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Melzer-Ribeiro DL, Napolitano IC, Leite SA, Alencar de Souza JA, Vizzotto ADB, Di Sarno ES, Fortes M, Gomes ML, de Oliveira GM, Avrichir BS, Talib LL, Correll CU, Elkis H. Randomized, double-blind, sham-controlled trial to evaluate the efficacy and tolerability of electroconvulsive therapy in patients with clozapine-resistant schizophrenia. Schizophr Res 2024; 268:252-260. [PMID: 38151432 DOI: 10.1016/j.schres.2023.11.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 11/20/2023] [Accepted: 11/21/2023] [Indexed: 12/29/2023]
Abstract
There is no established treatment for patients with clozapine-resistant schizophrenia (CRS). Clozapine augmentation strategies with antipsychotics or others substances are effective in comparison with placebo while and Electroconvulsive therapy (ECT) showed to be effective in comparison with treatment as usual (TAU) but not with placebo (sham-ECT). In the present double- blind randomized controlled trial, we compared 40 outpatients who received 20 sessions of ECT (n = 21) or sham-ECT (n = 19) (age = 37.40 ± 9.62, males = 77.5 %, illness duration = 14.95 ± 8.32 years, mean total Positive and Negative Syndrome Scale (PANSS) = 101.10 ± 24.91) who fulfilled well-defined CRS criteria including baseline clozapine plasma levels ≥350 ng/mL. The primary outcome was the ≥50 % PANSS Total Score reduction; secondary outcomes were the scores of the PANSS subscales, PANSS five-factor dimensions, PANSS-6 and the Calgary Depression Rating Scale (CDRS). Treatment response was analyzed by percentage reduction, Linear Mixed Models and effect sizes. At baseline both groups showed no differences except for years of school education (included as a covariate). At endpoint, only 1/19 of the completers (5.26 %) in the ECT group and 0/17 in the sham-ECT group showed a ≥50 % total PANSS score reduction. Both groups showed no significant differences of the total PANSS score (F = 0.12; p = 0.73), Positive (F = 0.27, p = 0.61), Negative (F = 0.25, p = 0.62), and General Psychopathology scores (F = 0.01, p = 0.94) as well for all PANSS five factors, the PANSS-6 and CDRS. Thus, the present study found no evidence that ECT is better than Sham-ECT in patients with CRS. Future sham-ECT controlled studies with larger sample sizes are warranted to test the efficacy of ECT for patients with CRS.
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Affiliation(s)
- D L Melzer-Ribeiro
- Department and Institute of Psychiatry, University of São Paulo Medical School (FMUSP), Brazil
| | - I C Napolitano
- Department and Institute of Psychiatry, University of São Paulo Medical School (FMUSP), Brazil
| | - S A Leite
- Department and Institute of Psychiatry, University of São Paulo Medical School (FMUSP), Brazil
| | - J A Alencar de Souza
- Department and Institute of Psychiatry, University of São Paulo Medical School (FMUSP), Brazil
| | - A D B Vizzotto
- Department and Institute of Psychiatry, University of São Paulo Medical School (FMUSP), Brazil
| | - E S Di Sarno
- Department and Institute of Psychiatry, University of São Paulo Medical School (FMUSP), Brazil
| | - M Fortes
- Department and Institute of Psychiatry, University of São Paulo Medical School (FMUSP), Brazil
| | - M L Gomes
- Department and Institute of Psychiatry, University of São Paulo Medical School (FMUSP), Brazil
| | - G M de Oliveira
- Department and Institute of Psychiatry, University of São Paulo Medical School (FMUSP), Brazil
| | - B S Avrichir
- Department and Institute of Psychiatry, University of São Paulo Medical School (FMUSP), Brazil
| | - L L Talib
- Department and Institute of Psychiatry, University of São Paulo Medical School (FMUSP), Brazil
| | - C U Correll
- The Zucker Hillside Hospital, Department of Psychiatry, Northwell Health, Glen Oaks, NY, USA; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Department of Psychiatry and Molecular Medicine, Hempstead, NY, USA; Charité - Universitätsmedizin Berlin, Department of Child and Adolescent Psychiatry, Berlin, Germany
| | - H Elkis
- Department and Institute of Psychiatry, University of São Paulo Medical School (FMUSP), Brazil.
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Dong Y, Zhu M, Li Y, Liu N, Wang X, Yang B, Li S, Li Z. Association of cytokines levels, psychopathology and cognition among CR-TRS patients with metabolic syndrome. SCHIZOPHRENIA (HEIDELBERG, GERMANY) 2024; 10:47. [PMID: 38627438 PMCID: PMC11021544 DOI: 10.1038/s41537-024-00469-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 04/02/2024] [Indexed: 04/19/2024]
Abstract
Clozapine-resistant treatment-refractory schizophrenia (CR-TRS) patients face significant clinical challenges. While links between metabolic syndrome (MetS) and inflammatory cytokines in schizophrenia have been established, the relationship between MetS and cytokine levels in CR-TRS patients remains unexplored. This study aimed to investigate the relationship between cytokines levels, clinical symptoms and cognitive impairments in CR-TRS patients, both with and without MetS. The study included 69 CR-TRS patients (31with MetS and 38 without MetS) and 84 healthy controls. The levels of IL-2, IL-6, TNF-α and routine biochemical parameters were measured. Psychopathological symptoms and cognitive function were assessed using the Positive and Negative Syndrome Scale (PANSS) and the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), respectively. We found that CR-TRS patients with MetS displayed lower cognitive function scores compared to those without MetS, even when accounting for potential confounders. TNF-α levels were significantly higher in CRTRS patients with MetS compared to those without MetS, demonstrating substantial pathophysiological potential for CR-TRS patients with MetS via receiver operating characteristic curve (ROC). In CR-TRS patients without MetS, IL-2 independently contributed to the total score and general psychopathology subscore of PANSS. Additionally, IL-6 exhibited an independent contribution to the positive subscore of PANSS. In terms of cognition function, IL-6 independently contributed to the delayed memory of RBANS in CR-TRS patients without MetS. TNF-α could potentially serve as a predictive marker for distinguishing between CR-TRS patients with/without MetS, while IL-2 and IL-6 could independently contribute to psychopathological symptoms or cognitive function in CRTRS patients without MetS. Our study provided insights into the potential interplay between cytokines, clinical symptoms and cognitive impairments in CR-TRS patients with/without MetS.
