utilization in several resource categories occurred significantly more frequently among patients whose regimens were switched (vs those continuing index medications). These included using psychiatric (24.2% vs 14.5%; P < 0.001) or nonpsychiatric (31.5% vs 24.3%; P < 0.05) emergency services; being admitted to a hospital (10.6% vs 7.4%; P < 0.05); making nonpsychiatric outpatient hospital visits (43.3% vs 36.4%; P < 0.05) or nonpsychiatric physician visits (62.7% vs 56.4%; P < 0.05); and using other outpatient psychiatric (53.3% vs 40.7%; P < 0.001) or nonpsychiatric (82.7% vs 74.6%; P < 0.001) services.

CONCLUSIONS

Switching antipsychotic medications is associated with significantly increased health care resource utilization (vs continuing treatment).

Clinical and economic ramifications of switching antipsychotics in the treatment of schizophrenia

BACKGROUND

Switching between antipsychotic medications is common in the treatment of schizophrenia. However, data on clinical and economic outcomes from antipsychotic switching, in particular acute care service use, is fairly limited. The goal of this research was to assess the clinical and economic ramifications of switching antipsychotics during outpatient management of schizophrenia.

METHODS

Data from a 1-year randomized, open-label cost-effectiveness study involving typical and atypical antipsychotics were assessed. The study protocol permitted switching of antipsychotics when clinically warranted. The risk of crisis-related events, use of acute-care services, and the time to the initial use of such services were determined in outpatients who switched antipsychotics compared with those who continued with their initial medications. Health care resource utilization data were abstracted from medical records and other sources (e.g., patient self-report), and direct costs were estimated using previously published benchmarks.

RESULTS

Almost one-third of patients (29.3%) underwent a switch from their initial antipsychotic agent, with an average duration of 100 days before such treatment alterations. Compared with their counterparts who remained on their initial therapies, individuals who switched antipsychotics experienced a significantly higher risk of acute-care services, including hospitalization (p = .013) and crisis services (p = .011). Patients undergoing medication switches also used acute-care services significantly sooner (p = .004) and accrued an additional $3,000 (a 25% increase) in annual total health care costs per patient, most of which was due to acute-care expenditures.

CONCLUSION

Switching antipsychotic medications was found to be associated with considerably poorer clinical and economic outcomes, as reflected by, more frequent and more rapid use of acute-care services compared with persons remaining on their initial treatments.

TRIAL REGISTRATION

Trial ID 2325 in LillyTrials.com (also accessible via ClinicalStudyResults.org).

The risks and benefits of switching antipsychotics: a case study approach

PURPOSE

Progression of metabolic illness in a patient with schizophrenia who was stabilized on an atypical antipsychotic is described using a case study framework. Risks and benefits of staying on current treatment versus switching to another agent and switching strategies are described.

CONCLUSIONS

Switching an antipsychotic with more favorable side effects may improve metabolic parameters if other weight loss strategies have failed. Switching or stopping medications too quickly may exacerbate psychiatric symptoms. There is little evidence to support which is the best switching strategy.

PRACTICE IMPLICATIONS

The psychiatric mental health nurse practitioner carries a significant responsibility of discussing risks and benefits of switching and closely monitoring the patient during a switch of medications. Ensuring that the patient decides and agrees upon the treatment plan will improve the overall outcome.

Does switching to a new antipsychotic improve outcomes? Data from the CATIE Trial

PURPOSE

Previous analysis of data from CATIE showed that patients randomly assigned to switch to a new medication were more likely to discontinue study drug than those who stayed on the medication they had been taking prior to randomization. This study addresses additional outcomes measures evaluating symptoms, neurocognition, quality of life, neurological side effects, weight, and health costs. First, considering patients randomized to olanzapine or risperidone, outcomes among patients who had been on the drug to which they were randomized prior to CATIE (N=129 "stayers") were compared to outcomes of those who switched to either of these two drugs (N=269 "switchers"). A second set of analyses considered patients on baseline monotherapy with olanzapine (N=297); risperidone (N=252) or quetiapine (n=87) and compared those randomly assigned to stay on each of these medications with those assigned to switch to any of the other five phase 1 medications in CATIE. In mixed models of each outcome the independent variable of primary interest represented stay vs. switch, with multivariate adjustment for potential confounding factors.

