Double-blind comparison of half-dose and standard-dose flupenthixol decanoate in the maintenance treatment of stabilised out-patients with schizophrenia

Risk Factors for Psychotic Relapse After Dose Reduction or Discontinuation of Antipsychotics in Patients With Chronic Schizophrenia. A Meta-Analysis of Randomized Controlled Trials

BACKGROUND AND HYPOTHESIS

Although maintenance treatment with antipsychotics protects against psychotic relapse, high doses may hamper recovery. Therefore, dose reduction or discontinuation may be considered in patients with chronic schizophrenia. Here, we identified risk factors for psychotic relapse when doses are reduced.

STUDY DESIGN

We systematically searched MEDLINE, EMBASE, and PsycINFO from January 1950 through January 2021 and reviewed randomized controlled trials (RCTs) that reported relapse rates after antipsychotic dose reduction or discontinuation in patients with chronic schizophrenia. We calculated relative risks (RRs) with 95% confidence intervals (CIs) per person-year and sought to identify potential risk factors for relapse. The study is registered with PROSPERO (CRD42017058296).

STUDY RESULTS

Forty-seven RCTs (54 patient cohorts, 1746 person-years) were included. The RR for psychotic relapse with dose reduction/discontinuation versus maintenance treatment was 2.3 per person-year (95% CI: 1.9 to 2.8). The RR was higher with antipsychotic discontinuation, dose reduction to less than 3-5 mg haloperidol equivalent (HE), or relatively rapid dose reduction (<10 weeks). The RR was lower with long-acting injectable agents versus oral antipsychotic dose reduction. Other factors that increased the risk of psychotic relapse were younger age and short follow-up time.

CONCLUSIONS

Clinicians should take several risk factors for psychotic relapse into account when considering dose reduction in patients with chronic schizophrenia. Studies of a relatively fast reduction in antipsychotic dose support a minimum dose of 3-5 mg HE. However, if the dose is tapered more gradually, relapses related to medication withdrawal might be avoided, possibly enabling lower-end doses to be achieved.

Antipsychotic dose reduction compared to dose continuation for people with schizophrenia

BACKGROUND

Antipsychotic drugs are the mainstay treatment for schizophrenia, yet they are associated with diverse and potentially dose-related side effects which can reduce quality of life. For this reason, the lowest possible doses of antipsychotics are generally recommended, but higher doses are often used in clinical practice. It is still unclear if and how antipsychotic doses could be reduced safely in order to minimise the adverse-effect burden without increasing the risk of relapse.

OBJECTIVES

To assess the efficacy and safety of reducing antipsychotic dose compared to continuing the current dose for people with schizophrenia.

SEARCH METHODS

We conducted a systematic search on 10 February 2021 at the Cochrane Schizophrenia Group's Study-Based Register of Trials, which is based on CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, PubMed, ClinicalTrials.gov, ISRCTN, and WHO ICTRP. We also inspected the reference lists of included studies and previous reviews.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing any dose reduction against continuation in people with schizophrenia or related disorders who were stabilised on their current antipsychotic treatment.  DATA COLLECTION AND ANALYSIS: At least two review authors independently screened relevant records for inclusion, extracted data from eligible studies, and assessed the risk of bias using RoB 2. We contacted study authors for missing data and additional information. Our primary outcomes were clinically important change in quality of life,  rehospitalisations and dropouts due to adverse effects; key secondary outcomes were clinically important change in functioning, relapse, dropouts for any reason, and at least one adverse effect. We also examined scales measuring symptoms, quality of life, and functioning as well as a comprehensive list of specific adverse effects. We pooled outcomes at the endpoint preferably closest to one year. We evaluated the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included 25 RCTs, of which 22 studies provided data with 2635 participants (average age 38.4 years old). The median study sample size was 60 participants (ranging from 18 to 466 participants) and length was 37 weeks (ranging from 12 weeks to 2 years). There were variations in the dose reduction strategies in terms of speed of reduction (i.e. gradual in about half of the studies (within 2 to 16 weeks) and abrupt in the other half), and in terms of degree of reduction (i.e. median planned reduction of 66% of the dose up to complete withdrawal in three studies). We assessed risk of bias across outcomes predominantly as some concerns or high risk.  No study reported data on the number of participants with a clinically important change in quality of life or functioning, and only eight studies reported continuous data on scales measuring quality of life or functioning. There was no difference between dose reduction and continuation on scales measuring quality of life (standardised mean difference (SMD) -0.01, 95% confidence interval (CI) -0.17 to 0.15, 6 RCTs, n = 719, I2 = 0%, moderate certainty evidence) and scales measuring functioning (SMD 0.03, 95% CI -0.10 to 0.17, 6 RCTs, n = 966, I2 = 0%, high certainty evidence). Dose reduction in comparison to continuation may increase the risk of rehospitalisation based on data from eight studies with estimable effect sizes; however, the 95% CI does not exclude the possibility of no difference (risk ratio (RR) 1.53, 95% CI 0.84 to 2.81, 8 RCTs, n = 1413, I2 = 59% (moderate heterogeneity), very low certainty evidence). Similarly, dose reduction increased the risk of relapse based on data from 20 studies (RR 2.16, 95% CI 1.52 to 3.06, 20 RCTs, n = 2481, I2 = 70% (substantial heterogeneity), low certainty evidence).   More participants in the dose reduction group in comparison to the continuation group left the study early due to adverse effects (RR 2.20, 95% CI 1.39 to 3.49, 6 RCTs with estimable effect sizes, n = 1079, I2 = 0%, moderate certainty evidence) and for any reason (RR 1.38, 95% CI 1.05 to 1.81, 12 RCTs, n = 1551, I2 = 48% (moderate heterogeneity), moderate certainty evidence). Lastly, there was no difference between the dose reduction and continuation groups in the number of participants with at least one adverse effect based on data from four studies with estimable effect sizes (RR 1.03, 95% CI 0.94 to 1.12, 5 RCTs, n = 998 (4 RCTs, n = 980 with estimable effect sizes), I2 = 0%, moderate certainty evidence).  AUTHORS' CONCLUSIONS: This review synthesised the latest evidence on the reduction of antipsychotic doses for stable individuals with schizophrenia. There was no difference between dose reduction and continuation groups in quality of life, functioning, and number of participants with at least one adverse effect. However, there was a higher risk for relapse and dropouts, and potentially for rehospitalisations, with dose reduction. Of note, the majority of the trials focused on relapse prevention rather potential beneficial outcomes on quality of life, functioning, and adverse effects, and in some studies there was rapid and substantial reduction of doses. Further well-designed RCTs are therefore needed to provide more definitive answers.

Factors associated with successful antipsychotic dose reduction in schizophrenia: a systematic review of prospective clinical trials and meta-analysis of randomized controlled trials

This systematic review and meta-analysis examined predictors of successful antipsychotic dose reduction in schizophrenia. Prospective clinical trials and randomized controlled trials (RCTs) investigating antipsychotic dose reduction in schizophrenia were selected for systematic review and meta-analysis, respectively. In total, 37 trials were identified. Only 8 studies focused on second-generation antipsychotics (SGAs); no studies investigated long-acting injectable SGAs. Of 24 studies evaluating relapse or symptom changes, 20 (83.3%) met the criteria for successful dose reduction. Factors associated with successful dose reduction were study duration < 1 year, age > 40 years, duration of illness > 10 years, and post-reduction chlorpromazine equivalent (CPZE) dose > 200 mg/day. Clinical deterioration was mostly re-stabilized by increasing the dose to the baseline level (N = 7/8, 87.5%). A meta-analysis of 18 RCTs revealed that relapse rate was significantly higher in the reduction group than the maintenance group (risk ratio [RR] = 1.96; 95% confidence interval [CI], 1.23-3.12), whereas neurocognition was significantly improved (standardized mean difference = 0.69; 95% CI, 0.25-1.12). A subgroup analysis indicated that only a post-reduction CPZE dose ≤ 200 mg/day was associated with an increased risk of relapse (RR = 2.79; 95% CI, 1.29-6.03). Thus, when reducing antipsychotic doses, clinicians should consider the long-term risk of relapse in younger patients with a relatively short illness duration and keep the final doses higher than CPZE 200 mg/day. Further studies, particularly those involving SGAs, are warranted to determine the optimal strategies for successful antipsychotic dose reduction in schizophrenia.