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Affiliation(s)
- Yeqing Dong
- Institute of Mental Health, Tianjin Anding Hospital, Mental Health Center of Tianjin Medical University, Tianjin, 300222, China
- Psychoneuromodulation Center, Tianjin Anding Hospital, Mental Health Center of Tianjin Medical University, Tianjin, 300222, China
| | - Minghuan Zhu
- Clinical Research Center for Mental Disorders, Shanghai Pudong New Area Mental Health Center, School of Medicine, Tongji University, Shanghai, 200124, China
| | - Yanzhe Li
- Institute of Mental Health, Tianjin Anding Hospital, Mental Health Center of Tianjin Medical University, Tianjin, 300222, China
- Psychoneuromodulation Center, Tianjin Anding Hospital, Mental Health Center of Tianjin Medical University, Tianjin, 300222, China
| | - Nannan Liu
- Institute of Mental Health, Tianjin Anding Hospital, Mental Health Center of Tianjin Medical University, Tianjin, 300222, China
- Psychoneuromodulation Center, Tianjin Anding Hospital, Mental Health Center of Tianjin Medical University, Tianjin, 300222, China
| | - Xinxu Wang
- Institute of Mental Health, Tianjin Anding Hospital, Mental Health Center of Tianjin Medical University, Tianjin, 300222, China
- Psychoneuromodulation Center, Tianjin Anding Hospital, Mental Health Center of Tianjin Medical University, Tianjin, 300222, China
| | - Bing Yang
- Department of Cell Biology, College of Basic Medical Sciences, Tianjin Medical University, Tianjin, 300070, China
| | - Shen Li
- Institute of Mental Health, Tianjin Anding Hospital, Mental Health Center of Tianjin Medical University, Tianjin, 300222, China.
- Psychoneuromodulation Center, Tianjin Anding Hospital, Mental Health Center of Tianjin Medical University, Tianjin, 300222, China.
| | - Zezhi Li
- Department of Nutritional and Metabolic Psychiatry, the Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, 510370, China.
- Guangdong Engineering Technology Research Center for Translational Medicine of Mental Disorders, Guangzhou, China.
- Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Guangzhou Medical University, Guangzhou, China.
- Jiangsu Key Laboratory of Neurodegeneration, Nanjing Medical University, Nanjing, China.
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Machine Learning Algorithm-Based Prediction Model for the Augmented Use of Clozapine with Electroconvulsive Therapy in Patients with Schizophrenia. J Pers Med 2022; 12:jpm12060969. [PMID: 35743753 PMCID: PMC9224640 DOI: 10.3390/jpm12060969] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 06/10/2022] [Accepted: 06/12/2022] [Indexed: 12/17/2022] Open
Abstract
The augmentation of clozapine with electroconvulsive therapy (ECT) has been an optimal treatment option for patients with treatment- or clozapine-resistant schizophrenia. Using data from the Research on Asian Psychotropic Prescription Patterns for Antipsychotics survey, which was the largest international psychiatry research collaboration in Asia, our study aimed to develop a machine learning algorithm-based substantial prediction model for the augmented use of clozapine with ECT in patients with schizophrenia in terms of precision medicine. A random forest model and least absolute shrinkage and selection operator (LASSO) model were used to develop a substantial prediction model for the augmented use of clozapine with ECT. Among the 3744 Asian patients with schizophrenia, those treated with a combination of clozapine and ECT were characterized by significantly greater proportions of females and inpatients, a longer duration of illness, and a greater prevalence of negative symptoms and social or occupational dysfunction than those not treated. In the random forest model, the area under the curve (AUC), which was the most preferred indicator of the prediction model, was 0.774. The overall accuracy was 0.817 (95% confidence interval, 0.793−0.839). Inpatient status was the most important variable in the substantial prediction model, followed by BMI, age, social or occupational dysfunction, persistent symptoms, illness duration > 20 years, and others. Furthermore, the AUC and overall accuracy of the LASSO model were 0.831 and 0.644 (95% CI, 0.615−0.672), respectively. Despite the subtle differences in both AUC and overall accuracy of the random forest model and LASSO model, the important variables were commonly shared by the two models. Using the machine learning algorithm, our findings allow the development of a substantial prediction model for the augmented use of clozapine with ECT in Asian patients with schizophrenia. This substantial prediction model can support further studies to develop a substantial prediction model for the augmented use of clozapine with ECT in patients with schizophrenia in a strict epidemiological context.