RESULTS

With one exception, there were no significant differences between stayers and switchers on any outcome measure in either set of analyses. The exception was that, in the second set of analyses, patients who stayed on olanzapine showed greater weight gain than those who switched from olanzapine to other drugs.

CONCLUSION

Switching to a new medication yielded no advantage over staying on the previous medication. Staying on olanzapine was associated with greater weight gain.

Time course of the changes in antipsychotic-induced hyperprolactinemia following the switch to aripiprazole

Hyperprolactinemia is an important but neglected adverse effect of antipsychotic medication. All first generation antipsychotics and the second generation antipsychotics amisulpride and risperidone have been shown to cause marked elevation in serum prolactin levels, whereas most other second generation antipsychotics and aripiprazole appear to have little or no effect on serum prolactin levels. This study was aimed to assess the time course of changes in antipsychotic-induced hyperprolactinemia during the process of antipsychotic switching to aripiprazole. Twenty-three female schizophrenic subjects with risperidone- or sulpiride-induced symptomatic hyperprolactinemia were recruited into the study and 20 of them completed the trial. We added aripiprazole to the therapeutic dose first, then overlapped the preexisting antipsychotic treatment and aripiprazole, and finally tapered the preexisting antipsychotic treatment. Clinical status was assessed by using the Positive and Negative Syndrome Scale (PANSS) and the Clinical Global Impression Severity Scale (CGI-S). Assessment scales and serum prolactin levels were measured at baseline, during the combination treatment period, and four weeks after having completed discontinuation of the preexisting antipsychotic treatment. Switching antipsychotic drugs to aripiprazole was effective in reducing serum prolactin levels and restoring menstruation in schizophrenic patients who received prolactin-raising antipsychotics. Mean serum prolactin levels at baseline, during combination period, and after the switch were 97.0+/-69.0 ng/ml, 27.2+/-10.6 ng/ml (p<0.001, vs. baseline), and 12.2+/-5.3 ng/ml (p<0.001, vs. baseline), respectively. None of the study subjects experienced any serious adverse effects during the switching process. No significant changes were noted in the PANSS and CGI-S scores during the switching process. The prolactin-normalizing effects of aripiprazole are likely caused by the unique characteristics of the dopamine partial agonist with its high affinity for dopamine D2 receptors.

Do effectiveness ("real world") studies on antipsychotics tell us the real truth?

In recent years, so-called "effectiveness studies" have gained increasing importance in the context of evidence-based medicine. These studies supposedly follow less restrictive methodological standards than phase III studies in terms of patient selection, co-medication and other design issues, and their results should therefore be better generalisable than those of phase III studies. Effectiveness studies, like other types of phase IV studies, can therefore contribute to the knowledge about antipsychotics or other psychopharmaceuticals and supply relevant information in addition to that gained from phase III trials. However, the less restrictive design and inherent methodological problems of phase IV studies mean that their results cannot falsify the results of phase III studies. The greater complexity of phase IV studies, for example the greater variance caused by the different kinds of confounders, means that their results have to be interpreted with great care and especially with a high degree of awareness of problematic design issues, such as insensitive primary outcome criteria, biased randomisation, unblinded treatment conditions, inclusion of chronic refractory patients, etc. Some recently published effectiveness studies on antipsychotic treatment of schizophrenia will be discussed under these methodological aspects. The main conclusions of these trials will be questioned on the basis of their severe methodological pitfalls.

