First-episode schizophrenia: a focus on pharmacological treatment and safety considerations

The Effects of Antipsychotic Treatment on the Brain of Patients With First-Episode Schizophrenia: A Selective Review of Longitudinal MRI Studies

A large number of neuroimaging studies have detected brain abnormalities in first-episode schizophrenia both before and after treatment, but it remains unclear how these abnormalities reflect the effects of antipsychotic treatment on the brain. To summarize the findings in this regard and provide potential directions for future work, we reviewed longitudinal structural and functional imaging studies in patients with first-episode schizophrenia before and after antipsychotic treatment. A total of 36 neuroimaging studies was included, involving 21 structural imaging studies and 15 functional imaging studies. Both anatomical and functional brain changes in patients after treatment were consistently observed in the frontal and temporal lobes, basal ganglia, limbic system and several key components within the default mode network (DMN). Alterations in these regions were affected by factors such as antipsychotic type, course of treatment, and duration of untreated psychosis (DUP). Over all we showed that: (a) The striatum and DMN were core target regions of treatment in schizophrenia, and their changes were related to different antipsychotics; (b) The gray matter of frontal and temporal lobes tended to reduce after long-term treatment; and (c) Longer DUP was accompanied with faster hippocampal atrophy after initial treatment, which was also associated with poorer outcome. These findings are in accordance with previous notions but should be interpreted with caution. Future studies are needed to clarify the effects of different antipsychotics in multiple conditions and to identify imaging or other biomarkers that may predict antipsychotic treatment response. With such progress, it may help choose effective pharmacological interventional strategies for individuals experiencing recent-onset schizophrenia.

[The effectiveness and feasibility of preventive interventions for psychoses]

In recent years, prevention of psychosis in people, who have early signs of its development, but do not fully meet the diagnostic criteria of mental disorder, has been an important issue of research in psychiatry. The article considers the approaches to the intervention in high-risk states of psychosis. At present, it can be considered obvious that early intervention in ultra-high-risk (UHR) individuals, most often consisting of cognitive-behavioral therapy and second generation antipsychotics, is safe, effective and cost-effective even in cases, in which psychosis develops because of the increase in the time before it occurs, reduction of the intensity of stress and improvement of outcomes by reducing the duration of untreated psychosis and lowering probability of hospitalization. Comparative studies of the first generation antipsychotics would be appreciated in UHR. The available data make it possible to state that not only the psychosis prevention should be the goal of interventions, but also trying to maintain personal and social functioning of people with UHR. The main purpose of interventions should be considered not to prevent psychosis, but to achieve more favorable outcomes.

A commentary on the efficacy of olanzapine for the treatment of schizophrenia: the past, present, and future

Olanzapine is a second-generation atypical antipsychotic with proven efficacy for the treatment of schizophrenia. Approved in 1996, olanzapine is one of the most studied antipsychotics, resulting in a considerable amount of clinical data across diverse patient populations. Despite the fact that olanzapine is associated with a known risk of metabolic side effects, including weight gain, many clinicians continue to prescribe olanzapine for the treatment of schizophrenia with the expectation of additional therapeutic antipsychotic efficacy relative to other first-line atypical antipsychotics. The goal of this narrative is to revisit the role of oral olanzapine in the management of patients with schizophrenia, including those with recently diagnosed schizophrenia ("first-episode"), those with an established schizophrenia diagnosis who experience acute exacerbations, those receiving long-term antipsychotic treatment as a maintenance intervention, and those with suboptimal response to antipsychotic treatment, including treatment resistance. Collectively, data from published literature support the favorable efficacy of olanzapine compared with other first- and second-generation antipsychotics, including lower rates of treatment discontinuation and clinically meaningful improvements in the symptoms of schizophrenia. The development of antipsychotic medications with the favorable efficacy of olanzapine, but with reduced weight gain, could address a major unmet need in the treatment of schizophrenia.

A Bayesian Approach to Modeling Risk of Hospital Admissions Associated With Schizophrenia Accounting for Underdiagnosis of the Disorder in Administrative Records

Schizophrenia is a debilitating serious mental illness characterized by a complex array of symptoms with varying severity and duration. Patients may seek treatment only intermittently, contributing to challenges diagnosing the disorder. A misdiagnosis may potentially bias and reduce study validity. Thus we developed a statistical model to assess the risk of 1-year hospitalization for patients diagnosed with schizophrenia, accounting for when schizophrenia is underreported in administrative databases. A retrospective study design identified patients seeking care during 2010 within an integrated health care system from the Health Maintenance Organization Research Network located in the southwestern United States. Bayesian analysis addressed the problem of underdiagnosed schizophrenia with a statistical measurement error model assuming varying rates of underreporting. Results were then compared to classical multivariable logistic regression. Assuming no underreporting, there was an 87% greater relative odds of hospitalization associated with schizophrenia, OR = 1.87, CI [1.08, 3.23]. Effect sizes and interval estimates representing the association between hospitalization and schizophrenia were reduced with the Bayesian approach accounting for underdiagnosis, suggesting that less severe patients may be underrepresented in studies of schizophrenia. The analytical approach has useful applications in other contexts where the identification of patients with a given condition may be underreported in administrative records.

Treatment effect with paliperidone palmitate compared with oral antipsychotics in patients with recent-onset versus more chronic schizophrenia and a history of criminal justice system involvement

AIM

Long-acting injectable antipsychotics (APs) are not well studied in recent-onset schizophrenia. This exploratory analysis of a study designed to reflect real-world schizophrenia, as defined by patients, interventions and outcomes, compared relative treatment effect between once-monthly paliperidone palmitate (PP) and daily oral APs in patients with recent-onset or chronic illness METHODS: This randomized, open-label, event monitoring board-blinded study compared treatment response in subjects with schizophrenia and a history of criminal justice system involvement following treatment with PP or oral APs for 15 months (ClinicalTrials.gov identifier, NCT01157351). Event-free probabilities were estimated using Kaplan-Meier method; hazard ratios (HRs) were estimated using Cox proportional hazard models. This subgroup analysis analysed data by disease duration (≤5 (recent-onset) or >5 years (chronic illness) since first psychiatric diagnosis).

