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Musco S, McAllister V, Caudle I. Dopamine-receptor blocking agent-associated akathisia: a summary of current understanding and proposal for a rational approach to treatment. Ther Adv Psychopharmacol 2020; 10:2045125320937575. [PMID: 32922732 PMCID: PMC7457694 DOI: 10.1177/2045125320937575] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 06/02/2020] [Indexed: 12/17/2022] Open
Abstract
Dopamine-receptor blocking agent-associated akathisia (DRBA-A) is an adverse effect that can significantly limit the use of these important medications for the treatment of a variety of psychiatric diseases, yet there is no unifying theory regarding its pathophysiology. This knowledge gap limits clinicians' ability to effectively manage DRBA-A and mitigate negative outcomes in an already vulnerable patient population. Based on a review of the current literature on the subject, it is hypothesized that dopaminergic and noradrenergic signaling is perturbed in DRBA-A. Accordingly, it is proposed that the optimal agent to manage this extrapyramidal symptom should increase dopamine signaling in the affected areas of the brain and counteract compensatory noradrenergic signaling via antagonism of adrenergic or serotonergic receptors.
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Affiliation(s)
- Shaina Musco
- Department of Clinical Sciences, High Point University Fred Wilson School of Pharmacy, One University Parkway, High Point, NC 27262, USA
| | - Vivian McAllister
- High Point University David R. Hayworth College of Arts and Sciences, One University Parkway, High Point, NC, USA
| | - Ian Caudle
- High Point University Fred Wilson School of Pharmacy, One University Parkway, High Point, NC, USA
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Hirjak D, Kubera KM, Bienentreu S, Thomann PA, Wolf RC. [Antipsychotic-induced motor symptoms in schizophrenic psychoses-Part 1 : Dystonia, akathisia und parkinsonism]. DER NERVENARZT 2019; 90:1-11. [PMID: 30128734 DOI: 10.1007/s00115-018-0582-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Acute antipsychotic-induced movement disorders (AIMD) are clinically relevant since they are frequently associated with high subjective distress, and since over the long-term they can negatively impact treatment adherence of patients with schizophrenic psychoses. This review article summarizes the relevant studies on the prevalence, risk factors, prevention and treatment options and instruments for early prediction of acute AIMD in schizophrenic psychoses. The current evidence and treatment recommendations are divided into three main areas: acute dystonia, akathisia, and parkinsonism. For the treatment of acute dystonia trihexyphenidyl and biperiden have shown their efficacy. Considering pharmacological treatment of akathisia, there is some preliminary evidence for medication with lipophilic beta-receptor blockers (propranolol and pindolol), clonidine, benzodiazepines, mianserin, mirtazapine und trazodone. The treatment options for drug-induced parkinsonism include reduction or switching from one antipsychotic to another with a lower affinity for dopamine D2 receptors, amantadine or in the regular administration of anticholinergic drugs. In conclusion, acute AIMD is easily to recognize but is not always effectively and durably treated. Early recognition and treatment of acute AIMD could be associated with improved treatment outcomes.
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Affiliation(s)
- D Hirjak
- Zentralinstitut für Seelische Gesundheit, Klinik für Psychiatrie und Psychotherapie, Medizinische Fakultät Mannheim, Universität Heidelberg, J5, 68159, Mannheim, Deutschland.