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Llorca PM, Nuss P, Fakra É, Alamome I, Drapier D, Hage WE, Jardri R, Mouchabac S, Rabbani M, Simon N, Vacheron MN, Azorin JM. Place of the partial dopamine receptor agonist aripiprazole in the management of schizophrenia in adults: a Delphi consensus study. BMC Psychiatry 2022; 22:364. [PMID: 35643542 PMCID: PMC9142729 DOI: 10.1186/s12888-022-04008-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 05/16/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Aripiprazole is a second-generation antipsychotic, efficacious in patients with schizophrenia during acute episodes. Due to its pharmacological profile, aripiprazole may be of interest in patients with specific clinical profiles who have not been studied extensively in randomised clinical trials. OBJECTIVES To capture experience with aripiprazole in everyday psychiatric practice using the Delphi method in order to inform decision-making on the use of aripiprazole for the treatment of patients with schizophrenia in clinical situations where robust evidence from clinical trials is lacking. METHODS The scope of the survey was defined as the management of schizophrenia in adults. A systematic literature review was performed to identify the different clinical situations in which aripiprazole has been studied, and to describe the level of clinical evidence. Clinical profiles to include in the Delphi survey were selected if there was a clear interest in terms of medical need but uncertainty over the efficacy of aripiprazole. For each clinical profile retained, five to seven specific statements were generated and included in a questionnaire. The final 41-item questionnaire was proposed to a panel of 406 French psychiatrists with experience in the treatment of schizophrenia. Panellists rated their level of agreement using a Likert scale. A second round of voting on eleven items was organised to clarify points for which a consensus was not obtained in the first round. RESULTS Five clinical profiles were identified in the literature review (persistent negative symptoms, pregnancy, cognitive dysfunction, addictive comorbidity and clozapine resistance). Sixty-two psychiatrists participated in the first round of the Delphi survey and 33 in the second round. A consensus was obtained for 11 out of 41 items in the first round and for 9/11 items in the second round. According to the panellists' clinical experience, aripiprazole can be used as maintenance treatment for pregnant women, is relevant to preserve cognitive function and can be considered an option in patients with a comorbid addictive disorder or with persistent negative symptoms. CONCLUSION These findings may help physicians in choosing relevant ways to use aripiprazole and highlight areas where more research is needed to widen the evidence base.
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Affiliation(s)
- Pierre-Michel Llorca
- Department of Psychiatry, Clermont-Ferrand University Hospital, Clermont Auvergne University, Clermont-Ferrand, France.
| | - Philippe Nuss
- grid.412370.30000 0004 1937 1100Psychiatry and Medical Psychology Department, Saint-Antoine Hospital, Paris Sorbonne University, Paris, France
| | - Éric Fakra
- grid.412954.f0000 0004 1765 1491University Hospital Psychiatry Group, Saint-Étienne University Hospital, Saint-Étienne, France
| | - Isabelle Alamome
- Department of Psychiatry, Polyclinic of Limoges, Limoges, France
| | - Dominique Drapier
- grid.410368.80000 0001 2191 9284University Hospital Adult Psychiatry Group, Guillaume-Régnier Hospital, University of Rennes 1, Rennes, France
| | - Wissam El Hage
- grid.12366.300000 0001 2182 6141UMR 1253, iBrain, Tours University, Inserm, Tours, France
| | - Renaud Jardri
- grid.410463.40000 0004 0471 8845Lille Neuroscience & Cognition Centre, INSERM U1172, Fontan Hospital, Lille University Hospital, Lille, France
| | - Stéphane Mouchabac
- grid.412370.30000 0004 1937 1100Psychiatry and Medical Psychology Department, Saint-Antoine Hospital, Paris Sorbonne University, Paris, France
| | - Marc Rabbani
- Medical Affairs Department, Lundbeck SAS, Puteaux, France
| | - Nicolas Simon
- grid.464064.40000 0004 0467 0503Department of Clinical Pharmacology, Aix Marseille University, INSERM, SESSTIM, Hospital Sainte Marguerite, CAP, Marseille, IRD France
| | | | - Jean-Michel Azorin
- grid.414438.e0000 0000 9834 707XDepartment of Psychiatry, Sainte Marguerite Hospital, Marseille, France
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Vasiliu O. Third-generation antipsychotics in patients with schizophrenia and non-responsivity or intolerance to clozapine regimen: What is the evidence? Front Psychiatry 2022; 13:1069432. [PMID: 36523870 PMCID: PMC9744942 DOI: 10.3389/fpsyt.2022.1069432] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 11/02/2022] [Indexed: 11/30/2022] Open
Abstract
Clozapine is considered « the golden standard » for the management of treatment-resistant schizophrenia, but many patients do not present adequate responsivity even to this antipsychotic. If we add the need to strictly monitor the hematologic and cardiometabolic adverse events during each clozapine trial and the difficulty of preserving therapeutic adherence in patients with low insight, residual negative/positive symptoms, or economic challenges, then the necessity of exploring alternative interventions for these patients becomes obvious. Also, in case of intolerance to clozapine or where clozapine did not induce remission, clinicians have to find new ways to help their patients. Switching to other antipsychotics or using these agents as add-ons to clozapine are the main interventions explored in this review, for patients with schizophrenia resistant to clozapine (ultra-resistant schizophrenia, URS). When clozapine intolerance is detected, conversion to another antipsychotic with distinct pharmacologic properties or formulation (e.g., long-acting intramuscular injectable agents, LAI) may be a useful option. Third-generation antipsychotics (TGA) have been selected for their distinct pharmacodynamically profile, which allows, at a theoretical level, their use in combination with clozapine. This narrative review is based on searching four electronic databases, that retrieved 19 primary and secondary reports on aripiprazole (seven case reports or case series presenting 24 patients; nine clinical trials, and three systematic reviews/meta-analyses), two primary reports on brexpiprazole (case report and case series, N = 3 patients), and six primary reports on cariprazine (case reports and case series, N = 14 patients). Based on the information collected from these reports, which included oral and LAI formulations, the TGA most supported by evidence for the augmentation of clozapine is aripiprazole (high-and medium-quality data), followed by cariprazine (low-quality data). Brexpiprazole has not yet been systematically explored for this indication, and in the case of lumateperone, no report could be found. The efficacy of aripiprazole and cariprazine was supported in the domains of positive, negative, and general symptoms, and aripiprazole may positively impact the metabolic profile in patients with URS. Also, adding TGA may lead to a decrease in the dose of clozapine concomitantly administered. More data derived from good quality research are needed in order to confirm the circumstances of TGAs recommendation in patients with URS, either as monotherapy, or added to clozapine.