RESULTS

Seventy-seven subjects met the criteria for recent-onset illness; 365 for chronic illness. HRs (95% CI) for treatment failure for oral APs versus PP were 1.73 (0.87-3.45; P = 0.121) for recent-onset and 1.37 (1.02-1.85; P = 0.039) for chronic illness. Most common adverse events for PP versus oral APs were injection site pain (recent-onset, 26% vs. 0%; chronic, 17% vs. 0%), increased weight (14% vs. 6%; 12% vs. 6%), akathisia (14% vs. 9%; 10% vs. 7%), insomnia (12% vs. 17%; 18% vs. 10%) and anxiety (12% vs. 6%; 10% vs. 8%).

CONCLUSIONS

Although neither pre-planned nor adequately powered, the estimated HRs suggest that the relative advantage of PP over oral APs for reducing the risk for treatment failure may be greater in patients with recent-onset schizophrenia than in those with more chronic illness.

New developments in diagnosis and treatment update: Schizophrenia/first episode psychosis in children and adolescents

Childhood onset schizophrenia (COS) is diagnosed before the age of 13 years, and early onset schizophrenia (EOS) is diagnosed before the age of 18 years. EOS is considered extremely rare and its prevalence in comparison to the worldwide prevalence of schizophrenia (1%) has not adequately been studied. Patients who experience the first episode of psychosis need to be treated early and optimally to lessen the morbidity and improve the outcome of the illness. Treatment needs to be a combination of both pharmacological and non-pharmacological modalities. Pharmacological intervention is necessary for remission, improvement of positive symptoms and to aid with the efficacy of psychosocial interventions. There is a lack of efficacy and safety data of the use of antipsychotic medication in children, with most of the information available being extrapolations of adult data. An increased use of atypical antipsychotic drugs in the treatment of EOS has been accompanied by growing concern about the appropriate use and associated side effects in children and adolescents. This update highlights new developments, concepts and treatment trends in EOS.

Patient safety in ambulance services: a scoping review

Background

The role of ambulance services has changed dramatically over the last few decades with the introduction of paramedics able to provide life-saving interventions, thanks to sophisticated equipment and treatments available. The number of 999 calls continues to increase, with adverse events theoretically possible with each one. Most patient safety research is based on hospital data, but little is known concerning patient safety when using ambulance services, when things can be very different. There is an urgent need to characterise the evidence base for patient safety in NHS ambulance services.

Objective

To identify and map available evidence relating to patient safety when using ambulance services.

Design

Mixed-methods design including systematic review and review of ambulance service documentation, with areas for future research prioritised using a Delphi process.

Setting and participants

Ambulance services, their staff and service users in UK.

Data sources

A wide range of data sources were explored. Multiple databases, reference lists from key papers and citations, Google and the NHS Confederation website were searched, and experts contacted to ensure that new data were included in the review. The databases MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, Science Direct, Emerald, Education Resources Information Center (ERIC), Applied Social Sciences Index and Abstracts, Social Services Abstracts, Sociological Abstracts, International Bibliography of the Social Sciences (IBSS), PsycINFO, PsycARTICLES, Health Management Information Consortium (HMIC), NHS Evidence, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE), NHS Economic Evaluation Database (NHS EED),Health Technology Assessment, the FADE library, Current Awareness Service for Health (CASH), OpenDOAR (Directory of Open Access Repositories) and Open System for Information on Grey Literature in Europe (OpenSIGLE) and Zetoc (The British Library's Electronic Table of Contents) were searched from 1 January 1980 to 12 October 2011. Publicly available documents and issues identified by National Patient Safety Agency (NPSA), NHS Litigation Authority (NHSLA) and coroners’ reports were considered. Opinions and perceptions of senior managers, ambulance staff and service users were solicited.

Review methods

Data were extracted from annual reports using two-stage thematic analysis, data from quality accounts were collated with safety priorities tabulated and considered using thematic analysis, NPSA incident report data were collated and displayed comparatively using descriptive statistics, claims reported to NHSLA were analysed to identify number and cost of claims from mistakes and/or poor service, and summaries of coroners’ reports were assessed using thematic analysis to identify underlying safety issues. The depth of analysis is limited by the remit of a scoping exercise and availability of data.

Results

We identified studies exploring different aspects of safety, which were of variable quality and with little evidence to support activities currently undertaken by ambulance services. Adequately powered studies are required to address issues of patient safety in this service, and it appeared that national priorities were what determined safety activities, rather than patient need. There was inconsistency of information on attitudes and approaches to patient safety, exacerbated by a lack of common terminology.

Conclusion

Patient safety needs to become a more prominent consideration for ambulance services, rather than operational pressures, including targets and driving the service. Development of new models of working must include adequate training and monitoring of clinical risks. Providers and commissioners need a full understanding of the safety implications of introducing new models of care, particularly to a mobile workforce often isolated from colleagues, which requires a body of supportive evidence and an inherent critical evaluation culture. It is difficult to extrapolate findings of clinical studies undertaken in secondary care to ambulance service practice and current national guidelines often rely on consensus opinion regarding applicability to the pre-hospital environment. Areas requiring further work include the safety surrounding discharging patients, patient accidents, equipment and treatment, delays in transfer/admission to hospital, and treatment and diagnosis, with a clear need for increased reliability and training for improving handover to hospital.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Efficacy, safety, and impact on hospitalizations of paliperidone palmitate in recent-onset schizophrenia

OBJECTIVE

To evaluate the efficacy, safety, and impact on hospitalizations of long-acting injectable paliperidone palmitate (PP) treatment, in patients with recent-onset schizophrenia who had not responded satisfactorily to oral antipsychotics.