| | - K M Kubera
- Zentrum für Psychosoziale Medizin, Klinik für Allgemeine Psychiatrie, Universität Heidelberg, Heidelberg, Deutschland
| | - S Bienentreu
- Fachklinik für Psychiatrie und Psychotherapie, MARIENBORN GmbH, Zülpich, Deutschland
| | - P A Thomann
- Zentrum für Psychosoziale Medizin, Klinik für Allgemeine Psychiatrie, Universität Heidelberg, Heidelberg, Deutschland
- Zentrum für Seelische Gesundheit, Gesundheitszentrum Odenwaldkreis, Erbach, Deutschland
| | - R C Wolf
- Zentrum für Psychosoziale Medizin, Klinik für Allgemeine Psychiatrie, Universität Heidelberg, Heidelberg, Deutschland
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Sienaert P, van Harten P, Rhebergen D. The psychopharmacology of catatonia, neuroleptic malignant syndrome, akathisia, tardive dyskinesia, and dystonia. HANDBOOK OF CLINICAL NEUROLOGY 2019; 165:415-428. [PMID: 31727227 DOI: 10.1016/b978-0-444-64012-3.00025-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Although highly prevalent, motor syndromes in psychiatry and motor side effects of psychopharmacologic agents remain understudied. Catatonia is a syndrome with specific motor abnormalities that can be seen in the context of a variety of psychiatric and somatic conditions. The neuroleptic malignant syndrome is a lethal variant, induced by antipsychotic drugs. Therefore, antipsychotics should be used with caution in the presence of catatonic signs. Antipsychotics and other dopamine-antagonist drugs can also cause motor side effects such as akathisia, (tardive) dyskinesia, and dystonia. These syndromes share a debilitating impact on the functioning and well-being of patients. To reduce the risk of inducing these side effects, a balanced and well-advised prescription of antipsychotics is of utmost importance. Clinicians should be able to recognize motor side effects and be knowledgeable of the different treatment modalities.
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Affiliation(s)
- Pascal Sienaert
- Academic Center for ECT and Neuromodulation (AcCENT), University Psychiatric Center KU Leuven, Kortenberg, Belgium.
| | - Peter van Harten
- Research Department, GGz Centraal Innova, Amersfoort, and Department of Mental Health and Neuroscience, Faculty of Health Medicine and Life Sciences, University of Maastricht, Maastricht, The Netherlands
| | - Didi Rhebergen
- Department of Psychiatry and Institute for Health and Care Research, VU University Medical Centre, Amsterdam, The Netherlands
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Stroup TS, Gray N. Management of common adverse effects of antipsychotic medications. World Psychiatry 2018; 17:341-356. [PMID: 30192094 PMCID: PMC6127750 DOI: 10.1002/wps.20567] [Citation(s) in RCA: 243] [Impact Index Per Article: 40.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 06/13/2018] [Accepted: 06/13/2018] [Indexed: 12/16/2022] Open
Abstract
The benefits of antipsychotic medications are sometimes obscured by their adverse effects. These effects range from relatively minor tolerability issues (e.g., mild sedation or dry mouth) to very unpleasant (e.g., constipation, akathisia, sexual dysfunction) to painful (e.g., acute dystonias) to disfiguring (e.g., weight gain, tardive dyskinesia) to life-threatening (e.g., myocarditis, agranulocytosis). Importantly, adverse effect profiles are specific to each antipsychotic medication and do not neatly fit into first- and second-generation classifications. This paper reviews management strategies for the most frequent side effects and identifies common principles intended to optimize net antipsychotic benefits. Only use antipsychotics if the indication is clear; only continue antipsychotics if a benefit is discernible. If an antipsychotic is providing substantial benefit, and the adverse effect is not life-threatening, then the first management choice is to lower the dose or adjust the dosing schedule. The next option is to change the antipsychotic; this is often reasonable unless the risk of relapse is high. In some instances, behavioral interventions can be tried. Finally, concomitant medications, though generally not desirable, are necessary in many instances and can provide considerable relief. Among concomitant medication strategies, anticholinergic medications for dystonias and parkinsonism are often effective; beta-blockers and anticholinergic medications are useful for akathisia; and metformin may lead to slight to moderate weight loss. Anticholinergic drops applied sublingually reduce sialorrhea. Usual medications are effective for constipation or dyslipidemias. The clinical utility of recently approved treatments for tardive dyskinesia, valbenazine and deutetrabenazine, is unclear.