Risk Factors for Psychotic Relapse After Dose Reduction or Discontinuation of Antipsychotics in Patients With Chronic Schizophrenia: A Systematic Review and Meta-analysis

High doses of antipsychotics in patients with chronic schizophrenia might lead to more severe side effects and possibly hamper recovery, but dose reduction carries the risk of psychotic relapse. It would be helpful to establish risk factors for relapse during dose reduction. We systematically searched MEDLINE, EMBASE, and PsycINFO from January 1950 through June 2019 and reviewed studies that reported on relapse rates (event rates [ERs]) after dose reduction or discontinuation of antipsychotics in cohorts of patients with chronic schizophrenia. We calculated ERs (with 95% CIs) per person-year and sought to identify potential risk factors, such as patient characteristics, dose reduction/discontinuation characteristics, and study characteristics. Of 165 publications, 40 describing dose reduction or discontinuation in 46 cohorts (1677 patients) were included. The pooled ER for psychotic relapse was 0.55 (95% CI 0.46–0.65) per person-year. The ER was significantly higher in inpatients, patients with a shorter duration of illness, patients in whom antipsychotics were discontinued or in whom the dose was reduced to less than 5 mg haloperidol equivalent, studies with a short follow-up or published before 1990, and studies in which relapse was based on clinical judgment (ie, rating scales were not used). Clinicians should consider several robust risk factors for psychotic relapse in case of dose reduction in chronic schizophrenia.

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

These updated guidelines from the British Association for Psychopharmacology replace the original version published in 2011. They address the scope and targets of pharmacological treatment for schizophrenia. A consensus meeting was held in 2017, involving experts in schizophrenia and its treatment. They were asked to review key areas and consider the strength of the evidence on the risk-benefit balance of pharmacological interventions and the clinical implications, with an emphasis on meta-analyses, systematic reviews and randomised controlled trials where available, plus updates on current clinical practice. The guidelines 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. It is hoped that the practice recommendations presented will support clinical decision making for practitioners, serve as a source of information for patients and carers, and inform quality improvement.

Estimating the optimal dose of flupentixol decanoate in the maintenance treatment of schizophrenia-a systematic review of the literature

RATIONALE

The licensed dose range for the long-acting injectable antipsychotic flupentixol decanoate (Depixol®) in the treatment of schizophrenia is very broad. This provides little useful direction to prescribers and may ultimately result in patients receiving unnecessarily high doses.

OBJECTIVES

We aimed to estimate the effect of dose of flupentixol decanoate on relapse rates in schizophrenia and on tolerability by expanding on an earlier review and including non-RCT and German-language studies, as well as using pharmacokinetic and pharmacodynamic data to offer guidance on dosing.

METHODS

A literature review using EMBASE, Medline, PsycINFO and PubMed was conducted. Treatment success rates at 6 months were extracted or extrapolated from the studies and plotted against dose to estimate a dose-response curve.

RESULTS

Data from 16 studies (n = 514) allowed estimation of a dose-response curve which rises steeply between the chosen placebo anchor (25% success rate) and 10 mg every 2 weeks before reaching a maximum between 20 and 40 mg every 2 weeks (80-95% success rates). Extrapyramidal side effects (EPSEs) were frequently seen (12-71% of participants) in that dose range. Two -weekly injections seem to provide the highest trough plasma concentration per dose administered and the lowest peak-to-trough concentration ratio. Plasma concentration varied up to 5-fold among individuals receiving the same dose.

CONCLUSIONS

The optimal dose of flupentixol decanoate is likely to be between 20 mg and 40 mg every 2 weeks although higher doses may be required in some individuals owing to variation in drug handling. Doses of flupentixol should be individually established in the range of 10 to 40 mg every 2 weeks according to response and tolerability.

Dose reduction of high-dose first-generation antipsychotics or switch to ziprasidone in long-stay patients with schizophrenia: A 1-year double-blind randomized clinical trial

Long-stay patients with severe schizophrenia are frequently treated with high doses of first-generation antipsychotics (FGA). Dose reduction or switching to ziprasidone may reduce the severity of negative symptoms and side effects. We investigated in a randomized double-blind trial whether a dose-reduction strategy to achieve an adequate dose of a FGA (5 mg/day haloperidol equivalents, n = 24) or switching to ziprasidone (160 mg/day, n = 24) in treatment resistant patients would decrease negative symptoms after 1 year of treatment. We found that negative symptoms did not change significantly in either condition. Positive symptoms, excited symptoms, and emotional distress worsened over time with ziprasidone, resulting in a significant difference between conditions in favour of FGA dose reduction. Relapse and treatment failure, defined as a prolonged or repeated relapse, occurred more often with ziprasidone than with FGA (45.8% versus 20.8%, and 25.0% versus 16.7%, respectively). Treatment with ziprasidone was superior for extrapyramidal symptoms. Our study establishes that lowering high FGA doses to an equivalent of 5 mg/day haloperidol or switching to ziprasidone is feasible in the vast majority of patients but does not improve negative or other symptoms. Neither FGA dose reduction nor switching to ziprasidone is an adequate alternative to clozapine for long-stay patients with severe treatment resistant schizophrenia.

Antipsychotic reduction and/or cessation and antipsychotics as specific treatments for tardive dyskinesia

BACKGROUND

Since the 1950s antipsychotic medication has been extensively used to treat people with chronic mental illnesses such as schizophrenia. These drugs, however, have also been associated with a wide range of adverse effects, including movement disorders such as tardive dyskinesia (TD) - a problem often seen as repetitive involuntary movements around the mouth and face. Various strategies have been examined to reduce a person's cumulative exposure to antipsychotics. These strategies include dose reduction, intermittent dosing strategies such as drug holidays, and antipsychotic cessation.

OBJECTIVES

To determine whether a reduction or cessation of antipsychotic drugs is associated with a reduction in TD for people with schizophrenia (or other chronic mental illnesses) who have existing TD. Our secondary objective was to determine whether the use of specific antipsychotics for similar groups of people could be a treatment for TD that was already established.

SEARCH METHODS

We updated previous searches of Cochrane Schizophrenia's study-based Register of Trials including the registers of clinical trials (16 July 2015 and 26 April 2017). We searched references of all identified studies for further trial citations. We also contacted authors of trials for additional information.

SELECTION CRITERIA

We included reports if they assessed people with schizophrenia or other chronic mental illnesses who had established antipsychotic-induced TD, and had been randomly allocated to (a) antipsychotic maintenance versus antipsychotic cessation (placebo or no intervention), (b) antipsychotic maintenance versus antipsychotic reduction (including intermittent strategies), (c) specific antipsychotics for the treatment of TD versus placebo or no intervention, and (d) specific antipsychotics versus other antipsychotics or versus any other drugs for the treatment of TD.

DATA COLLECTION AND ANALYSIS

We independently extracted data from these trials and estimated risk ratios (RR) or mean differences (MD), with 95% confidence intervals (CI). We assumed that people who dropped out had no improvement.