METHODS

In this 18-month, open-label, Phase-IIIb study from Asia-Pacific region, patients (18-50 years) with recent-onset (≤5 years) schizophrenia unsatisfactorily treated with previous oral antipsychotics were initiated on PP 150 mg eq on day 1, 100 mg eq on day 8, followed by flexible once monthly maintenance doses of 50-150 mg eq. The number and duration of hospitalizations were compared using a mirror analysis method between two periods: retrospective (12 months before PP initiation) and prospective (12 and 18 months after PP treatment) periods.

RESULTS

A total of 303 out of 521 (58%) patients (mean age, 28.7 years; 65.5% men, 92.5% Asian) completed the study. Positive and Negative Syndrome Scale (PANSS) total score improved significantly from baseline to month 18 (mean [standard deviation, SD] change: -11.3 [21.38], P<0.0001, primary endpoint). Subgroup analysis revealed greater improvements among patients with worse disease severity at baseline: PANSS ≥70 versus <70 (mean [SD] change: -23.1 [24.62] vs -4.7 [15.98], P<0.0001 each). Secondary efficacy endpoints such as Clinical Global Impression of Schizophrenia (CGI-SCH), Medication Satisfaction Questionnaire (MSQ) scores showed significant improvements (P<0.0001) from baseline; 33.3% patients achieved symptom remission. In mirror analyses set (N=474), PP significantly (P<0.0001) reduced mean number of hospitalization days/person/year (12-month: 74.3 vs 19.7; 18-month: 74.3 vs 18.9) as well as percentage of patients requiring hospitalization in past 12 months (12-month: 39.7% vs 24.6%; 18-month: 39.7% vs 25%), and PP treatment increased the proportion of patients not requiring hospitalization (12-month: 60.3% vs 75.4%; 18-month: 60.3% vs 75%) from retrospective to prospective period. Adverse events (≥15%) were extrapyramidal symptoms-related (31.3%), injection-site pain (18.6%), and insomnia (15.2%).

CONCLUSION

PP was efficacious and generally tolerable with significant reductions observed in both number of hospitalizations and days spent in hospital.

The role of long-acting injectable antipsychotics in schizophrenia: a critical appraisal

Despite their widespread use, long-acting injectable (LAI) antipsychotics (APs) are often regarded with some negativity because of the assumption of punishment, control and insufficient evolution towards psychosocial development of patients. However, LAI APs have proved effective in schizophrenia and other severe psychotic disorders because they assure stable blood levels, leading to a reduction of the risk of relapse. Therapeutic opportunities have also arisen after introduction of newer, second-generation LAI APs in recent years. Newer LAI APs are more readily dosed optimally, may be better tolerated and are better suited to integrated rehabilitation programmes. This review outlines the older and newer LAI APs available for the treatment of schizophrenia, with considerations of past and present pharmacological and therapeutic issues. Traditional, evidence-based approaches to systematic reviews and randomized clinical trials are of limited utility in this area so this paper's blending of experimental trials with observational research is particularly appropriate and effective.

Olanzapine abuse

Olanzapine is a thienobenzodiazepine that blocks especially the serontonin (5-hydroxytryptamine [5-HT]) 5-HT2A and the dopamine D2 receptors as well as muscarinic (M1), histamine (H1), 5-HT2C, 5-HT3 to 5-HT6, adrenergic (α(l)), and D4 receptors. This case report presents an olanzapine abuse. A 48-year-old, primary school graduate, married woman applied to psychiatry clinic with tachycardia, insomnia, and anxiety complaints. In psychiatric evaluations, it was determined that these complaints have been continuing for 15 years at intervals and that she has been using citalopram 40 mg/day and olanzapine 50 mg/day for the last 3 years. As diabetes mellitus was diagnosed in follow-ups, interruption of olanzapine treatment was planned. The patient stated that she started taking the medicine again upon discomfort, increase in anxiety, dysphoria, insomnia, and nervousness, which started just after olanzapine was interrupted. She said that she was feeling dense stress when she did not take the medicine, and she thought that this situation would recover only by taking that medicine and hence she could not discontinue the medicine. In addition to medications with obvious abuse potential such as benzodiazepines and methylphenidate, and other stimulants, abuse of a number of commonly prescribed psychiatric medications has been reported. There are only 2 cases of olanzapine abuse in literature.

Antipsychotic interventions in prodromal psychosis: safety issues

In recent years, psychopharmacological intervention in prodromal psychosis, also known as the ultra-high risk (UHR) mental state for psychosis, has attracted much attention. Whilst it has been shown that antipsychotic use in UHR individuals may be effective in potentially delaying or even averting progression to frank psychosis, their use in subjects that do not necessarily convert to psychosis has raised considerable ethical concerns because of their adverse effects. Recent treatment guidelines for patients at UHR for psychosis recommend the use of antipsychotics only in exceptional conditions and with great precautions. To date only a few studies have investigated the use of antipsychotic medications in UHR patients and the potential benefits and risks related to their use in prodromal psychosis remain unclear. We review here all published studies that included UHR patients treated with antipsychotics, regardless of study design. These studies were all of second-generation antipsychotics, given that first-generation antipsychotics cannot be recommended because of their adverse drug reactions. We specifically examine the available descriptions of adverse reactions of the individual antipsychotic medication in each study and discuss the potential effects of various demographic and clinical factors that may impact on safety issues of pharmacological interventions in UHR patients. Clinical trials to date investigating potential benefits of antipsychotic treatments in preventing transition to psychosis were of relatively short duration and have involved a small number of patients. Whilst it appears that pharmacological intervention at this stage may be effective in both reducing the psychopathology and decreasing transition rates, and is potentially safe, in the absence of sufficient evidence-based knowledge to guide treatment, definitive clinical recommendations and guidelines cannot be derived. Certain adverse events take time to develop, such as metabolic syndrome and endocrine-related effects, thus longer term clinical trials with a larger number of patients are needed to determine the effectiveness of antipsychotic intervention and the relationship of its duration to emergence of adverse events. This can inform the development of timely strategies to prevent serious negative impacts and thus maximize the benefits of antipsychotic intervention in UHR patients that outweigh the risks associated with their use.