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Affiliation(s)
- T Scott Stroup
- New York State Psychiatric Institute, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Neil Gray
- Department of Psychiatry, John A. Burns School of Medicine, University of Hawaii, Honolulu, HI, USA
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Sinha P, Shetty DJ, Bairy LK, Andrade C. Antidepressant-related jitteriness syndrome in anxiety and depressive disorders: Incidence and risk factors. Asian J Psychiatr 2017; 29:148-153. [PMID: 29061415 DOI: 10.1016/j.ajp.2017.06.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 06/01/2017] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Jitteriness syndrome (JS) is a poorly understood but important adverse effect of antidepressant drugs. This study examined the incidence and pattern of antidepressant-related JS and its predictors. METHODS 209 patients diagnosed with any anxiety or depressive disorder and started on mirtazapine, sertraline, desvenlafaxine, escitalopram or fluoxetine were assessed at baseline, after 2 weeks, and after 6 weeks with psychopathology rating scales and for predefined categories of JS. RESULTS The incidence of JS during the 6-week study was 27.7%, but only 6.7% in first 2 weeks. JS rates were similar in anxiety and depressive disorders. Mirtazapine was associated with the lowest rate of 14.3%, and other antidepressants with rates of 23-34%. High dose antidepressant treatment was significantly associated with JS (OR, 2.68; 95% CI, 1.37-5.25). No other variable predicted JS. JS was associated with significantly higher objective ratings of psychopathology. DISCUSSION We conclude that up to a quarter of patients may suffer JS during the first 6 weeks of antidepressant initiation; higher antidepressant dose is a risk factor.
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Affiliation(s)
- Preeti Sinha
- Department of Psychiatry, Kasturba Medical College, Manipal, Karnataka 576119, India.
| | - Disha Jayaram Shetty
- Department of Pharmacology, Kasturba Medical College, Manipal, Karnataka 576119, India.
| | - Laxminarayana K Bairy
- Department of Pharmacology, Kasturba Medical College, Manipal, Karnataka 576119, India.
| | - Chittaranjan Andrade
- Department of Psychopharmacology, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, Karnataka 560029, India.
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Heintjes EM, Overbeek JA, Penning-van Beest FJA, Brobert G, Herings RMC. Post authorization safety study comparing quetiapine to risperidone and olanzapine. Hum Psychopharmacol 2016; 31:304-12. [PMID: 27297785 DOI: 10.1002/hup.2539] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 03/26/2016] [Accepted: 04/15/2016] [Indexed: 11/08/2022]
Abstract
OBJECTIVES To compare rates of specific adverse outcomes between patients starting quetiapine, olanzapine, or risperidone use in the Netherlands. METHODS Observational study using the PHARMO Database Network, including patients starting quetiapine (4658), olanzapine (5856), or risperidone (7229) in 2000-2009, comparing rates of all-cause mortality, failed suicide attempts, extrapyrimidal symptoms (EPS), diabetes mellitus (DM), hypothyroidism, and acute myocardial infarction (AMI). KEY FINDINGS Median follow-up until discontinuation/end of follow-up was 0.6 years. Prescribed doses were generally lower than the approved defined daily doses, especially for quetiapine. Quetiapine was significantly associated with lower EPS rates (HR 0.18; 95% CI 0.13-0.24), but higher failed suicide attempt rates (HR 2.07; 95% CI 1.35-3.16) compared to risperidone. Quetiapine was significantly associated with lower EPS rates (HR 0.59; 95% CI 0.42-0.84) and DM rates (HR 0.66; 95% CI 0.44-0.97) compared to olanzapine. Rates for all-cause mortality, hypothyroidism, and stroke were similar between groups. AMI events were too infrequent to draw conclusions. CONCLUSIONS Quetiapine was associated with lower EPS, but higher failed suicide attempt rates compared to risperidone. Quetiapine was associated with lower EPS and DM rates compared to olanzapine. The results should be interpreted with caution because of possible channelling and residual confounding. Copyright © 2016 John Wiley & Sons, Ltd.
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8
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Illustrative cases to support the Cal-VAT guidelines. CNS Spectr 2015; 20:311-8. [PMID: 25817927 DOI: 10.1017/s1092852915000127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
There is increasing interest in developing more nuanced methods for managing aggression and violence in long-term psychiatric inpatient settings. However, the dearth of controlled studies has, at times, hampered presentation of viable options. Following the publication of guidelines developed in the California State Hospital forensic system, the authors present a group of 7 cases illustrating different approaches to violence management, including pharmacological, psychotherapeutic, and environmental interventions.