Clinical consequences of switching antipsychotic drugs in outpatients with schizophrenia: 36-month results from the European Schizophrenia Outpatient Health Outcomes study

Data from the European Schizophrenia Outpatient Health Outcomes, a 3-year, prospective, observational study of health outcomes associated with antipsychotic treatment in outpatients with schizophrenia (n=10 972 enrolled), were used to assess the impact of the first switching of antipsychotic medications, with a focus on olanzapine, on clinical status and tolerability outcomes. Patients were defined as those who (1) started olanzapine at baseline and changed treatment; (2) started another antipsychotic at baseline and changed to olanzapine; and (3) changed from and to a non-olanzapine antipsychotic. A logistic regression model was used to analyse the impact of switching on treatment response and tolerability. Patients switching from olanzapine were less likely to respond than patients switching to olanzapine (OR: 0.59; 95% CI: 0.40, 0.87). Patients who switched from olanzapine and those who switched neither from nor to olanzapine were more likely to have extrapyramidal symptoms (OR: 3.79; 95% CI: 2.02, 7.10 and OR: 2.18; 95% CI: 1.23, 3.86, respectively) and loss of libido (OR: 1.89; 95% CI: 1.21, 2.96 and OR: 1.56; 95% CI: 1.04, 2.35, respectively) compared with patients who switched from another antipsychotic to olanzapine. Patients who switched to olanzapine experienced a higher weight gain. In conclusion, among patients switching antipsychotic medication, those who switched to olanzapine had better long-term outcomes.

Management of physical health in schizophrenia: a stepping stone to treatment success

While patients with schizophrenia are known to have an increased risk of physical health co-morbidity including coronary heart disease, diabetes, hypertension, stroke and emphysema, their physical wellbeing often goes unnoticed by health care professionals. In many cases the patient's only contact with the health service is through the mental health team. However, many psychiatrists consider their primary function to be the provision of clinical care in terms of symptom control and are reluctant to switch medication despite the presence of physical health issues. Nevertheless outcomes in schizophrenia may be improved by expanding the remit of the clinician to include assessments of both physical and mental health. Simple measurements such as waist circumference, weight, height, blood pressure and blood sampling would provide the psychiatrist with useful information that could be used to optimize treatment and improve overall quality of life for patients with schizophrenia.

Switching from risperidone to olanzapine in a one-year, randomized, open-label effectiveness study of schizophrenia

OBJECTIVE

Switching medications is common in the treatment of schizophrenia. This study examines the effectiveness of olanzapine therapy following a clinically warranted switch from risperidone during treatment of patients with schizophrenia.

RESEARCH DESIGN AND METHODS

This post-hoc analysis used data from the risperidone arm of a randomized, open-label, 1-year study of patients with schizophrenia. Study protocol permitted antipsychotic switching when clinically warranted, and outcomes were assessed with standard psychiatric measures. Statistical analyses assessed changes from pre- to post-medication switch and endpoint comparisons between patients switched from risperidone to olanzapine and patients continued on risperidone.

RESULTS

Most patients who switched from risperidone switched to olanzapine (43/60; 71.7%). Average duration of risperidone treatment prior to switching was 86 days (mean modal dose 4.0 mg/day). Most switchers (86%) completed the 1-year study on olanzapine (average duration 241 days; mean modal dose 12.0 mg/day). Following switch to olanzapine, patients experienced significant improvements on clinical (Brief Psychiatric Rating Scale) and social (Quality of Life Inventory) parameters, with similar proportions of patients achieving remission status at endpoint compared with risperidone patients not requiring medication switch (41.9 vs. 35.5%). Mean weight gain for switchers was approximately 0.4 kg while on risperidone (average treatment duration < 3 months) and 2.4 kg on olanzapine (average treatment duration approximately 8 months).

CONCLUSIONS

This study suggests that olanzapine is an effective treatment option for schizophrenia patients requiring a switch from risperidone. Given the small sample size and lack of a comparative group, one cannot determine if other medication options would have been as effective as the switch to olanzapine. Thus, further research is warranted.