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Affiliation(s)
- Octavian Vasiliu
- Department of Psychiatry, Dr. Carol Davila University Emergency Central Military Hospital, Bucharest, Romania
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Chakrabarti S. Clozapine resistant schizophrenia: Newer avenues of management. World J Psychiatry 2021; 11:429-448. [PMID: 34513606 PMCID: PMC8394694 DOI: 10.5498/wjp.v11.i8.429] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 04/12/2021] [Accepted: 07/13/2021] [Indexed: 02/06/2023] Open
Abstract
About 40%-70% of the patients with treatment-resistant schizophrenia have a poor response to adequate treatment with clozapine. The impact of clozapine-resistant schizophrenia (CRS) is even greater than that of treatment resistance in terms of severe and persistent symptoms, relapses and hospitalizations, poorer quality of life, and healthcare costs. Such serious consequences often compel clinicians to try different augmentation strategies to enhance the inadequate clozapine response in CRS. Unfortunately, a large body of evidence has shown that antipsychotics, antidepressants, mood stabilizers, electroconvulsive therapy, and cognitive-behavioural therapy are mostly ineffective in augmenting clozapine response. When beneficial effects of augmentation have been found, they are usually small and of doubtful clinical significance or based on low-quality evidence. Therefore, newer treatment approaches that go beyond the evidence are needed. The options proposed include developing a clinical consensus about the augmentation strategies that are most likely to be effective and using them sequentially in patients with CRS. Secondly, newer approaches such as augmentation with long-acting antipsychotic injections or multi-component psychosocial interventions could be considered. Lastly, perhaps the most effective way to deal with CRS would be to optimize clozapine treatment, which might prevent clozapine resistance from developing. Personalized dosing, adequate treatment durations, management of side effects and non-adherence, collaboration with patients and caregivers, and addressing clinician barriers to clozapine use are the principal ways of ensuring optimal clozapine treatment. At present, these three options could the best way to manage CRS until research provides more firm directions about the effective options for augmenting clozapine response.
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Affiliation(s)
- Subho Chakrabarti
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
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Rodrigues-Silva C, Semedo AT, Neri HFDS, Vianello RP, Galaviz-Hernández C, Sosa-Macías M, de Brito RB, Ghedini PC. The CYP2C19*2 and CYP2C19*17 Polymorphisms Influence Responses to Clozapine for the Treatment of Schizophrenia. Neuropsychiatr Dis Treat 2020; 16:427-432. [PMID: 32103962 PMCID: PMC7023876 DOI: 10.2147/ndt.s228103] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 12/21/2019] [Indexed: 02/03/2023] Open
Abstract
INTRODUCTION Clozapine (CLZ) is the gold standard drug for treatment-refractory schizophrenia (TRS). However, approximately 30% of patients partially respond to CLZ, defining this subset with super refractory schizophrenia (SRS). Alterations in enzyme activity may affect CLZ responses; the CYP3A4, CYP1A2 and CYP2C19 genes are primarily responsible for CLZ metabolism. OBJECTIVE The aim of this study was to assess if CYP2C19 variants were associated with TRS or SRS. METHODS CYP2C19*2 loss-of-function and CYP2C19*17 gain-of-function polymorphism genotype testing were performed in 108 individuals undergoing pharmacological treatment for TRS or SRS. DNA was extracted and polymorphisms were analyzed by polymerase chain reaction (PCR) and sequencing. RESULTS CYP2C19*17 had positive correlations with SRS and lower Brief Psychiatric Rating Scale (BPRS) scores for TRS. In addition, CYP2C19*2 was associated with lower CLZ dosages for TRS. CONCLUSION These results show that CYP2C19*2 and CYP2C19*17 polymorphisms influence CLZ responses during schizophrenia treatment.