MAIN RESULTS

We included 13 RCTs with 711 participants; eight of these studies were newly included in this 2017 update. One trial is ongoing.There was low-quality evidence of a clear difference on no clinically important improvement in TD favouring switch to risperidone compared with antipsychotic cessation (with placebo) (1 RCT, 42 people, RR 0.45 CI 0.23 to 0.89, low-quality evidence). Because evidence was of very low quality for antipsychotic dose reduction versus antipsychotic maintenance (2 RCTs, 17 people, RR 0.42 95% CI 0.17 to 1.04, very low-quality evidence), and for switch to a new antipsychotic versus switch to another new antipsychotic (5 comparisons, 5 RCTs, 140 people, no meta-analysis, effects for all comparisons equivocal), we are uncertain about these effects. There was low-quality evidence of a significant difference on extrapyramidal symptoms: use of antiparkinsonism medication favouring switch to quetiapine compared with switch to haloperidol (1 RCT, 45 people, RR 0.45 CI 0.21 to 0.96, low-quality evidence). There was no evidence of a difference for switch to risperidone or haloperidol compared with antipsychotic cessation (with placebo) (RR 1 RCT, 48 people, RR 2.08 95% CI 0.74 to 5.86, low-quality evidence) and switch to risperidone compared with switch to haloperidol (RR 1 RCT, 37 people, RR 0.68 95% CI 0.34 to 1.35, very low-quality evidence).Trials also reported on secondary outcomes such as other TD symptom outcomes, other adverse events outcomes, mental state, and leaving the study early, but the quality of the evidence for all these outcomes was very low due mainly to small sample sizes, very wide 95% CIs, and risk of bias. No trials reported on social confidence, social inclusion, social networks, or personalised quality of life, outcomes that we designated as being important to patients.

AUTHORS' CONCLUSIONS

Limited data from small studies using antipsychotic reduction or specific antipsychotic drugs as treatments for TD did not provide any convincing evidence of the value of these approaches. There is a need for larger trials of a longer duration to fully investigate this area.

The effects of dose of flupentixol decanoate on relapse rates in schizophrenia

Aims and method

To systematically review the published literature with respect to formulating a dose-response curve for flupentixol decanoate. A systematic literature search using the Cochrane Database was performed for studies that published both dosage information and data on relapse rates.

Results

The data showed modest effects of dose on survival rates. Increasing dose may be associated with increased survival rates up to around 50–60 mg of flupentixol decanoate every 4 weeks. There was no evidence of increased survival rates at higher doses and higher doses may be associated with lower rates of survival. There is considerable uncertainty as to the true effects of dose of flupentixol decanoate on relapse rates.

Clinical implications

There is no evidence that survival rates improve for doses above 50–60 mg every 4 weeks. These doses are much lower than doses commonly prescribed. Clinicians may wish to consider these data when prescribing flupentixol decanoate.

Flupenthixol decanoate (depot) for schizophrenia or other similar psychotic disorders

BACKGROUND

Long-acting depot injections of drugs such as flupenthixol decanoate are extensively used as a means of long-term maintenance treatment for schizophrenia.

OBJECTIVES

To evaluate the effects of flupenthixol decanoate in comparison with placebo, oral antipsychotics and other depot neuroleptic preparations for people with schizophrenia and other severe mental illnesses, in terms of clinical, social and economic outcomes.

SEARCH METHODS

We identified relevant trials by searching the Cochrane Schizophrenia Group Trials Register in March 2009 and then for this update version, a search was run in April 2013. The register is based on regular searches of CINAHL, EMBASE, MEDLINE and PsycINFO. References of all identified studies were inspected for further trials. We contacted relevant pharmaceutical companies, drug approval agencies and authors of trials for additional information.

SELECTION CRITERIA

All randomised controlled trials that focused on people with schizophrenia or other similar psychotic disorders where flupenthixol decanoate had been compared with placebo or other antipsychotic drugs were included. All clinically relevant outcomes were sought.

DATA COLLECTION AND ANALYSIS

Review authors independently selected studies, assessed trial quality and extracted data. For dichotomous data we estimated risk ratios (RR) with 95% confidence intervals (CI) using a fixed-effect model. Analysis was by intention-to-treat. We summated normal continuous data using mean difference (MD), and 95% CIs using a fixed-effect model. We presented scale data only for those tools that had attained prespecified levels of quality. Using Grading of Recommendations Assessment, Development and Evaluation (GRADE) we created 'Summary of findings tables and assessed risk of bias for included studies.

MAIN RESULTS

The review currently includes 15 randomised controlled trials with 626 participants. No trials compared flupenthixol decanoate with placebo.One small study compared flupenthixol decanoate with an oral antipsychotic (penfluridol). Only two outcomes were reported with this single study, and it demonstrated no clear differences between the two preparations as regards leaving the study early (n = 60, 1 RCT, RR 3.00, CI 0.33 to 27.23,very low quality evidence) and requiring anticholinergic medication (1 RCT, n = 60, RR 1.19, CI 0.77 to 1.83, very low quality evidence).Ten studies in total compared flupenthixol decanoate with other depot preparations, though not all studies reported on all outcomes of interest. There were no significant differences between depots for outcomes such as relapse at medium term (n = 221, 5 RCTs, RR 1.30, CI 0.87 to 1.93, low quality evidence), and no clinical improvement at short term (n = 36, 1 RCT, RR 0.67, CI 0.36 to 1.23, low quality evidence). There was no difference in numbers of participants leaving the study early at short/medium term (n = 161, 4 RCTs, RR 1.23, CI 0.76 to 1.99, low quality evidence) nor with numbers of people requiring anticholinergic medication at short/medium term (n = 102, 3 RCTs, RR 1.38, CI 0.75 to 2.25, low quality evidence).Three studies in total compared high doses (100 to 200 mg) of flupenthixol decanoate with the standard doses (˜40mg) per injection. Two trials found relapse at medium term (n = 18, 1 RCT, RR 1.00, CI 0.27 to 3.69, low quality evidence) to be similar between the groups. However people receiving a high dose had slightly more favourable medium term mental state results on the Brief Psychiatric Rating Scale (BPRS) (n = 18, 1 RCT, MD -10.44, CI -18.70 to -2.18, low quality evidence). There was also no significant difference in the use of anticholinergic medications to deal with side effects at short term (2 RCTs n = 47, RR 1.12, CI 0.83 to 1.52 very low quality evidence). One trial comparing a very low dose of flupenthixol decanoate (˜6 mg) with a low dose (˜9 mg) per injection reported no difference in relapse rates (n = 59, 1 RCT, RR 0.34, CI 0.10 to 1.15, low quality evidence).

AUTHORS' CONCLUSIONS

In the current state of evidence, there is nothing to choose between flupenthixol decanoate and other depot antipsychotics. From the data reported in clinical trials, it would be understandable to offer standard dose rather than the high dose depot flupenthixol as there is no difference in relapse. However, data reported are of low or very low quality and this review highlights the need for large, well-designed and reported randomised clinical trials to address the effects of flupenthixol decanoate.

World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of schizophrenia, part 2: update 2012 on the long-term treatment of schizophrenia and management of antipsychotic-induced side effects

Abstract These updated guidelines are based on a first edition of the World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of schizophrenia published in 2006. For this 2012 revision, all available publications pertaining to the biological treatment of schizophrenia were reviewed systematically to allow for an evidence-based update. These guidelines provide evidence-based practice recommendations that are clinically and scientifically meaningful. They are intended to be used by all physicians diagnosing and treating people suffering from schizophrenia. Based on the first version of these guidelines, a systematic review of the MEDLINE/PUBMED database and the Cochrane Library, in addition to data extraction from national treatment guidelines, has been performed for this update. The identified literature was evaluated with respect to the strength of evidence for its efficacy and then categorised into six levels of evidence (A-F) and five levels of recommendation (1-5) ( Bandelow et al. 2008a ,b, World J Biol Psychiatry 9:242, see Table 1 ). This second part of the updated guidelines covers long-term treatment as well as the management of relevant side effects. These guidelines are primarily concerned with the biological treatment (including antipsychotic medication and other pharmacological treatment options) of adults suffering from schizophrenia.

Low-dose neuroleptic therapy and relapse in schizophrenia: meta-analysis of randomized controlled trials

We assessed the relative efficacy and effectiveness of low-versus standard-dose neuroleptic therapy in reducing relapse rate in schizophrenic patients. Six long-term randomized controlled trials were retrieved through a MEDLINE search. A dose regimen between 50 and 100 mg equivalent of chlorpromazine, compared to a conventional one between 200 and 500 mg, was found to increase the likelihood of relapse in chronic schizophrenic patients. Differences, however, were statistically significant at 12 but not at 24 months of treatment.