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Bossini L, Casolaro I, Koukouna D, Cecchini F, Fagiolini A. Off-label uses of trazodone: a review. Expert Opin Pharmacother 2012; 13:1707-17. [DOI: 10.1517/14656566.2012.699523] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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10
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Torrey EF, Davis JM. Adjunct treatments for schizophrenia and bipolar disorder: what to try when you are out of ideas. ACTA ACUST UNITED AC 2012; 5:208-216. [PMID: 22182458 DOI: 10.3371/csrp.5.4.5] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The pharmacologic treatment of schizophrenia and bipolar disorder leaves much to be desired. Repurposed drugs, which are approved for other medical conditions, represent an underutilized therapeutic resource for patients who have not responded to other drugs. Using experience gained from a decade of repurposed drug studies by the Stanley Medical Research Institute and search of the literature, we have identified nine such drugs for which there is some evidence of efficacy for schizophrenia and/or bipolar disorder. These include: aspirin; celecoxib; estrogen/raloxifene; folate; minocycline; mirtazapine; omega-3 fatty acids; pramipexole; and, pregnenolone. The evidence of efficacy is reviewed for each drug. Because there is little or no financial incentive for pharmaceutical companies to promote such drugs, there is a paucity of definitive trials, and these drugs are less widely known than they deserve to be. Biomarker studies should also be carried out to identify subgroups of patients who do respond to these drugs.
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Affiliation(s)
- E Fuller Torrey
- The Stanley Medical Research Institute, Chevy Chase, MD 20815, USA.
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Watkins CC, Pieper AA, Treisman GJ. Safety considerations in drug treatment of depression in HIV-positive patients: an updated review. Drug Saf 2011; 34:623-39. [PMID: 21751824 DOI: 10.2165/11592070-000000000-00000] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Major depressive disorder (MDD) is one of the most prevalent illnesses associated with HIV infection, and negatively affects medication adherence, disease progression and mortality in HIV disease. Co-morbid treatment of major depression in HIV disease is the optimal therapeutic approach, but discriminating MDD from normal fluctuations in mood state, personality or physiology is difficult. Definitive diagnosis of MDD is critical for drug safety and for avoiding unnecessary exposure to psychotropic medications. HIV patients respond to antidepressant treatment like the general population, and medication adverse effects and patient adherence are the best predictors of treatment outcome. This review attempts to assist the medical provider with the diagnosis and treatment of MDD in HIV patients. We outline the initial steps in screening and psychiatric referral, the antidepressants that are particularly useful in HIV-infected patients, and the adverse effects and pharmacological strategies for overcoming potential barriers to medication adherence. Potential interactions between the various classes of antidepressants and HIV/antiretroviral therapy, as well as management of HIV medication-related psychiatric adverse effects, are also discussed.
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Affiliation(s)
- Crystal C Watkins
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
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Lee J, Cho SJ, Lee KS, Yook K, Choe AY, Lee S, Kim B, Kim KH, Choi TK, Lee SH. The Tolerability of Mirtazapine Augmentation in Schizophrenic Patients Treated with Risperidone: A Preliminary Randomized Placebo-controlled Trial. CLINICAL PSYCHOPHARMACOLOGY AND NEUROSCIENCE 2011; 9:73-7. [PMID: 23431108 PMCID: PMC3569079 DOI: 10.9758/cpn.2011.9.2.73] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/13/2011] [Revised: 07/22/2011] [Accepted: 08/09/2011] [Indexed: 11/29/2022]
Abstract
Objective Some patients with schizophrenia may need mirtazapine augmentation to improve negative and cognitive symptoms. However there have been a few studies about the tolerability of mirtazapine augmentation to antipsychotics such as akathisia, extrapyramydal symptoms, weight gain, and body mass index (BMI). Methods This study was an eight-week double-blind, randomized controlled trial (RCT) of mirtazapine augmentation to risperidone. Twenty-one stabilized participants diagnosed with schizophrenia and undergoing treatment with risperidone were randomized to adjunctive treatment with mirtazapine (15 mg/day for the first two weeks, 30 mg/day for the next six weeks) or placebo. Eleven patients were assigned to the mirtazapine group, and nine patients were given placebo. Results There was no significant difference between the mirtazapine and placebo groups with respect to Barnes Akathisia rating Scale (BAS) and Sympsom-Angus Scale (SAS). However, the mirtazapine group exhibited a statistically significant increase in weight and BMI (p<0.05). Conclusion These results suggest that mirtazapine augmentation can be tolerable in schizophrenic patients treated with risperidone; however, we should pay attention to the weight gain with mirtazapine. Our results should be replicated in a large-scale lengthy trial.