One-year, randomized, open trial comparing olanzapine, quetiapine, risperidone and ziprasidone effectiveness in antipsychotic-naive patients with a first-episode psychosis

The aim of this study was to compare the 12-month effectiveness of several second-generation antipsychotic drugs, with that of haloperidol in never-treated patients with first-episode psychosis. In total, 114 patients without life time exposure to any psychotropic medication were randomized to haloperidol, olanzapine, risperidone, quetiapine or ziprasidone. Primary outcome was time to all-cause discontinuation. Secondary outcomes included discontinuation rates and symptom change as measured by the Positive and Negative Syndrome Scale (PANSS). The overall discontinuation rate 64%. At 12 months, the proportion of patients discontinuing treatment was 40.0% for olanzapine, 56.5% for quetiapine, 64.0% for risperidone, 80.0% for ziprasidone and 85.7% for haloperidol. Mean time to antipsychotic discontinuation was higher in patients randomized to second-generation antipsychotics than in those taking haloperidol. Significantly lower discontinuation was noted in patients on olanzapine than on haloperidol, or ziprasidone. Our results suggest that olanzapine might lead to longer treatment continuation in treatment naïve FEP patients than haloperidol and, possibly ziprasidone. Global psychopathology was significantly less reduced by haloperidol than with each individual SGA in this earliest phase of treatment.

Akathisia and suicidal ideation in first-episode schizophrenia

Patients with first-episode schizophrenia (FES) are known to be notably sensitive for developing extrapyramidal adverse effects, but the relation of akathisia and suicidal ideation has rarely been studied. The current report is an ongoing analysis of an 8-week double-blind randomized controlled multicenter trial in 289 FES, comparing risperidone and haloperidol. Assessments were conducted weekly and included the Hillside Akathisia Scale and 21-item Hamilton Depression Rating Scale ratings. Suicidal ideation was significantly associated with clinician observed akathisia, depressed mood, younger age, and use of propranolol. The allocated treatment, anxiety, and nervousness had no influence. The present findings suggest a promoting effect of akathisia on suicidal ideation can not be ruled out in patients with FES.

Long-acting injectable antipsychotics for first-episode schizophrenia: the pros and cons

Clinical and psychosocial deterioration associated with schizophrenia occurs within the first few years following the onset of the illness. Therefore, to improve the long-term prognosis, it is important to provide schizophrenia patients with intensive treatment following their first episode. Relapse is highly associated with partial medication adherence or nonadherence in patients with first-episode schizophrenia. Recent studies suggest that long-acting injectable (LAI) antipsychotics compared with oral antipsychotics are more effective for medication adherence and relapse prevention. Moreover, some clinical guidelines for the treatment of schizophrenia suggested that LAI antipsychotics should be considered when patients are nonadherent "at any stage." Decreased compliance is a common cause of relapse during the initial stages of the disease. Therefore, LAI antipsychotics should be highly considered when treating patients with first-episode schizophrenia. In the present paper, clinical trial data and current guidelines on the use of LAI antipsychotics for first-episode schizophrenia are discussed as well as the pros and cons of this treatment option.

Long-term (3-year) effectiveness of haloperidol, risperidone and olanzapine: results of a randomized, flexible-dose, open-label comparison in first-episode nonaffective psychosis

RATIONALE

To enhance the effectiveness of antipsychotics in first-episode psychosis is crucial in order to achieve the most favourable prognosis. Difference in effectiveness between antipsychotics is still under debate.

OBJECTIVE

The purpose of this study is to determine the long-term (3-year) effectiveness and efficacy of haloperidol, risperidone and olanzapine in first-episode schizophrenia-spectrum disorders.

METHOD

This is a prospective, randomized, open-label study. Data for the present investigation were obtained from a large epidemiologic and 3-year longitudinal intervention programme of first-episode psychosis. One hundred seventy-four patients were randomly assigned to haloperidol (N = 56), olanzapine (N = 55), or risperidone (N = 63) and followed up for 3 years. The primary effectiveness measure was all-cause of treatment discontinuation. In addition, an analysis based on per-protocol populations was conducted in the analysis for clinical efficacy.

RESULTS

The treatment discontinuation rate for any cause differed significantly between treatment groups (χ (2) = 10.752; p = 0.005), with a higher rate in haloperidol than in risperidone and olanzapine. The difference in the discontinuation rate between risperidone and olanzapine showed a tendency towards significance (χ (2) = 3.022; p = 0.082). There was a significant difference in the mean time to all-cause discontinuation between groups (log-rank χ ( 2 ) = 12.657;df = 2; p = 0.002). There were no significant advantages to any of the three treatments in reducing the psychopathology severity.

CONCLUSIONS

After 3 years of treatment, a lower effectiveness was observed in haloperidol compared to second-generation antipsychotics (SGAs). The use of SGAs for the treatment of early phases of nonaffective psychosis may enhance the effectiveness of antipsychotics.