Low-dose neuroleptic therapy and extrapyramidal side effects in schizophrenia: An effect size analysis

A meta-analysis of the published literature was performed in order to quantify the efficacy of low-dose neuroleptic therapy in reducing extrapyramidal side effects in schizophrenic patients. A low-dose regimen between 50-100 mg equivalents of chlorpromazine, in comparison to a standard-dose regimen between 200-500 mg reduced extrapyramidal side effects by a 0.30 (+/-0.12) standard deviation, which is only a limited effect.

Relapse Prevention: A Model for Psychosis?

Evidence suggests that there are substantial costs (in a variety of spheres: personal, social, financial, etc.) associated with psychotic relapse. Furthermore, relapse increases the likelihood of future relapses and increased costs. This paper explores the application of a model of relapse prevention (RP) outlined by Marlatt and Gordon (1985) to the field of psychosis. The original model was designed to help individuals who abuse substances to maintain control over their habit. The advantages and limitations of applying the original model to the prevention of psychotic relapse are explored in detail in the context of an amended model. One major advantage of the RP model is that it provides a framework for the coordination of treatment interventions. The complex intervention packages, which may be useful in the management of psychotic illnesses, are described. The RP framework may be used to coordinate treatments in a manner that maximises their potential and emphasises patient control.

Antipsychotic treatment for schizophrenia in the maintenance phase: a systematic review of the guidelines and algorithms

OBJECTIVE

Antipsychotic treatment strategy for the maintenance phase of schizophrenia has been inconsistent in the literature. The purpose of this systematic review is to overview recommendations in various guidelines and algorithms.

METHODS

The guidelines and algorithms for schizophrenia that were published or updated in English after 2000 were searched, using Medline, PubMed, EMBASE, and PsycINFO with the following key words: guideline, algorithm, schizophrenia, and psychosis (last search: July 2011). The reference lists of the relevant reports were also examined.

RESULTS

Fourteen guidelines and algorithms were identified; only five of them clearly defined terms about the maintenance phase and treatment. Ten of 11 guidelines and algorithms did not recommend discontinuation of antipsychotics within five years; six of them partially recommended antipsychotic discontinuation for patients with first-episode schizophrenia exclusive. All nine guidelines and algorithms that referred to intermittent or targeted antipsychotic strategy endorsed against this strategy. Although being a hot topic of controversy, dose reduction of antipsychotics or lower dose therapy in the maintenance phase compared to the acute dosage is not recommended on the whole concerning atypical antipsychotics, whereas dose reduction appears sometimes considered acceptable for typical antipsychotics.

CONCLUSION

What constitutes maintenance phase and its treatment in schizophrenia has not yet been established in the literature. While discontinuation and intermittent or targeted strategies are not generally recommended, there is controversy regarding dose reduction or lower dose therapy, especially with regards to atypical antipsychotics. Further evidence is needed in order to derive treatment recommendations on antipsychotics in this critical treatment phase of schizophrenia.

Depressive symptoms in schizophrenic patients

Distinction between true negative and depressive symptoms in schizophrenia is difficult. In the present study we seek to establish the psychological profile of depression-prone schizophrenic patients. We addressed the issue by comparing the expression of psychological indices, such as the feelings of being in control of events, anxiety, mood, and the style of coping with stress in depressive and non-depressive schizophrenics. We also analyzed the strength of the association of these indices with the presence of depressive symptoms. A total of 49 patients (18 women and 31 men, aged 23-59) were enrolled into the study, consisting of a self-reported psychometric survey. We found that the prevalence of clinically significant depression in schizophrenic patients was 61%. The factors which contributed to the intensification of depressive symptoms were the external locus of control, anxiety, gloomy mood, and the emotion-oriented coping with stress. We conclude that psychological testing may discern those schizophrenic patients who would be at risk of depression development and may help separate the blurred boundaries between depressive and negative symptoms of schizophrenia.

How long to wait before reducing antipsychotic dosage in stabilized patients with schizophrenia? A retrospective chart review

OBJECTIVE

Antipsychotic dose reduction is generally recommended to occur after six months of clinical stabilization despite inadequate evidence. This timing issue was addressed in this study.

METHODS

This is an observational, retrospective and medical chart-based study. Inclusion criteria were (1) diagnosis of schizophrenia (DSM-IV), (2) being acutely psychotic at their first outpatient visit from May, 2002 to April, 2003, (3) having responded to antipsychotics and achieved clinical stabilization of acute symptoms, indexed as a fixation of regimen for four or more weeks, and (4) having one or more years of follow-up. Patients who had their antipsychotic doses reduced were then identified, and they were divided into two groups based on the waiting period before dose reduction: <24 weeks (Early Group) and ≥24 weeks (Standard Group). The rate of dose escalation for ≥20% during follow-up period was investigated as a proxy of clinical worsening.

RESULTS

After excluding stable patients at baseline, 211 patients met inclusion criteria. The mean ± SD waiting period before reducing antipsychotics was 122 ± 102 days. The rates of patients needing dose escalation were not significantly different between patients whose dose was reduced (N = 83) and those who was not (N = 128) (57.8% vs. 59.4%), and between Early Group (N = 59) and Standard Group (N = 24) (61.0% vs. 50.0%) although the reduction rate in antipsychotic dosage was significantly greater in Early Group (58.7% vs. 43.3%, p < 0.05).

CONCLUSION

These findings may indicate that timeline until antipsychotic reduction in stable patients with schizophrenia could be earlier than recommended, although caution is needed in interpreting our retrospective results.

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.

Are we using excessive neuroleptics? An argument for systematic neuroleptic dose reduction in stable patients with schizophrenia with specific reference to clozapine

Pharmacological intervention using antipsychotic agents is the cornerstone of treatment in schizophrenia. Polypharmacy and the use of higher doses is often practised in the hope of getting better symptom control in multi-episode, chronically unwell, people with schizophrenia. However, these regimes often pose unacceptable and at times dangerous risks. The current review examines the factors that influence dosing and argues that optimization is transient and needs ongoing consideration throughout the course of the illness. What is defined as 'the optimal dose' changes over the course of the illness and this should be reflected in treatment. The evidence presented in the current paper suggests that given the negative symptoms associated with neuroleptic medication, dosage should be discussed as part of the case review process and dosage should be systematically reduced as part of the standard treatment protocol. A case-study is presented of a patient who had her dosage of clozapine reduced and the subsequent health and lifestyle benefits from this reduction. We argue that the focus needs to be shifted away from the specific aim of treatment of psychotic symptoms to a more holistic view of treatment that incorporates function and psychosocial function as a measure of improvement.

Psychopharmacology and adverse effects of antipsychotic long-acting injections: a review

BACKGROUND

Depot antipsychotics are widely used in clinical practice. Long-acting formulations of second-generation antipsychotics are now being developed and introduced.

AIMS

To review the pharmacology, pharmacokinetics and adverse effect profiles of currently available antipsychotic long-acting injections (LAIs).

METHOD

The psychopharmacological properties of first- and second-generation antipsychotic LAIs are reviewed using data available up to October 2008.

RESULTS

First-generation antipsychotic (FGA) LAIs are associated with a high rate of acute and chronic movement disorders. Risperidone LAI is better tolerated in this respect, but is associated with hyperprolactinaemia and weight gain. Olanzapine LAI causes weight gain and other metabolic effects but appears not to be associated with an important incidence of movement disorders.

CONCLUSIONS

Dosing of LAIs is complicated by delayed release of drug, changes in plasma levels without change in dose, and by the lack of data establishing clear dose requirements. All LAIs offer the prospect of assured adherence (although patients may still default on treatment) but their use is complicated by adverse effects, complex pharmacokinetics and confusion over dose-response relationships.