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Affiliation(s)
- Christielly Rodrigues-Silva
- Department of Pharmacology, Institute of Biological Sciences, Federal University of Goiás, Goiânia, GO, Brazil
| | - Agostinho Tavares Semedo
- Department of Pharmacology, Institute of Biological Sciences, Federal University of Goiás, Goiânia, GO, Brazil
| | | | | | | | - Martha Sosa-Macías
- Instituto Politécnico Nacional, Academia de Genómica, CIIDIR-Durango, Durango, México
| | - Rodrigo Bernini de Brito
- Department of Pharmacology, Institute of Biological Sciences, Federal University of Goiás, Goiânia, GO, Brazil
- Brain Institute Medical Clinic, Bueno Medical Center Building, Goiânia, GO, Brazil
| | - Paulo César Ghedini
- Department of Pharmacology, Institute of Biological Sciences, Federal University of Goiás, Goiânia, GO, Brazil
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Okhuijsen-Pfeifer C, Sterk AY, Horn IM, Terstappen J, Kahn RS, Luykx JJ. Demographic and clinical features as predictors of clozapine response in patients with schizophrenia spectrum disorders: A systematic review and meta-analysis. Neurosci Biobehav Rev 2020; 111:246-252. [PMID: 31982601 DOI: 10.1016/j.neubiorev.2020.01.017] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 12/19/2019] [Accepted: 01/18/2020] [Indexed: 12/27/2022]
Abstract
OBJECTIVES Clozapine (CLZ) is prescribed to (relatively) treatment-resistant patients with schizophrenia spectrum disorders. Currently, it is unknown what factors predict response to CLZ. Therefore, we performed meta-analyses to identify predictors of CLZ response, hence aiming to facilitate timely and efficient prescribing of CLZ. METHODS A systematic search was performed in 'Pubmed' and 'Embase' until 1 January 2019. Articles were eligible if they provided data on predictors of CLZ response measured demographic and clinical factors at baseline or biochemical factors at follow-up in schizophrenia spectrum disorder patients. RESULTS A total of 34 articles, total number of participants = 9386; N unique = 2094, were eligible. Factors significantly associated with better CLZ response were: lower age, lower PANSS negative score and paranoid schizophrenia subtype. CONCLUSION The results of our meta-analyses suggest that three baseline demographic and clinical features are associated with better clozapine response, i.e. relatively young age, few negative symptoms and paranoid schizophrenia subtype. These variables may be taken into account by clinicians who consider treating a specific patient with CLZ.
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Affiliation(s)
- C Okhuijsen-Pfeifer
- Department of Psychiatry, Brain Center, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA, Utrecht, The Netherlands.
| | - A Y Sterk
- Department of Psychiatry, Brain Center, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA, Utrecht, The Netherlands
| | - I M Horn
- Department of Psychiatry, Brain Center, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA, Utrecht, The Netherlands
| | - J Terstappen
- Department of Psychiatry, Brain Center, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA, Utrecht, The Netherlands
| | - R S Kahn
- Department of Psychiatry, Brain Center, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA, Utrecht, The Netherlands; Department of Psychiatry, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1230, 10029, New York City, New York, United States
| | - J J Luykx
- Department of Psychiatry, Brain Center, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA, Utrecht, The Netherlands; GGNet Mental Health, Deventerstraat 459, 7323 PT, Apeldoorn, The Netherlands; Department of Translational Neuroscience, University Medical Center Utrecht, Universiteitsweg 100, 3584 CG, Utrecht, The Netherlands
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Freitas R, Dos Santos B, Altamura C, Bernasconi C, Corral R, Evans J, Malla A, Krebs MO, Nordstroem AL, Zink M, Haro JM, Elkis H. Can the Positive and Negative Syndrome scale (PANSS) differentiate treatment-resistant from non-treatment-resistant schizophrenia? A factor analytic investigation based on data from the Pattern cohort study. Psychiatry Res 2019; 276:210-217. [PMID: 31108345 DOI: 10.1016/j.psychres.2019.05.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Revised: 02/14/2019] [Accepted: 05/01/2019] [Indexed: 12/25/2022]
Abstract
Treatment-Resistant Schizophrenia (TRS) and Non-Treatment-Resistant Schizophrenia (NTRS) may represent different subtypes of schizophrenia. However, few studies have investigated their PANSS symptom dimensions by Exploratory (EFA) or Confirmatory (CFA). Data from the present study are derived from 1429 patients of the Pattern study. TRS was defined by the use of clozapine in the previous year whereas NTRS by the use of non-clozapine antipsychotics ("by proxy"). Factors were chosen based on the Kaiser criterion and considered valid when loadings were greater than or equal to 0.5. The fit to the data was evaluated by CFA in comparison with well-established PANSS models, using fit indexes. The EFA yielded similar five-factor model in both groups: Negative, Positive, Anxiety/Depression, Cognitive and Excited. CFA showed a satisfactory, but not perfect, fit to the data, as compared with the previous PANSS factor analytic models. Despite the limitations regarding the 'by proxy' definition of TRS, the results of the present study show that there are no differences in the factorial structure of PANSS in patients with TRS and NTRS.
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Affiliation(s)
- Rosana Freitas
- Departamento e Instituto de Psiquiatria-Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Bernardo Dos Santos
- Departamento e Instituto de Psiquiatria-Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Carlo Altamura
- University of Milan, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122 Milano, Italy
| | | | - Ricardo Corral
- Fundación para el Estudio y Tratamiento de las Enfermedades Mentales (FETEM), Cerviño 4634 5th floor Apt. B Buenos Aires, (C1425AHQ), Argentina
| | - Jonathan Evans
- Center for Academic Mental Health, University of Bristol, Bristol BS8 2BN, UK
| | - Ashok Malla
- Douglas Mental Health University Institute, McGill University, Montréal, QC H4H 1R3, Canada
| | - Marie-Odile Krebs
- Service Hospitalo Universitaire, Laboratoire de Physiopathologie des Maladies Psychiatriques, Inserm, Université Paris Descartes, Hôpital Sainte-Anne, Paris, France
| | | | - Mathias Zink
- Central Institute of Mental Health, Department of Psychiatry and Psychotherapy, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Josep Maria Haro
- Parc Sanitari Sant Joan de Déu, CIBERSAM, Sant Boi de Llobregat, Barcelona, Spain; Universitat de Barcelona, Spain
| | - Helio Elkis
- Departamento e Instituto de Psiquiatria-Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil.