Long-term tolerability of once-monthly injectable paliperidone palmitate in subjects with recently diagnosed schizophrenia

BACKGROUND

A post hoc analysis from a multiphase trial with open-label transition and maintenance phases, a double-blind relapse prevention phase, and an optional open-label extension examined the long-term tolerability with continuous once-monthly injectable paliperidone palmitate 39, 78, 117, or 156 mg (25, 50, 75, or 100 mg equivalents [mg eq] of paliperidone) in subjects with recently diagnosed (≤5 years; n = 216) versus chronic illness (>5 years; n = 429) schizophrenia.

METHODS

Adverse events reported at a ≥2% margin between subgroups were identified. Relative risks (in the recently diagnosed compared with the chronically ill) and 95% confidence intervals (CI) were determined, and CI not including 1 were considered potentially significant.

RESULTS

In both subgroups, the mean monthly dose was 109 mg (69.9 mg eq). Continuous mean exposures were 333.9 ± 271.9 and 308.7 ± 278.3 days in the recently diagnosed and chronic illness subgroups, respectively. Using the criteria outlined in the methods, nasopharyngitis was a potentially significant event reported in more chronically ill than recently diagnosed subjects at months 6, 9, 12, and endpoint (7.2% versus 2.8%; relative risk 0.384; 95% CI 0.163-0.907). Influenza (2.8% versus 0.7%; relative risk 3.9; 95% CI 1.003-15.730) and amenorrhea (3.2% versus 0.9%; relative risk 3.476; 95% CI 1.029-11.744) at endpoint were potentially significant events in more recently diagnosed than chronically ill subjects. Mean weight changes, sedation/somnolence, any extrapyramidal symptom-related or glucose-related events were generally similar between the groups. The mean prolactin level increased in both sexes in both subgroups (changes from baseline of +41.8 ng/mL and +26.5 ng/mL in recently diagnosed and chronic illness females and +12.3 ng/mL and +15.1 ng/mL in recently diagnosed and chronic illness males, respectively), and were higher in females with recently diagnosed illness than in females who were chronically ill (P = 0.0002 at endpoint). Prolactin-related events were reported by 7.9% of recently diagnosed subjects with schizophrenia and 3.5% of those who were chronically ill.

CONCLUSION

The long-term tolerability of paliperidone palmitate was generally similar in recently diagnosed schizophrenia subjects and those with more chronic illness, with the exception of some prolactin-related measures.

Tolerability of initiation doses of once-monthly paliperidone palmitate in patients with recently diagnosed schizophrenia in an acute treatment trial

OBJECTIVE

To examine the tolerability of the recommended initiation doses for once-monthly injectable paliperidone palmitate in patients who have recently been diagnosed with schizophrenia and for whom high doses may pose tolerability concerns.

METHODS

A post hoc analysis from a 13-week double-blind study of patients with schizophrenia randomized 1:1:1:1 to placebo or paliperidone palmitate at 25, 100, or 150 mg equivalents (mg eq) of paliperidone (corresponding to 39, 156, or 234 mg respectively). This analysis focused on the recently diagnosed subgroup (≤5 years; N = 146) who received the recommended initiation dosage of paliperidone palmitate [150 mg eq on day 1 (n = 109) followed by 100 mg eq on day 8 (n = 39)] or placebo (n = 37). Adverse events (AEs), reported in ≥2% of patients receiving paliperidone palmitate during days 1-7 or ≥5% during days 8-36, and in a higher percentage of patients receiving paliperidone palmitate than placebo, were identified. AE relative risks (RRs) and 95% confidence intervals (CIs) were determined. A RR was considered potentially significant when its 95% CI did not include 1.

RESULTS

Overall, day 1-7 AE rates were 37.6% (41 of 109) and 29.7% (11 of 37) with paliperidone palmitate and placebo respectively; injection site pain (5.5% versus 2.7%, RR 2.0; 95% CI 0.25 to 16.37), agitation (4.6% versus 2.7%; RR 1.7; 95% CI 0.21 to 14.06), and headache (3.7% versus 0.0%; RR 3.1; 95% CI 0.17 to 56.41) met the ≥2% criteria. Day 8-36 AE rates were 41.0% (16 of 39) and 37.8% (14 of 37) with paliperidone palmitate and placebo respectively; anxiety (5.1% versus 0.0%; RR 4.8; 95% CI 0.24 to 95.76) met the ≥5% criteria. Key limitations were that some patients may have been ill for a significant time before formal diagnosis and that the number of patients is low in this subgroup, limiting the ability to detect statistical significance for AE RRs.

CONCLUSIONS

Paliperidone palmitate initiation doses (150 mg eq day 1, 100 mg eq day 8) were tolerated in this subgroup of patients who were recently diagnosed with schizophrenia, with no unexpected findings. Although the same size was small, these data identified AEs that may be encountered during the week and month after initiation dosing. These findings may assist clinicians when paliperidone palmitate is considered an appropriate treatment choice for these patients.

Weight gain associated with taking psychotropic medication: an integrative review

People with serious mental illness have higher morbidity and mortality rates than general populations, and overweight/obesity-related conditions are prevalent. Psychotropic medications are a primary factor in significant weight gain. Adolescents and young adults, particularly those with first-episode psychoses taking atypical antipsychotics, are susceptible to weight gain. This paper reports findings from an integrative review of research investigating the impact and treatment of psychotropic-induced weight gain. Four databases were searched, yielding 522 papers. From these and hand-searched papers, 36 research reports were systematically classified and analysed. The review revealed people experiencing psychotropic-induced weight gain perceive it as distressing. It impacts on quality of life and contributes to treatment non-adherence. Weight management and prevention strategies have primarily targeted adults with existing/chronic illness rather than those with first-episode psychoses and/or drug naiveté. Single and multimodal interventions to prevent or manage weight gain produced comparable, modest results. This review highlights that the effectiveness of weight management interventions is not fully known, and there is a lack of information regarding weight gain prevention for young people taking psychotropics. Future research directions include exploring the needs of young people regarding psychotropic-related weight gain and long-term, follow-up studies of lifestyle interventions to prevent psychotropic-related weight gain.