Neuroleptic reduction and/or cessation and neuroleptics as specific treatments for tardive dyskinesia

BACKGROUND

Since the 1950s neuroleptic medication has been extensively used to treat people with chronic mental illnesses such as schizophrenia. These drugs, however, have been also associated with a wide range of adverse effects, including movement disorders such as tardive dyskinesia (TD). Various strategies have been examined to reduce a person's cumulative exposure to neuroleptics. These studies include dose reduction, intermittent dosing strategies such as drug holidays, and neuroleptic cessation.

OBJECTIVES

To determine whether a reduction or cessation of neuroleptic drugs is associated with a reduction in TD, for people with schizophrenia (or other chronic mental illnesses) who have existing TD. Our secondary objective was to determine whether the use of specific neuroleptics for similar groups of people could be a treatment for TD that was already established.

SEARCH STRATEGY

We updated previous searches of the Cochrane Schizophrenia Groups Register (1997), Biological Abstracts (1982-1997), EMBASE (1980-1997), LILACS (1982-1996), MEDLINE (1966-1997), PsycLIT (1974-1997), and SCISEARCH (1997) by searching the Cochrane Schizophrenia Groups Register (July 2003). We searched references of all identified studies for further trial citations. We also contacted the principal authors of trials for further unpublished trials.

SELECTION CRITERIA

We included reports if they assessed people with schizophrenia or other chronic mental illnesses who had established neuroleptic-induced TD, and had been randomly allocated to (a) neuroleptic maintenance versus neuroleptic cessation (placebo or no intervention), (b) neuroleptic maintenance versus neuroleptic reduction (including intermittent strategies), and (c) specific neuroleptics for the treatment of TD versus, placebo or intervention. A post hoc decision was made to broaden comparison (c) to include specific neuroleptics versus other neuroleptics for the treatment of TD.

DATA COLLECTION AND ANALYSIS

We (KSW, JR) independently inspected citations and, where possible, abstracts, ordered papers, and re-inspected and quality assessed these and extracted data. We analysed dichotomous data using random effects relative risk (RR) and estimated the 95% confidence interval (CI). Where possible we calculated the number needed to treat (NNT) or number needed to harm statistic (NNH). We excluded continuous data if more than 50% of people were lost to follow up, but, where possible, we calculated the weighted mean difference (WMD). It was assumed that those leaving the study early showed no improvement.

MAIN RESULTS

We included five trials and excluded 102. One small two week study (n=18), reported on the 'masking' effects of molindone and haloperidol on TD, which favoured haloperidol (RR 3.44 CI 1.1 to 5.8). Two (total n=17) studies found no reduction in TD associated with neuroleptic reduction (RR 0.38 CI 0.1 to 1.0). One study (n=20) found no significant differences in oral dyskinesia (RR 2.45 CI 0.3 to 19.7) when neuroleptics were compared as a specific treatment for TD. Dyskinesia was found to be not significantly different (n=32, RR 0.62 CI 0.3 to 1.26) between quetiapine and haloperidol when these neuroleptics were used as specific treatments for TD, although the need for additional neuroleptics was significantly lower in the quetiapine group (n=47, RR 0.49 CI 0.2 to 1.0) than in those given haloperidol.

AUTHORS' CONCLUSIONS

Limited data from small studies using neuroleptic reduction or specific neuroleptic drugs as treatments for TD did not provide any convincing evidence of the value of these approaches. There is a need for larger trials of a longer duration in order to fully investigate this area.

Training in cognitive behavioural interventions on acute psychiatric inpatient wards

There has been a drive towards addressing the types of care and therapeutic interventions available to people with serious mental illness, which is reflected in the latest government mental health policy initiatives. Recent evidence strongly supports the implementation of psychological and social interventions for people with psychosis, and in particular the use of cognitive behavioural techniques. Until now, the main focus has been on people living in the community. This study examines the delivery of psychosocial interventions training to qualified psychiatric nurses and unqualified staff on seven acute psychiatric admission wards in London, UK. The approach had the strength of on-site delivery, follow-up role modelling of the interventions and clinical supervision. Despite this, in some cases the training was less successful, mainly because of staffing and leadership weaknesses. The impact of training in these methods and the implications for mental health education and practice development are discussed.

Dose response and atypical antipsychotics in schizophrenia

Based on information from clinical trials, both the efficacy and adverse effects of conventional antipsychotics in the treatment of schizophrenia are dose related. The overlapping nature of these dose-response profiles limits the use of these agents. Atypical antipsychotics provide greater relief across the comorbid symptom domains of schizophrenia, but dose-response studies and clinical experience have revealed that some of these drugs also have dose limitations. This article reviews the dose-response relationships of the atypical antipsychotics as presented predominantly in pivotal, randomised studies (double-blind and otherwise). Limited data indicate that clozapine shows dose-related efficacy up to 600 mg/day in patients with treatment-resistant schizophrenia. However, higher dosages of clozapine may be associated with the risk of seizures. Risperidone demonstrates dose-related adverse events that compromise efficacy. The dose-response relationships for ziprasidone, quetiapine and aripiprazole are less well established. The efficacy of olanzapine appears to be dose related within the recommended dosage range of 10-20 mg/day, but clinical trials that have explored higher dosages suggest improved efficacy. Furthermore, the higher doses are not associated with a significantly increased incidence of adverse events. Further studies are clearly needed to fully characterise the dose-response relationships of atypical antipsychotics.

A double-blind, randomized, placebo-controlled trial of olanzapine in the prevention of psychotic relapse

Sustained response to antipsychotic therapy is an important outcome measure for patients with psychotic disorders. Placebo control in studies of relapse prevention contributes valuable information yet provokes much debate. This study, using placebo as a control, evaluated olanzapine's efficacy in preventing a psychotic relapse. Participants were stable minimally symptomatic outpatients with schizophrenia or schizoaffective disorder. The study included 4 phases: (1) 4-day to 9-day screening/evaluation (N = 583), (2) 6-week conversion to open-label olanzapine (N = 493; 10-20 mg/d), (3) 8-week stabilization on olanzapine (N = 458; 10-20 mg/d), and (4) 52-week randomized (2:1), double-blind maintenance with olanzapine (N = 224; 10-20 mg/d) or placebo (N = 102). Primary relapse criteria were clinically significant changes in the Brief Psychiatric Rating Scale (BPRS) positive item cluster or rehospitalization due to positive symptoms. Statistical methodology allowed sequential real-time estimation of efficacy across blinded treatment groups and multiple interim analyses, which permitted study termination when efficacy was significantly different between treatments. A significant between-treatment difference emerged 210 days after first patient randomization to double-blind treatment. Thus, 151 (46.3%) of the randomized patients were discontinued early and 34 (10.4%) of the planned patient enrollment were not required. The olanzapine group had a significantly longer time to relapse (P < 0.0001) than the placebo group. The 6-month cumulative estimated relapse rate (Kaplan-Meier) was 5.5% for olanzapine-treated patients versus 55.2% for placebo-treated patients. The design of this study enabled appropriate statistical testing of the primary hypothesis while minimizing exposure of patients to a less effective treatment than olanzapine. In remitted stabilized patients with schizophrenia or schizoaffective disorder, olanzapine demonstrated a positive benefit-to-risk profile in relapse prevention.

Evaluating the parental fitness of psychiatrically diagnosed individuals: advocating a functional-contextual analysis of parenting

The parental fitness of psychiatrically diagnosed individuals is often questioned in termination of parental rights cases. The goal of this article is to shift the focus from a predisposing bias of unfitness to a functional-contextual analysis of parenting behavior and competency. Three underlying biased assumptions are relevant for the courts' decision making: (a) that a diagnosis (past or present) predicts inadequate parenting and child risk, (b) that a diagnosis predicts unamenability to parenting interventions, and (c) that a diagnosis means the parent is forever unfit. Each assumption will be considered in light of empirical evidence, with major depression, schizophrenia, substance abuse, and mental retardation provided as examples of diagnostic labels often assumed to render a parent unfit. A research agenda to improve clinicians' ability to assess parental fitness and understanding of how parental mental illness, mental retardation, or substance abuse might compromise parenting capacities is discussed for forensic purposes.