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Gałaszkiewicz J, Rębisz K, Morylowska-Topolska J, Karakuła-Juchnowicz H, Kozak G. Clozapine-resistant schizophrenia – non pharmacological augmentation methods. CURRENT PROBLEMS OF PSYCHIATRY 2018. [DOI: 10.1515/cpp-2017-0021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Abstract
Clozapine is the drug of choice for drug-resistant schizophrenia, but despite its use, 30-40% patients fail to achieve satisfactory therapeutic effects. In such situations, augmentation attempts are made by both pharmacological and non-pharmacological methods. To date, most of the work has been devoted to pharmacological strategies, much less to augemantation of clozapine with electroconvulsive therapy (C+ECT), transcranial direct current stimulation (tDCS) or transcranial magnetic stimulation (TMS).
Aim: The aim of the work is to present biological, non-pharmacological augmentation treatment methods with clozapine.
Material and methods: A review of the literature on non-pharmacological augmentation treatment methods with clozapine was made. PubMed database was searched using key words: drug-resistant schizophrenia, clozapine, ECT, transcranial magnetic stimulation, transcranial electrical stimulation and time descriptors: 1980-2017.
Results: Most studies on the possibility of increasing the efficacy of clozapine was devoted to combination therapy with clozapine + electric treatments. They have shown improved efficacy when using these two methods simultaneously from 37.5 to 100%. The only randomized trial so far has also confirmed the effectiveness of this procedure. Despite the described side effects of tachycardia or prolonged seizures, most studies indicate the safety and efficacy of combined use of clozapine and electroconvulsive therapy. Transcranial magnetic stimulation also appears to be a safe method in patients treated with clozapine. However, further research is needed before ECT can be included in standard TRS treatment algorithms. The data for combining transcranial electrical stimulation with clozapine, come only from descriptions of cases and need to be confirmed in controlled studies.
Conclusions: The results of studies on the possibility of increasing the effectiveness of clozapine using biological non-pharmacological treatment methods indicate a potentially beneficial effect of this type of methods in breaking the super-resistance in schizophrenia. Combination of clozapine and ECT can be considered as the most recommended strategy among these treatment methods.
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Affiliation(s)
- Joanna Gałaszkiewicz
- I Department of Psychiatry, Psychotherapy and Early Intervention , Medical University of Lublin
| | - Krzysztof Rębisz
- I Department of Psychiatry, Psychotherapy and Early Intervention , Medical University of Lublin
| | | | | | - Gustaw Kozak
- I Department of Psychiatry, Psychotherapy and Early Intervention , Medical University of Lublin
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Melzer-Ribeiro DL, Rigonatti SP, Kayo M, Avrichir BS, Ribeiro RB, Santos BD, Fortes M, Elkis H. Efficacy of electroconvulsive therapy augmentation for partial response to clozapine: a pilot randomized ECT – sham controlled trial. ARCH CLIN PSYCHIAT 2017. [DOI: 10.1590/0101-60830000000116] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
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Abstract
Although treatment-resistant schizophrenia (TRS) was described 50 years ago and has a gold standard treatment with clozapine based on well-defined criteria, there is still a matter of great interest and controversy. In terms of the underlying mechanisms of the development of TRS, progress has been made for the elucidation of the neurochemical mechanisms. Structural neuroimaging studies have shown that patients with TRS have significant reduction of the prefrontal cortex volume when compared with non- TRS. This article updates and enhances our previous review with new evidence mainly derived from new studies, clinical trials, systematic reviews, and meta-analyses.
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Affiliation(s)
- Helio Elkis
- Instituto de Psiquiatria HC- FMUSP, Rua Ovidio Pires de Campos 785-São Paulo, SP-05403-010, Brazil.
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de Brito RB, de Carvalho Araújo L, Diniz MJA, de Castro Georg R, Nabout JC, Vianelo RP, da Silva Santos R, da Silva Cruz AH, Ghedini PC. The CYP1A2 -163C > A polymorphism is associated with super-refractory schizophrenia. Schizophr Res 2015; 169:502-503. [PMID: 26530626 DOI: 10.1016/j.schres.2015.10.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 10/04/2015] [Accepted: 10/09/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Rodrigo Bernini de Brito
- Post-Graduate Program in Biological Sciences, Institute of Biological Sciences, Federal University of Goiás, Goiânia, GO, Brazil; Brain Institute, Bueno Medical Center, Goiânia, GO, Brazil
| | | | | | - Raphaela de Castro Georg
- Post-Graduate Program in Biological Sciences, Institute of Biological Sciences, Federal University of Goiás, Goiânia, GO, Brazil
| | | | - Rosana Pereira Vianelo
- Post-Graduate Program in Biological Sciences, Institute of Biological Sciences, Federal University of Goiás, Goiânia, GO, Brazil
| | - Rodrigo da Silva Santos
- Post-Graduate Program in Biological Sciences, Institute of Biological Sciences, Federal University of Goiás, Goiânia, GO, Brazil
| | - Aline Helena da Silva Cruz
- Post-Graduate Program in Biological Sciences, Institute of Biological Sciences, Federal University of Goiás, Goiânia, GO, Brazil
| | - Paulo César Ghedini
- Post-Graduate Program in Biological Sciences, Institute of Biological Sciences, Federal University of Goiás, Goiânia, GO, Brazil.