Effectiveness of haloperidol, risperidone and olanzapine in the treatment of first-episode non-affective psychosis: results of a randomized, flexible-dose, open-label 1-year follow-up comparison

The aim of this study was to investigate the long-term effectiveness and efficacy of haloperidol, risperidone and olanzapine in first-episode schizophrenia-spectrum disorders. This was a prospective, randomized, open-label study. Data for the present investigation were obtained from a large epidemiological and 3-year longitudinal intervention programme of first-episode psychosis conducted at the University Hospital Marques de Valdecilla, Santander, Spain. One hundred and seventy-four patients were randomly assigned to haloperidol (N = 56), olanzapine (N = 55), or risperidone (N = 63) and followed up for 1 year. The primary effectiveness measure was all causes of treatment discontinuation. Effectiveness analyses were based on intend-to-treat populations. In addition, an analysis based on per protocol populations was conducted in the analysis for clinical efficacy. The treatment discontinuation rate for any cause was higher with haloperidol than with risperidone and olanzapine (χ(2) = 8.517; p = 0.014). The difference in discontinuation rate between risperidone and olanzapine was not significant (χ(2) = 0.063; p = 0.802). There were no significant advantages of any of the three treatments in reducing the severity of psychopathology. Risperidone and olanzapine demonstrated higher effectiveness relative to haloperidol, but the three antipsychotics were equally effective in reducing the severity of psychopathology. Specific clinical programmes and the use of second-generation antipsychotics may enhance the effectiveness of antipsychotic treatments.

Weight gain in antipsychotic-naive patients: a review and meta-analysis

BACKGROUND

Weight gain is a long-recognized side-effect of antipsychotic (AP) drugs and a major health concern in the treatment of psychosis. The strength of the causal relationship between AP drug exposure and weight gain can only be gauged by a drugs trial conducted on AP-naive patients.

METHOD

We conducted a review of the literature regarding the amount of weight gain induced by APs in AP-naive patients and carried out a meta-analysis of mean weight gains.

RESULTS

We found 11 primary studies reporting the effects of APs on body weight or body mass index (BMI) in AP-naive patients. The mean body weight and BMI gains in AP-naive patients were highly significant from the first weeks of treatment. When we limited the analysis to studies conducted on patients hospitalized and without any adjunctive treatment potentially affecting weight, the resultant sample showed less heterogeneity and confirmed the final picture of weight gain at around 3.8 kg and 1.2 points BMI.

CONCLUSIONS

Weight gain associated with AP therapy in AP-naive patients occurs rapidly in the first few weeks and continues during the following months. Clinicians should be aware of the high probability of causing weight gain in AP-naive patients and should strictly monitor such patients.

The 2009 schizophrenia PORT psychopharmacological treatment recommendations and summary statements

In light of the large number of studies published since the 2004 update of Schizophrenia Patient Outcomes Research Team psychopharmacological treatment recommendations, we conducted an extensive literature review to determine whether the current psychopharmacological treatment recommendations required revision and whether there was sufficient evidence to warrant new treatment recommendations for prespecified outcomes of interest. We reviewed over 400 articles, which resulted in 16 treatment recommendations: the revision of 11 previous treatment recommendations and 5 new treatment recommendations. Three previous treatment recommendations were eliminated. There were 13 interventions and/or outcomes for which there was insufficient evidence for a treatment recommendation, and a statement was written to summarize the current level of evidence and identify important gaps in our knowledge that need to be addressed. In general, there was considerable consensus among the Psychopharmacology Evidence Review Group and the expert consultants. Two major areas of contention concerned whether there was sufficient evidence to recommend specific dosage ranges for the acute and maintenance treatment of first-episode and multi-episode schizophrenia and to endorse the practice of switching antipsychotics for the treatment of antipsychotic-related weight gain. Finally, there continue to be major gaps in our knowledge, including limited information on (1) the use of adjunctive pharmacological agents for the treatment of persistent positive symptoms or other symptom domains of psychopathology, including anxiety, cognitive impairments, depressive symptoms, and persistent negative symptoms and (2) the treatment of co-occurring substance or medical disorders that occur frequently in individuals with schizophrenia.

Regulation of pituitary adenylyl cyclase-activating polypeptide (PACAP, ADCYAP1: adenylyl cyclase-activating polypeptide 1) in the treatment of schizophrenia

BACKGROUND

Deficiency of pituitary adenylyl cyclase-activating polypeptide (PACAP) and its specific receptor, PAC1, causes a schizophrenia-like phenotype in mice. In addition, the relation of the PACAP and PAC1 genes to schizophrenia has been shown by single-nucleotide polymorphism association studies. Furthermore, PACAP is reported to be involved in the function of disrupted-in-schizophrenia 1.

OBJECTIVE

To summarize briefly the recent evidence relating the PACAP system and schizophrenia and discuss the application of PACAP to the treatment of schizophrenia.

RESULTS/CONCLUSION

The regulation of PACAPergic signals is an interesting potential treatment for schizophrenia. Further studies of PACAP signals and the association of PACAP signals with schizophrenia should shed the light on the utility of this approach in the treatment of schizophrenia.