Determining the optimal dose of haloperidol in first-episode psychosis

Uncertainty exists as to the most appropriate dose of haloperidol in first-episode psychosis. This study set out to determine whether ultra-low doses of haloperidol could successfully treat patients with first-episode psychosis. Thirty-five patients with a first episode of psychosis were treated with haloperidol in an open label, fixed protocol over a 12-week period with doses restricted to 1 mg per day for the first 4 weeks. Twenty-nine (83%) remained on haloperidol after 12 weeks at a mean dose of 1.78 mg per day, 16 (55%) had stabilized on 1 mg/day or less. The mean percentage reduction in Positive and Negative Symptom Scale score between baseline and 6 and 12 weeks was 30.3% (SD 20.9%) and 41.4% (SD 16.6%), respectively. There were no significant differences in mean extrapyramidal symptom ratings between baseline and 12 weeks. Ultra-low doses of haloperidol are effective and well tolerated in first-episode psychosis. Initial doses should be maintained for a sufficient period of time to allow for the medication to take full effect.

Reasoning about the optimal duration of prophylactic antipsychotic medication in schizophrenia: evidence and arguments

OBJECTIVE

To review evidence-based literature regarding the necessary duration of antipsychotic relapse prevention in schizophrenia and related psychoses.

METHOD

A computerized search was performed on Medline, Embase Psychiatry and PsycLIT which covered the period 1974-99. We also used cross-references.

RESULTS

Although schizophrenia refers mainly to an intrinsic biological vulnerability, only maintenance studies with a follow-up of 2 years at most are available. Relapses appear unpredictable and occur even after long-term successful remission during antipsychotic treatment.

CONCLUSION

Since rehabilitation efforts have effects only after long-term endeavours, antipsychotic relapse prevention should be maintained for long periods. It is reasonable to treat patients suffering from schizophrenia and related psychoses for longer periods than indicated by the current guidelines.

Depot flupenthixol decanoate for schizophrenia or other similar psychotic disorders

BACKGROUND

Anti-psychotic drugs are the mainstay treatment for schizophrenia and similar psychotic disorders. Long-acting depot injections of drugs such as flupenthixol decanoate are extensively used as a means of long-term maintenance treatment.

OBJECTIVES

To evaluate the effects flupenthixol decanoate in comparison with placebo, oral antipsychotics and other depot neuroleptic preparations for people with schizophrenia and other severe mental illnesses, 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 (December 1998), EMBASE (1980-1998), MEDLINE (1966-1998) and PsycLIT (1974-1998). The references of all identified trials were inspected for more studies and the first author of each included trial and relevant pharmaceutical companies were contacted.

SELECTION CRITERIA

All randomised controlled trials that focused on people with schizophrenia or other similar psychotic disorders where flupenthixol decanoate had been compared to placebo or other antipsychotic drugs. All clinically relevant outcomes were sought.

DATA COLLECTION AND ANALYSIS

Studies were reliably selected, quality rated and data extracted. For dichotomous data Peto odds ratios (OR) with 95% confidence intervals (CI) were estimated. Where possible, the number needed to treat statistic (NNT) was also 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

No trials compared flupenthixol decanoate to placebo. One small study compared flupenthixol decanoate with an oral antipsychotic (penfluridol). There were no clear differences between the two preparations. When flupenthixol decanoate was compared to other depot preparations, there were no differences between depots for outcomes such as death, global impression, relapse (OR 1.16 CI 0.7-1.9) or leaving the study early (OR 1.00 CI 0.6-1.7). Two small studies suggest that flupenthixol decanoate is responsible for less movement disorders than other depot antipsychotic drugs (OR 0.23 CI 0.08-0.7, NNT 5). This finding did not hold for specific side effects, such as tremor (OR 1.2 CI 0.3-4) and tardive dyskinesia (OR 1.60 CI 0.4-6). Two trials comparing high doses of flupenthixol decanoate to the standard approximately 40mg per injection reported no significant difference for the outcome of relapse (OR 0.32 CI 0.09-1.2). One small (n=59) trial comparing a very low dose of flupenthixol decanoate ( approximately 6 mg/IM) to a very low dose approximately 9 mg per injection also reported no difference in relapse rates (OR 0.3 CI 0.1-1.1).

REVIEWER'S CONCLUSIONS

From the data reported in clinical trials, it would be understandable if those suffering from schizophrenia, who are willing to take flupenthixol decanoate, would request the standard dose rather than the high dose. In the current state of evidence, there is nothing to choose between flupenthixol decanoate and other depot antipsychotics. The choice of which depot to use must therefore be based on clinical judgement and the preferences of people with schizophrenia and their carers. Managers and policy makers should expect better data than the research community has provided thus far. This review highlighted the need for large, well-designed and reported randomised clinical trials to address the effects of flupenthixol decanoate, in particular when compared to oral antipsychotics. Future studies should also consider hospital and service outcomes, satisfaction with care and record economic data.

Neuroleptic reduction and/or cessation and neuroleptics as specific treatments for tardive dyskinesia

BACKGROUND

Since the 1950s neuroleptic medication has been extensively used to treat people with chronic mental illnesses, such as schizophrenia. These drugs, however, have been also associated with a wide range of adverse effects, including movement disorders such as tardive dyskinesia (TD). Various strategies have been examined to reduce a person's cumulative exposure to neuroleptics. These studies include dose reduction, intermittent dosing strategies, such as drug holidays, and neuroleptic cessation.

OBJECTIVES

To determine whether, for those people with both schizophrenia (or other chronic mental illnesses) and tardive dyskinesia (TD), a reduction or cessation of neuroleptic drugs was associated with reduction in TD symptoms. A secondary objective was to determine whether the use of specific neuroleptics for similar groups of people could be a treatment for already established TD.

SEARCH STRATEGY

Electronic searches of Biological Abstracts (1982-1997), Cochrane Schizophrenia Group's Register of trials (1997), EMBASE (1980-1997), LILACS (1982-1996), MEDLINE (1966-1997), PsycLIT (1974-1997), and SCISEARCH (1997) were undertaken. References of all identified studies were searched for further trial citations. Principal authors of trials were contacted.

SELECTION CRITERIA

Reports were included if they assessed the treatment of neuroleptic-induced tardive dyskinesia in people with schizophrenia or other chronic mental illnesses and already established TD, who had been randomly allocated to (a) neuroleptic cessation (placebo or no intervention) versus neuroleptic maintenance; b. neuroleptic reduction (including intermittent strategies) versus neuroleptic maintenance; or c. specific neuroleptics for the treatment of TD versus placebo or no intervention.

DATA COLLECTION AND ANALYSIS

The reviewers extracted the data independently and the Odds Ratio (95% CI) or the average difference (95% CI) were estimated. The reviewers assumed that people who dropped out had no improvement.

MAIN RESULTS

Two trials were able to be included in this review. Sixty two were excluded and 16 are awaiting assessment. Seven trials are still pending classification. No randomised controlled trial-derived data were available to clarify the role of neuroleptics as treatments for TD. This includes the atypical antipsychotics including clozapine. Despite neuroleptic cessation being a frequently first-line recommendation, there were no RCT-derived data to support this. Two studies ( approximately approximately Cookson 1987 approximately approximately , approximately approximately Kane 1983 approximately approximately ) found a reduction in TD associated with neuroleptic reduction.

REVIEWER'S CONCLUSIONS

The lack of evidence to support the efficacy of neuroleptic cessation as a treatment for TD, combined with the accumulating evidence of an increased risk of relapse should antipsychotic drugs be reduced, makes this intervention a hazardous treatment for TD. Dose reduction may offer some benefit as a treatment for TD compared to standard levels of neuroleptic use. There is a need to evaluate the utility of clozapine and the 'atypical' antipsychotics as treatments for established TD.