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Suzuki T, Kanahara N, Yamanaka H, Takase M, Kimura H, Watanabe H, Iyo M. Dopamine supersensitivity psychosis as a pivotal factor in treatment-resistant schizophrenia. Psychiatry Res 2015; 227:278-82. [PMID: 25863824 DOI: 10.1016/j.psychres.2015.02.021] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2014] [Revised: 01/09/2015] [Accepted: 02/18/2015] [Indexed: 12/26/2022]
Abstract
There may be subtypes in treatment-resistant schizophrenia (TRS), and one of the subtypes may be related to dopamine supersensitivity psychosis (DSP). In developing strategies for prevention and treatment TRS, it is important to clarify the role of DSP in TRS. TRS patients were recruited from 3 hospitals for the present study. Through chart reviews, all patients were judged as either TRS or not, and then possible TRS patients were investigated about their past/present histories of DSP episode(s) by direct interviews. We then compared each factor between the groups with and without DSP episode(s). Out of 611 patients screened, 147 patients met the criteria for TRS and were included in the present analysis. These were divided into groups with and without DSP, comprising 106 (72.1%) and 41 patients (27.9%), respectively. Clinical characteristics in the two groups were similar, except for drug-induced movement disorders (DIMDs), which were significantly more important in DSP patients. Of the DSP patients, 42% and 56% experienced rebound psychosis and tolerance to antipsychotic effects, respectively. The present study revealed that approximately 70% of TRS patients experienced one or more DSP episodes, which may have a strong impact on the long-term prognosis of patients with schizophrenia.
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Affiliation(s)
- Tomotaka Suzuki
- Department of Psychiatry, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuou-ku, Chiba 260-8670, Japan; Department of Psychiatry, Koutoku-kai Sato Hospital, 948-1 Kunugizuka, Nanyo City, Yamagata 999-2221, Japan
| | - Nobuhisa Kanahara
- Department of Psychiatry, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuou-ku, Chiba 260-8670, Japan; Division of Medical Treatment and Rehabilitation, Center for Forensic Mental Health, Chiba University, 1-8-1 Inohana, Chuou-ku, Chiba 260-8670, Japan.
| | - Hiroshi Yamanaka
- Department of Psychiatry, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuou-ku, Chiba 260-8670, Japan; Department of Psychiatry, Chiba Psychiatric Medical Center, 5 Toyosuna, Mihama-ku, Chiba 261-0024, Japan
| | - Masayuki Takase
- Department of Psychiatry, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuou-ku, Chiba 260-8670, Japan
| | - Hiroshi Kimura
- Department of Psychiatry, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuou-ku, Chiba 260-8670, Japan
| | - Hiroyuki Watanabe
- Department of Psychiatry, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuou-ku, Chiba 260-8670, Japan; Division of Medical Treatment and Rehabilitation, Center for Forensic Mental Health, Chiba University, 1-8-1 Inohana, Chuou-ku, Chiba 260-8670, Japan
| | - Masaomi Iyo
- Department of Psychiatry, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuou-ku, Chiba 260-8670, Japan; Division of Medical Treatment and Rehabilitation, Center for Forensic Mental Health, Chiba University, 1-8-1 Inohana, Chuou-ku, Chiba 260-8670, Japan
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Teo C, Borlido C, Kennedy JL, De Luca V. The role of ethnicity in treatment refractory schizophrenia. Compr Psychiatry 2013; 54:167-72. [PMID: 23017781 DOI: 10.1016/j.comppsych.2012.07.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2011] [Revised: 07/02/2012] [Accepted: 07/09/2012] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE The goal of this research was to describe the relationship between treatment resistant schizophrenia, defined using the APA criteria and ethnic background in patients with schizophrenia spectrum disorders in a Canadian sample. A secondary goal was to analyze the number of antipsychotics failed due to side effects and number of antipsychotics failed due to non-response. METHOD We included 497 patients diagnosed with schizophrenia spectrum disorders using the SCID. The medication history was extracted from the electronic health records. Data collection included demographics (sex, age, ethnicity), principal diagnosis according to SCID (Diagnostic and Statistical Manual of Mental Disorders, 4th edition), duration of mental illness, number of psychiatric admissions and treatment information. If patients were on clozapine or polypharmacy treatment, this was recorded at the time of the SCID interview. Additional data, including prior antipsychotic history, were collected from the health records. RESULTS Thirty per cent of the patients were classified as resistant according to the APA criteria. There were significantly more white European subjects in the treatment resistant group (p=0.031). The duration of illness was significantly higher in the resistant group then in the non-resistant group (21.0 vs 15.1 years; p<0.001). Patients who were treatment resistant were more likely to be on polypharmacy compared with non-resistant patients (p=0.001; OR=2.424; 95%CI=1.446-4.065). When we considered the number of drug trials failed due to non response and drug trial failed because of side effects, we found a strong negative correlation in both white Europeans and non-white Europeans. CONCLUSIONS White European ethnicity is associated with treatment resistant schizophrenia. In addition, patients with treatment-resistant schizophrenia were on polypharmacy at higher rate than non resistant patients.