Long-term, naturalistic treatment with olanzapine, risperidone, quetiapine, or haloperidol monotherapy: 24-month results from the Intercontinental Schizophrenia Outpatient Health Outcomes (IC-SOHO) study

Objective. To compare the effectiveness of olanzapine, risperidone, quetiapine, or haloperidol monotherapy in patients with schizophrenia who were treated in routine clinical practice settings for a period of 2 years. The incidence and persistence of adverse events encountered during long-term therapy are also reported. Method. Outpatients with schizophrenia who entered this 3-year, prospective, observational study were classified according to their initially prescribed antipsychotic monotherapy: olanzapine (n=3222), risperidone (n=1116), quetiapine (n=189), or haloperidol (n=256). Patients were included in the analysis for as long as this treatment was maintained. Results. Over 2 years, olanzapine recipients had significantly (P≤0.001) greater reduction in overall CGI-S score (and the negative, depressive, and cognitive symptoms domains), lower incidence of sexual and motor dysfunction, and greater odds of response compared to risperidone or haloperidol-treated patients. However, olanzapine patients gained more weight than patients in other treatment groups. The incidence of motor dysfunction was significantly (P≤0.001) greater in haloperidol-treated patients, relative to the atypical treatment groups. Conclusion. The results of this observational study indicate that, in these patients with schizophrenia, long-term monotherapy with olanzapine may offer benefits over risperidone and haloperidol, but the potential for weight gain should be considered in the clinical management of these patients.

Weight gain, dyslipidemia and altered parameters for metabolic syndrome on first episode psychotic patients after six-month follow-up

OBJECTIVES: Obesity and metabolic abnormalities are frequent in psychotic patients, including first-episode psychosis. We evaluated weight and metabolic parameters in first-episode psychotic outpatients from the First Episode Psychosis Program, Universidade Federal de São Paulo. METHOD: Weight, height, waist and hip circumferences, glucose and lipid levels were measured at baseline and after a six-month period. RESULTS: Fifty-seven patients were included and 44 (77.2%) of them finished the study. Patients had a median age of 26.3 years, 60% were men and 43% had a diagnosis of schizophrenia at the endpoint. Weight and BMI values increased significantly during the follow-up (p < 0.01). The average weight gain at the follow-up was 10.1% of the baseline weight (SD = 11.9). Only women presented significant waist abnormalities: at the first assessment the waist mean was 79.12 cm (SD = 10.68) and 6 months later it had increased to 89.65 cm (SD = 11.19, z = -3.182, p = 0.001). After 6 months, the total cholesterol (p = 0.004), and triglyceride levels (p = 0.016) increased, while HDL-cholesterol levels decreased (p = 0.025). During the follow-up period one patient (2.3%) developed diabetes mellitus, one (2.3%) presented altered fasting glucose, 12 (27.2%) patients developed at least two altered parameters for metabolic syndrome and 3 (6.8%) patients developed metabolic syndrome (p = 0.001). DISCUSSION: The results of this study showed that in a short period of time individuals under antipsychotic treatment had their weight increased significantly and developed important metabolic abnormalities. CONCLUSIONS: Clinicians should be aware of these risks, choose an antipsychotic that causes less weight gain and should monitor these patients carefully, and recommend prophylactic measures as diet restriction and physical activities.

Schizophrenia endophenotypes as treatment targets

Schizophrenia is a complex disorder that encompasses several clinical symptom domains and functional impairments. Existing treatments are meager, effective only against positive symptoms without benefiting negative symptoms and functional impairments. The drug discovery process has focused mostly on targeting D2 dopamine receptors. This followed the serendipitous discovery of the antipsychotic effects of chlorpromazine in the 1950s and, more recently, clozapine. There is a need to identify novel mechanisms in order to discover novel drugs that are effective against each of the symptom clusters and functional impairments associated with the illness. Neurophysiological studies in schizophrenia over the past 3 decades have identified several brain deficits that are stable, using valid animal models that are related to the etiology of the disorder. Many of these deficits are distinct and heritable; these are called endophenotypes. Many have well-characterized neurobiology and may therefore provide molecular targets for drug development. In addition, these endophenotypes help reduce the heterogeneity by identifying homogeneous subgroups of patients with similar pathophysiology, symptoms and functional deficits. Clinical trials of drugs, whose development is based on an endophenotype, will have enhanced statistical power when the trial is carried out in an appropriate cohort of subjects using outcome measures related to the corresponding endophenotype. Furthermore, genes that are associated with these endophenotypes are beginning to be identified. These findings will identify novel molecular targets for drug development with treatment implications for clinical symptom complex and functional deficits marked by the endophenotype. As endophenotypes are present during childhood and adolescence, novel drugs that are developed on the basis of this subgroup could have implications for preventive strategies in schizophrenia.

Understanding and treating "first-episode" schizophrenia

"First-episode schizophrenia" is a clinical and research term that often is used to emphasize the special issues that arise when working with this patient population. The notion that schizophrenia has an inexorable downhill course or is a deteriorating illness is being challenged by more sophisticated understanding of what happens before the initial episode and new understanding of the interactions between biologic vulnerabilities and specific environmental risk during adolescence and early adulthood, such as marijuana use. While the incidence rate of "first-episode" will make this a relatively small percentage of a usual clinical caseload, it is a critically important time for the future course of the illness. The hope is that proper management during this critical period will favorably influence the long-term trajectory of outcome for this individual patient. A growing body of evidence suggests that certain approaches and interventions are more helpful than others, such as understanding of the overwhelming nature of the experience to patients and families, aiming to achieve a full and broad pharmacologic response to initial antipsychotic therapy, while also being on the lookout for vulnerability and extreme sensitivity to side effects, and to anticipate a high likelihood of premature medication discontinuation. Clinicians and treatment services should try to identify "first-episode" patients in time to be able to anticipate and address these issues.