Reduction in neuroleptic-induced movement disorders after a switch to quetiapine in patients with schizophrenia

BACKGROUND

Persistent neuroleptic-induced movement disorders limit effective pharmacological management of psychotic disorders. Although antipsychotic switching is a common strategy for managing extrapyramidal side effects (EPSs), there is insufficient empirical support to guide the clinician. We designed the present study to examine whether patients with preexisting EPS switched to quetiapine would show greater reduction in EPS compared with control patients.

METHODS

Twenty-two patients with schizophrenia meeting clinical criteria for tardive dyskinesia or coexisting parkinsonism were randomized either to switch from their current antipsychotic to quetiapine (n = 13) or to remain on their current treatment (n = 9). A battery of standard clinical assessments for EPS along with electromechanical instrumental measures was administered before randomization and again 1 and 3 months postrandomization.

RESULTS

We observed significant reduction in parkinsonism (P < 0.001) and akathisia (P = 0.02) based on clinical assessments and dyskinesia (P < 0.05) based on instrumental assessment for the quetiapine group. Subjects remaining on current treatment exhibited an increase in rigidity (P < 0.05) based on instrumental measures.

CONCLUSIONS

These findings support the switching to quetiapine in the management of preexisting neuroleptic-induced extrapyramidal side effects.

Switching from other antipsychotics to once-daily extended release quetiapine fumarate in patients with schizophrenia

OBJECTIVE

To evaluate the clinical benefit, efficacy and tolerability of switching patients experiencing suboptimal efficacy or tolerability with their current antipsychotic to once-daily extended release quetiapine fumarate (quetiapine XR).

RESEARCH DESIGN AND METHODS

12-week, multicenter, open-label study in adult, in- or outpatients with schizophrenia. Quetiapine XR (mg/day) was initiated during a 4-day cross-titration phase (day 1: 300; day 2: 600; days 4-84: 400-800 [flexible-dosing]). The primary endpoint was the percentage of patients achieving clinical benefit (improvement on the Clinical Global Impression-Clinical Benefit [CGI-CB] scale). Secondary endpoints included CGI-Improvement (CGI-I) and Positive and Negative Syndrome Scale (PANSS) total scores. Tolerability was assessed by adverse events (AEs), Simpson-Angus Scale (SAS) and Barnes Akathisia Rating Scale (BARS) scores. Changes in rating scale scores were analyzed using analysis of covariance and are presented as least squares mean (LSM) changes using the baseline level as a covariate.

RESULTS

Of 477 patients switched to quetiapine XR, 77.6% completed treatment. Following switching, 295 of 470 patients adequate for evaluation (62.8%) achieved a clinical benefit (95% confidence interval [CI] 58.4, 67.1; p < 0.0001). Significant improvements in LSM (95% CI) CGI-I of 2.88 (2.67, 3.08) and the LSM change in PANSS total scores of -12.3 (-14.95, -9.58) were observed (both p < 0.001). Common AEs included somnolence (17.8%), sedation (15.1%), dizziness and dry mouth (14.0% each). The incidence of extrapyramidal symptoms (EPS) was 8.0%. Mean improvements from baseline in SAS and BARS scores were -2.1 and -0.4, respectively (both p < 0.001).

CONCLUSIONS

Switching to quetiapine XR was associated with clinical benefit and good efficacy and tolerability.

Guidelines for clinical treatment of early course schizophrenia

Several practice guidelines have been developed for the management of schizophrenia based on the current evidence base, but only a few have focused on the early course of this illness. In this article, we review the current literature on the approaches to management of early schizophrenia (ie, the prodromal, psychotic, and recovery phases of this illness). The efficacy of psychosocial and antipsychotic agents in the prodromal phase is an area of active research. Atypical antipsychotics are the mainstay of treatment for stabilization of the acute psychotic phase. Effective approaches in the recovery phase include combining medications with individual and family interventions, supported employment, assertive community treatment, cognitive remediation, and social skills training. Although evidence-based interventions have generated new optimism among those with the illness, more efforts are needed to increase access to care in community settings.