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Affiliation(s)
- Celine Teo
- CAMH, Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada M5T 1R8
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Werneck AP, Hallak JC, Nakano E, Elkis H. Time to rehospitalization in patients with schizophrenia discharged on first generation antipsychotics, non-clozapine second generation antipsychotics, or clozapine. Psychiatry Res 2011; 188:315-9. [PMID: 21596442 DOI: 10.1016/j.psychres.2011.04.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2010] [Revised: 04/10/2011] [Accepted: 04/12/2011] [Indexed: 10/18/2022]
Abstract
Rehospitalization is an important outcome of drug effectiveness in schizophrenia. In this study, the hypothesis that clozapine and some second generation antipsychotics (SGA) were superior to first generation antipsychotics (FGA) in preventing rehospitalization of patients with schizophrenia discharged from a university hospital in Brazil was tested. A retrospective observational study was conducted designed to evaluate time to rehospitalization of patients with schizophrenia discharged on a regimen of oral FGA, depot FGA, risperidone, olanzapine and amisulpride, other SGA, or clozapine, during a three-year follow-up period. Risk factors associated with rehospitalization were examined. Of the 464 patients with schizophrenia discharged from hospital, 242 met criteria for study entry. Higher rehospitalization rates were observed in patients treated with depot FGA (30%), risperidone (30%) and other SGA groups (28.5%), respectively. Clozapine was significantly associated with lower rehospitalization risk compared with risperidone. The risk of rehospitalization in patients on olanzapine and amisulpride, and oral FGA, was similar to that of patients in use of clozapine. These results however, are limited by the heterogeneity of illness severity across the groups.
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Affiliation(s)
- Ana Paula Werneck
- Department and Institute of Psychiatry, University of Sao Paulo Medical School, Rua Dr. Ovidio Pires de Campos 785, Sao Paulo, 05403-010, Brazil.
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Influence of serotonin transporter gene polymorphisms on clozapine response in Brazilian schizophrenics. J Psychiatr Res 2010; 44:1158-62. [PMID: 20452607 DOI: 10.1016/j.jpsychires.2010.04.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2009] [Revised: 03/16/2010] [Accepted: 04/06/2010] [Indexed: 12/16/2022]
Abstract
Schizophrenia is a severe mental illness affecting around 1% of adults with a high degree of morbidity and mortality. Affected individuals are at increased risk for unemployment, handicap, obesity, diabetes mellitus, hearth attack and suicide. Antipsychotic drugs are the best treatment for this disease, but about 20% of patients display drug resistance, or refractoriness, and may receive a special neuroleptic named Clozapine. Despite its superiority from other neuroleptics, only 30-60% of drug-resistant patients are responsive to clozapine. Clozapine's action results from interactions between dopaminergic and serotonergic neurotransmitter systems and since clozapine appears to exert its effect strongly through the serotonergic systems, alterations in serotonin synaptic levels may influence antipsychotic response. The serotonin transporter (5-HTT) is responsible for pre-synaptic re-uptake of serotonin, making this transporter a logical candidate gene for prediction of clozapine response and to increase understanding about mechanisms of refractoriness. Therefore, we investigated the influence of two polymorphisms in the 5-HTT gene (HTTLPR/rs25531 and VNTR Stin2) in clozapine response in a sample of 116 schizophrenic individuals of European descent from South-Brazil. Significant differences between responders and non-responders to clozapine were observed for the HTTLPR/rs25531 polymorphism. Nonresponders to clozapine showed a higher frequency of S'-allele (P = 0.01) and also were more likely to be S'/S' homozygous or S'/L' heterozygous than those who did respond (P = 0.04). After controlling for confounding variables, logistic regression analyses confirmed this association (OR = 3.15; 95% CI: 1.13-8.80). The observed association suggests that increased availability of extracellular serotonin concentrations at all synapses may reduce clozapine effect.
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Sánchez P, Ojeda N, Elizagárate E, Peña J, Ballesteros J, Yoller AB, Gutiérrez M, Casais L, Ezcurra J. Déficit atencionales y respuesta al tratamiento farmacológico en pacientes con esquizofrenia resistente al tratamiento: Resultados mediante análisis factorial confirmatorio. REVISTA DE PSIQUIATRIA Y SALUD MENTAL 2010; 3:40-9. [DOI: 10.1016/j.rpsm.2010.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2009] [Accepted: 02/11/2010] [Indexed: 10/18/2022]
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A false case of clozapine-resistant schizophrenia. Case Rep Med 2010; 2010:534027. [PMID: 20300582 PMCID: PMC2837900 DOI: 10.1155/2010/534027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2009] [Revised: 01/18/2010] [Accepted: 01/19/2010] [Indexed: 11/18/2022] Open
Abstract
One of the subjects that most concerns physicians is treatment-resistance. About 30%-60% of schizophrenia patients do not respond adequately to antipsychotic treatment and are known as refractory schizophrenia patients. Clozapine has been the drug of choice in such cases. However, approximately 30% of them do not respond to clozapine either. Here, we describe a patient with an initial diagnosis of refractory schizophrenia who had a history of dramatic aggressiveness. However, in this case, "refractoriness" was a wrong diagnosis. A case of psychosis secondary to epilepsy had been treated as schizophrenia for almost 20 years. Reports like this one are important because they remind us of how a thorough investigation can lead to the correct diagnosis and improve the patient's prognosis.
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Abstract
The use of cognitive-behavior therapy (CBT) in addition to antipsychotic regimen to treat persistent psychotic symptoms of schizophrenia is growing. The aim of this study was to compare the efficacy of CBT to a befriending (BF) control group in patients with schizophrenia who are refractory to clozapine. Twenty-one patients completed the 21-week trial. In comparison with the control group, the CBT group showed a significant improvement in the General Psychopathology and total score of the Positive and Negative Syndrome Scale, as well as an improvement of Quality of Life scale. The improvement in psychopathology persisted at 6-month follow-up assessment.
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