Pharmacologic treatment of schizophrenia

The pharmacologic treatment of schizophrenia remains a critical component in the short- and long-term management of this disease. Considerable progress has been made in delineating different domains of this illness, ranging from positive and negative symptoms to cognitive dysfunction and psychosocial vulnerabilities. Increasingly, treatments are being studied in relation to a variety of different outcome measures with functional ability and quality of life achieving appropriate emphasis. The introduction of a new generation of antipsychotic drugs has helped to raise optimism and expectations. Overall, second-generation drugs do provide clear advantages in terms of reducing adverse effects (particularly drug-induced Parkinsonism, anesthesia, and, hopefully, tardive dyskinesia). Advantages in alleviating refractory symptoms, negative symptoms, depression, and suicidal behavior are found in some reports; however, much remains to be done methodologically in establishing the relative merits of specific drugs in the multiple domains of interest.

Oral olanzapine versus oral haloperidol in the maintenance treatment of schizophrenia and related psychoses

BACKGROUND

Three studies compared olanzapine and haloperidol given orally in maintenance therapy for schizophrenia and related psychoses.

METHOD

Data were from double-blind extensions of acute studies. The subjects met criteria for schizophrenia, schizophreniform disorder or schizoaffective disorder. Subjects had responded to acute therapy (Brief Psychiatric Rating Scale total score decreased > or = 40% from baseline (Studies 1, 2, and 3) or was < or = 18 (Studies 1 and 2)) and were out-patients at their last acute phase visit. Relapse was defined as hospitalisation for psychopathology. Subjects treated with olanzapine in the three studies were pooled to form the olanzapine group and subjects treated with haloperidol were pooled to form the haloperidol group.

RESULTS

Olanzapine-treated subjects experienced less relapse (P = 0.034). The Kaplan-Meier estimated one-year risk of relapse was 19.7% with olanzapine and 28% with haloperidol.

CONCLUSION

Olanzapine was superior to haloperidol in the maintenance therapy of schizophrenia and related psychoses.

DECLARATION OF INTEREST

This work was sponsored by Eli Lilly and Company.

The limitations of antipsychotic medication on schizophrenia relapse and adjustment and the contributions of psychosocial treatment

Whether psychosocial treatment adds substantially to the prophylactic efficacy of maintenance antipsychotic monotherapy requires a more accurate estimate of relapse risks than those contained in recent reviews. A reappraisal of the literature suggests a 1-year, post-hospital, relapse rate of 40% on medication, and a substantially higher rate among patients who live in stressful environments, rather than earlier estimates of 16%. Relapse rates of 65% at 1 year and over 80% by 2 years among drug discontinued or placebo substituted outpatients are also more accurate than the 53% relapse rate previously estimated. When psychosocial treatment is added to maintenance chemotherapy, there is compelling evidence that relapse rates are reduced by as much as 50% compared with relapse associated with medication and standard care. However, psychosocial treatment without medication is as ineffective as placebo. The additive effects appear greater for recent, theoretically based psychosocial approaches than earlier atheoretical, altruistic forms of caring. However, effects vary according to the patient's clinical state, the nature and timing of the intervention, and the presence of environmental stressors. Regarding adjustment, very little definitive information regarding psychosocial treatment effects has existed until recently. A novel, disorder-relevant approach has now been shown to have broad and significant effects on social adjustment compared with medication and support. However, the magnitude of effects is not fully realized until a third year of treatment: a distinct challenge in the era of managed care. Atypical antipsychotics and more definitive psychosocial strategies that target social cognitive deficits hold promise for enhanced outcomes in the next generation of studies.

Guidelines for depot antipsychotic treatment in schizophrenia. European Neuropsychopharmacology Consensus Conference in Siena, Italy

These guidelines for depot antipsychotic treatment in schizophrenia were developed during a two-day consensus conference held on July 29 and 30, 1995 in Siena, Italy. Depot antipsychotic medications were developed in the 1960s as an attempt to improve the long-term treatment of schizophrenia (and potentially other disorders benefiting from long-term antipsychotic medication). Depot drugs as distinguishable from shorter acting intramuscularly administered agents can provide a therapeutic concentration of at least a seven day duration in one parenteral dose. The prevention of relapse in schizophrenia remains an enormous public health challenge worldwide and improvements in this area can have tremendous impact on morbidity, mortality and quality of life, as well as direct and indirect health care costs. Though there has been debate as to what extent depot (long-acting injectable) antipsychotics are associated with significantly fewer relapses and rehospitalizations, in our view when all of the data from individual trials and metaanalyses are taken together, the findings are extremely compelling in favor of depot drugs. However in many countries throughout the world fewer than 20% of individuals with schizophrenia receive these medications. The major advantage of depot antipsychotics over oral medication is facilitation of compliance in medication taking. Non-compliance is very common among patients with schizophrenia and is a frequent cause of relapse. In terms of adverse effects, there are not convincing data that depot drugs are associated with a significantly higher incidence of adverse effects than oral drugs. Therefore in our opinion any patient for whom long-term antipsychotic treatment is indicated should be considered for depot drugs. In choosing which drug the clinician should consider previous experience, personal patient preference, patients history of response (both therapeutic and adverse effects) and pharmacokinetic properties. In conclusion the use of depot antipsychotics has important advantages in facilitating relapse prevention. Certainly pharmacotherapy must be combined with other treatment modalities as needed, but the consistent administration of the former is often what enables the latter.

Factors influencing relapse in the long-term course of schizophrenia

Highly effective neuroleptic drugs have been available for the past 40 years, but 50% of schizophrenic patients, under normal treatment conditions, relapse within 1 year after their latest episode, frequently spending 15-20% of their time in psychiatric institutions. The term relapse usually refers to a deterioration or recurrence of positive rather than negative features, and relapses appear to impair the course of the disease. Impairment is often longer than expected for those patients who discontinue antipsychotic medication and then relapse to their prediscontinuation clinical state of function. Drug therapy is an important defense against relapse. Marked differences in relapse rate between patients receiving placebo and neuroleptic drugs have been observed (approximately 69% after 1 year for the placebo group versus 26% for the neuroleptic group). First-year relapse rates can be reduced from 75% to 15% with prophylactic treatment with neuroleptics. Follow-up studies suggest that noncompliance with medication, pharmacological factors, psychosocial factors and alcohol and drug abuse contribute to setting off new psychotic episodes. The most important of these is noncompliance with medication. The overwhelming majority of schizophrenic patients who suffered a clinical exacerbation and required hospitalization (73%) did not comply with the treatment prescribed. The effect of new antipsychotic agents should be examined in patients who relapse despite maintenance treatment with conventional neuroleptics. We have found that the rate of current drug abuse among patients with schizophrenic relapse (44%) was significantly higher than that in schizophrenic patients who regularly attended outpatient clinics. Also, the rate of alcohol and substance abuse is higher in males (79%) than in females (21%). Psychiatric units should integrate addiction treatments with psychotic-relapse management.

Tolerability of low dose neuroleptics: a case control study of flupenthixol

There are no data available on the risk of extrapyramidal symptoms when using long-term flupenthixol in low dosage in patients suffering from anxiety and depressive disorders. In a case control study 106 patients essentially treated with the neuroleptic flupenthixol in a so-called low, non-antipsychotic dosage were compared to n=37 otherwise comparable patients who never had been treated with neuroleptics. The investigator was blind to the previous treatment conditions. Extrapyramidal symptoms were found although with a low prevalence and mild degree: 6.7% tardive dyskinesia, none in controls; pseudoparkinsonism 26%, 16% in controls. Extrapyramidal side-effects, especially tardive dyskinesia, have to be considered in the individual weighing of therapeutic benefits and risks even when prescribing flupenthixol in low dosages.