Long-acting formulations of atypical antipsychotics: time to reconsider when to introduce depot antipsychotics

The current availability of a long-acting injectable formulation of risperidone and the potential future availability of long-acting formulations of other atypical antipsychotics (such as paliperidone) should prompt a reconsideration of at what stage in the treatment of schizophrenia such long-acting agents should be introduced. At present, long-acting formulations, particularly of conventional antipsychotics (depots), are usually reserved for patients with chronic schizophrenia who are at high-risk of noncompliance. Recent and increasing data from other patient groups, such as those with first-episode psychosis, suggest that long-acting risperidone is associated with good efficacy and tolerability leading to high patient acceptance, and treatment continuation rates that are greater than with oral antipsychotics. The benefits of an atypical antipsychotic coupled with the assurance of medication delivery in the form of a long-acting injection imply that these novel formulations should be considered in first-episode patients, for whom optimal outcome is frequently compromised by early treatment discontinuation and poor adherence.

Weight gain in newly diagnosed first-episode psychosis patients and healthy comparisons: one-year analysis

BACKGROUND

Various antipsychotics are associated with body weight gain. However, most study samples include high proportions of patients with chronic schizophrenia. We examined neuroleptic-induced weight gain in drug-naïve first-episode psychotic patients to limit confounding variables such as multiple past medication trials, history of partial adherence; or poor diet and a sedentary lifestyle, associated with chronic mental illness.

METHODS

Newly diagnosed first-episode psychosis patients treated with antipsychotic medication, a small group of patients not receiving antipsychotics, and healthy comparisons were followed for one year. Body weight differences and proportions of subjects with more than 7% weight gain were calculated. The effects of concomitant psychotropic medication on weight gain were explored.

RESULTS

Ninety-eight first-episode psychotics patient and 30 healthy controls were examined. Patients receiving neuroleptics gained significantly more weight than healthy controls (p=0.002). Olanzapine (91% gained >7%) increased body weight by 37.3+/-27.7 lb, followed by risperidone (51%; +16.6+/-22) and haloperidol (47%; +9+/-12), and perphenazine (10%; +3.4+/-6). Younger patients (r=-0.24, p=0.02) and patients with more negative symptoms at baseline (SANS global; r=0.22, p=0.04) gained more weight. A greater number of co-medications per patient, and co-prescription of antidepressants significantly and independently increased antipsychotic-associated weight gain.

DISCUSSION

The results confirm substantial and clinically significant weight gain introduced by antipsychotic treatment in drug-naïve first-episode psychotic patients, and identify several treatment-associated risk factors for weight gain. The magnitude of weight gain induced highlights potential health risks and points to the need for preventive measures such as behavioral weight control programs along with the initiation of pharmacotherapy.

When should clozapine be initiated in schizophrenia?: Some arguments for and against earlier use of clozapine

Clozapine is one of the original atypical antipsychotics. It was withdrawn from the market in 1974 because of haematological safety concerns, but since 1989 has enjoyed a renaissance for the management of treatment-resistant schizophrenia under systems where case registration allows regular haematological monitoring. Clozapine continues to show enduring superiority across many aspects of the clinical pharmacology of the treatment of schizophrenia, e.g. it has specific anti-suicidal properties and recent broader trials have shown continuing superiority in wide groups of patients. This article considers some of the arguments for unshackling clozapine from its current license for schizophrenia (its superiority overall in treatment-resistant schizophrenia, its potential for use in first-episode patients, and its anti-suicidal potential), and tries to synthesise these into some of the national guidelines available for the treatment of schizophrenia.

Scientific and consumer models of recovery in schizophrenia: concordance, contrasts, and implications

Schizophrenia has traditionally been viewed as a chronic condition with a very pessimistic outlook, but that assumption may not be valid. There has been a growing consumer movement among people with schizophrenia that has challenged both the traditional perspective on the course of illness and the associated assumptions about the possibility of people with the illness living a productive and satisfying life. This new conception of the illness is supported by long-term studies that suggest that as much as 50% of people with the illness have good outcomes. There has also been a change in political and public health perspectives of the illness, stimulated in part by the President's New Freedom Commission on Mental Health. The purpose of this article is to provide an overview of some key themes about the recovery concept, as applied to schizophrenia. The article will address 3 questions: (1) What is recovery? (2) Is recovery possible? and (3) What are the implications of a recovery model for a scientific approach to treatment (ie, the use of evidence-based practices)? Scientific and consumer models of recovery are described, and commonalities and differences are discussed. Priorities for future research are suggested.

Dislipidemias e antipsicóticos atípicos

OBJETIVO: Um progressivo número de evidências surge associando o uso de antipsicóticos atípicos a dislipidemias, situação pouco atentada por considerável número de psiquiatras e preditora importante de doenças cardiovasculares (DCVs) e de morbimortalidade. O propósito deste estudo é revisar a associação entre o uso de antipsicóticos atípicos e o desenvolvimento de dislipidemias em pacientes com esquizofrenia. MÉTODOS: A pesquisa bibliográfica utilizou os bancos de dados MEDLINE e Scientific Electronic Library Online (SciELO), com os descritores: schizophrenia, dyslipidemia, hyperlipidemia e lipids, para identificar artigos originais publicados no período de 1997 a setembro de 2006. RESULTADOS: Os artigos foram agrupados segundo cada agente terapêutico, de acordo com o seu impacto sobre o perfil lipídico. CONCLUSÃO: Observa-se maior risco de desenvolvimento de dislipidemias em pacientes com esquizofrenia em uso de alguns antipsicóticos atípicos. Intervenções comportamentais e farmacológicas devem ser associadas nos indivíduos com esquizofrenia em tratamento antipsicótico e que desenvolvem dislipidemias.