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Affiliation(s)
- Jieun Lee
- Department of Psychiatry, Bundang CHA Medical Center, CHA University School of Medicine, Seongnam, Korea
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Peters AT, Nierenberg AA, Deckersbach T. A 32-Year-Old Male with Mania, Leg Pain, Migraines. Psychiatr Ann 2011. [DOI: 10.3928/00485713-20110627-09] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Benjamin S, Doraiswamy PM. Review of the use of mirtazapine in the treatment of depression. Expert Opin Pharmacother 2011; 12:1623-32. [DOI: 10.1517/14656566.2011.585459] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
PURPOSE OF REVIEW Akathisa is one of the most common and distressing neuroleptic-induced extrapyramidal side effects. Although it is well recognized in the context of conventional antipsychotic medications, there have been recent concerns raised by clinicians and researchers that this syndrome is overlooked in relation to second-generation or atypical antipsychotics. This review examines the recent literature relevant to second-generation antipsychotic (SGA)-induced akathisia. RECENT FINDINGS Recent studies using large databases clearly indicate that extrapyramidal side effects, in particular akathisia, do occur with the SGAs, although the frequency is not as high as with the conventional antipsychotics. Risk factors include use of high doses, high potency SGAs, or combinations of SGAs with other psychotropic drugs, bipolar depression, palliative care settings, and comorbid substance abuse in psychosis. The dopamine hypothesis remains plausible for understanding the pathophysiology of akathisia. There is emerging evidence that mirtazapine may be useful in the treatment of acute akathisia. SUMMARY Even though akathisia is less prevalent with SGAs than with the first-generation drugs, it remains clinically important and all clinicians should be conversant with its recognition and management.
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Current world literature. Addictive disorder. Curr Opin Psychiatry 2009; 22:331-6. [PMID: 19365188 DOI: 10.1097/yco.0b013e32832ae253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Add-on mirtazapine enhances antipsychotic effect of first generation antipsychotics in schizophrenia: a double-blind, randomized, placebo-controlled trial. Schizophr Res 2009; 108:245-51. [PMID: 19144501 DOI: 10.1016/j.schres.2008.12.002] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2008] [Revised: 12/03/2008] [Accepted: 12/04/2008] [Indexed: 11/22/2022]
Abstract
BACKGROUND Mirtazapine, an antidepressant with a broad spectrum of receptor affinity may, if combined with first generation antipsyhotics (FGAs), improve clinical profile of the FGAs. However, potentiation of the antipsychotic effect by mirtazapine has not been reported thus far. We explored the efficacy of adjunctive mirtazapine on symptoms of schizophrenia in patients having an insufficient response to different FGAs. METHODS Schizophrenia-diagnosed patients with a prolonged disease and a history of a poor response to numerous antipsychotics, who were at least moderately ill despite their FGAs treatment, received add-on mirtazapine (n=20) or placebo (n=19) in a 6-week double-blind randomized controlled trial (RCT). The analysis was made on a Modified Intent-to-Treat (MITT) basis with Last Observations Carried Forward (LOCF). RESULTS Mirtazapine outranged placebo on almost all measures. The clear-cut clinical relevance of this finding was demonstrated by a large effect size of 1.00 (95% CI 0.23-1.67, p=0.003) on the total Positive and Negative Syndrome Scale (PANSS) scores (the primary outcome). The PANSS positive subscale scores decreased by 17.2% with mirtazapine vs. 1.6% with placebo (p<0.001), and the PANSS negative subscale scores by 12% and 3% (p<0.001), correspondingly. CONCLUSIONS This is the first RCT reporting a robust additive antipsychotic effect of an adjunctive antidepressant. Mirtazapine-FGAs combination appears to be a safe, well-tolerated and efficacious treatment option in this challenging population. These findings are important due to the current re-emerging attention to FGAs. The focus of further studies should be expanded to include combinations with or switching to novel antipsychotics, different subpopulations of patients with schizophrenia, finding of optimal doses, and comparison with clozapine.
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2008. [DOI: 10.1002/pds.1492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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