Dose-response relationships for the antipsychotic effects and Parkinsonian side-effects of typical neuroleptic drugs: practical and theoretical implications

1. From a review of published literature it is concluded that the minimum dose of a neuroleptic drug (NLD) required to alleviate psychosis is very similar to that producing minimal parkinsonian side effects (PSE). This conclusion is reached both from group comparisons and individual comparisons of dose/response relations (DRR) for the two effects. 2. A lower dose of NLD is usually sufficient to prevent relapse in well stabilized patients than is needed to check an active psychotic state. 3. Anticholinergic agents used to reduce side effects of typical NLD can retard the therapeutic process during neuroleptic treatment of acute psychosis. Although it is not fully established that this is a central interaction, it is consistent with the idea that minimal side effects are a necessary condition for therapeutic effectiveness with typical antipsychotic drugs. 4. In relapse-free maintenance of psychosis-prone patients, tolerance occurs to PSE. Thus few patients need experience prolonged side effects during maintenance treatment with neuroleptics. 5. The evidence reviewed is discussed with respect to a previous hypothesis of the supposedly "indirect" action of typical neuroleptic drugs in therapy for psychosis. The evidence is consistent with the idea of a close causal relation between minimal PSE of these drugs, and their therapeutic effectiveness in the acute stage of treatment.

Psychoeducational training for schizophrenic patients: background, procedure and empirical findings

As neuroleptic therapy alone still fails to other effective relapse prevention in schizophrenic patients, psychoeducational therapeutic approaches have been developed as an additional aid for patients and their families. This article details the central characteristics of these approaches. A psychoeducational group program for schizophrenic outpatients, the efficacy of which was investigated within the scope of a German controlled intervention study on 191 patients, is also presented. The article describes in detail the methods used and the therapeutic objectives, reporting on changes in the attitudes of patients to their medication. At the end of the training program, patients who had attended regularly showed significantly better medication compliance and were more reserved with respect to their medication self-management. After 1 year the positive effects had diminished. However, booster sessions or participation of the psychiatrist in charge as group therapist would have had longer lasting effects.

Neuroleptic dosing and neuroleptic plasma levels in schizophrenia: determining the optimal regimen

OBJECTIVE

To recommend dose range and therapeutic plasma concentration for several neuroleptics, and to discuss conditions under which neuroleptic plasma levels are clinically useful.

METHOD

Neuroleptic drug therapy is a major component of the acute and maintenance treatment of schizophrenia. However, there is no consensus on what constitutes an appropriate or optimal dose of antipsychotic drug in individual patients. Low-dose medication has the potential to improve psychosocial function and reduces the frequency of side effects but can lead to an increase in positive symptoms and schizophrenic relapse. High doses may be associated with behavioural toxicity, symptom exacerbation, a worsening of secondary deficit symptoms, impaired social functioning and increased adverse effects such as acute extrapyramidal symptoms and tardive dyskinesia. Numerous clinical studies have attempted to determine the degree of correlation between dose, neuroleptic blood levels, and clinical response.

RESULTS

To date, this approach has met with only limited success: neuroleptic dose overall appears to be a poor predictor of clinical outcome, and the suggested therapeutic plasma level concentrations of some antipsychotic drugs cannot be regarded as established by any means. Furthermore, the ability to conduct neuroleptic plasma levels is not readily accessible in the usual clinical setting. In the acute treatment phase, titrating the dose until the onset of minimal cogwheel rigidity or hypokinesia (neuroleptic threshold dose) has met with some success and is preferable to standard dosing as a means of individualizing pharmacotherapy. During the maintenance phase, a slow and gradual dosage reduction with adjunctive psychosocial and psychotherapeutic intervention is the preferred strategy.

CONCLUSION

Reinforcing patient and physician compliance is a key element in achieving an optimal treatment regimen.

Maintenance treatment of schizophrenia: a review of dose reduction and family treatment strategies

Maintenance treatment in schizophrenia requires the integration of both medication and psychosocial treatment interventions for maximum effect. We review the recent evidence for strategies drawn from both domains. For the use of anti-psychotic medication we focus on studies of dose reduction using two strategies that differ in assumptions regarding the action of medication. They are: continuous low-dose and targeted, early intervention or intermittent treatment. For psychosocial interventions we focus on studies of family treatment. Regarding dose reduction, we conclude that both strategies are feasible but the targeted strategy incurs higher relapse and rehospitalization rates. Regarding family treatment, we conclude that family treatment provides benefits beyond other psychosocial interventions or usual care, but that there is no evidence for differences in efficacy among family treatments.

Long-term depot antipsychotics. A risk-benefit assessment

The main advantage of depot antipsychotic medication is that it overcomes the problem of covert noncompliance. Patients receiving depot treatment who refuse their injection or fail to receive it for any other reason can be immediately identified and appropriate action taken. In the context of a carefully monitored management programme, depot treatment can have a major impact on compliance and, consequently, the risk of relapse and hospitalisation can be reduced. Another major advantage is that the considerable individual variation in bioavailability and metabolism with oral antipsychotic drugs is markedly reduced with depot treatment. A better correlation between the dose administered and the concentration of medication found in blood or plasma is achieved with depot treatment, and thus, the clinician has greater control over the amount of drug being delivered to the site of activity. A further benefit of depot treatment is the achievement of stable plasma concentrations over long periods, allowing injections to be given every few weeks. However, this also represents a potential disadvantage in that there is a lack of flexibility of administration. Should adverse effects develop, the drug cannot be rapidly withdrawn. Furthermore, adjustment to the optimal dose becomes a long term strategy. The controlled studies of low dose maintenance therapy with depot treatment suggest that it can take months or years for the consequences of dose reduction, in terms of increased risk of relapse, to become manifest. When weighing up the risks and benefits of long term antipsychotic treatment for the individual patient with schizophrenia, the clinician must take into account the nature, severity and frequency of past relapses, and the degree of distress and disability related to any adverse effects. However, the clinical decision to prescribe either a depot or an oral antipsychotic for maintenance treatment will probably rest largely on an assessment of the risk of poor compliance in the particular patient. There is no convincing evidence that the range, nature or severity of adverse effects reported with depot treatment is significantly different from that seen with oral treatment, and depot treatment has been shown to be as good or better than oral medication in preventing or postponing relapse. Furthermore, when adjusting the dose or frequency of depot injection, to improve control of psychotic symptoms or reduce adverse effects, the clinician can be confident that the dose prescribed is the dose being received by the patient.

Depot antipsychotic drugs. Place in therapy

The pharmacokinetics of depot antipsychotic medications are such that an intramuscular injection given at intervals of from 1 to 4 weeks will produce adequate plasma concentrations that are sufficient to prevent relapse over the dosage interval. Such medication is useful in patients who do not reliably take their oral medication. The pharmacokinetics and clinical actions of various depot formulations of antipsychotic drugs have been extensively studied. Unfortunately, patients who do not reliably take their oral medications are unlikely to volunteer for controlled studies. This is because the same factors that influence a patient to not cooperate with the physician in taking the medication as prescribed will also interfere with their willingness to volunteer for research protocols. Thus, evidence from blinded controlled trials may not necessarily reflect the actual patient population at risk. We feel that particularly important evidence of efficacy of depot vs oral medication comes from mirror-image studies. In these trials, the number of hospitalisations after initiation of depot medication is compared with that observed when the patient was solely taking oral medication. Studies of this type show that depot medication substantially reduces the rate of relapse. There is considerable evidence about how long depot medications should be used. For many patients, depot medication to prevent relapse in schizophrenia should be used for the life of the patient. As the conventional antipsychotic agents are replaced by a new generation of agents, the need for depot formulations will continue, and the knowledge gained about the current formulations should transfer to future generations of drugs.

Antipsychotic drugs: is more worse? A meta-analysis of the published randomized control trials

Effectiveness and side-effects of high- versus low-dose neuroleptic treatment of chronic psychosis have been assessed through a meta-analysis of 22 published randomized control trials comparing different neuroleptic doses. No incremental clinical improvement was found at doses above 375 mg equivalent of chlorpromazine, while a significant increase in adverse reactions was observed.