Drug strategies and treatment-resistant schizophrenia

Long-term effect on outcome of clozapine in chronic therapy-resistant schizophrenic patients

Controlled clinical trials have shown that the atypical neuroleptic clozapine is highly effective in schizophrenic patients who are unresponsive to conventional neuroleptic agents. The long-term outcome of clozapine treatment was studied in 122 patients who were treated between 1974 and 1991. The mean duration of treatment was 5.2 years. At follow-up, 74 patients (61%) were still receiving clozapine. Only 11 patients discontinued treatment because of adverse events and eight because of poor compliance. Clinical improvement was seen in 87% of patients; 40% had resumed employment after 2 years' treatment. About one-third of patients who received clozapine for 5–10 years continued to improve during this time; this was probably because of a continuing process of socialisation. Thus, clozapine offers important advantages in schizophrenic patients resistant to conventional neuroleptics in terms of long-term efficacy and lack of extrapyramidal side-effects.

Group cognitive behavioural therapy for psychosis in the Asian context: a review of the recent studies

The cardinal symptoms of psychosis include hallucination and delusion, which can be both distressing and disabling. International guidelines recommend cognitive behavioural therapy for psychosis (CBTp) as an adjunctive intervention to medication management. Considering the difficulty in the widespread dissemination of the individual CBTp, group CBTp is an alternative in improving patients' access to psychological intervention. Although it has been found feasible and effective in various studies, systematic review on group CBTp, particularly in Asia, was not identified. Hence, this systematic review tried to examine the recent evidence of group CBTp in Asia in order to shed light on its implementation in routine psychiatric care. A relevant literature search was conducted in three databases (Pubmed, Web of Knowledge, and PsycINFO) during the period from January 2000 to December 2018. A total of 114 journal articles were identified. After a full-text review, four studies met our inclusion and exclusion criteria. Despite methodological shortcomings, positive results were found in terms of improvements on psychotic symptoms, functioning, and quality-of-life. These encouraging results indicate the need for future research studies with more rigorous methodology, leading to a better understanding on the applicability and effectiveness of group CBTp in the Asian context.

Neural Signature for Auditory Hallucinations in Schizophrenia: A High-Resolution Positron Emission Tomography Study with Fludeoxyglucose (18F)

Objective

Auditory hallucinations (AHs) are a core symptom of schizophrenia. We investigated the neural signature of AHs by comparing hallucinating patients with schizophrenia with non-hallucinating patients with schizophrenia.

Methods

We recruited hallucinating patients with schizophrenia meeting the criteria for persistent, prominent, and predominant AHs (n=10) and non-hallucinating patients with schizophrenia (n=12). Various clinical assessments were performed incluing Psychotic Symptom Rating Scale for Auditory Hallucinations. Using fludeoxyglucose (¹⁸F) positron emission tomography, regional differences in neural activity between the groups were analyzed.

Results

The regions of interest analysis showed significantly lower standardized uptake value ratio (SUVR) in the superior, middle, and inferior frontal gyri, and higher SUVR in the putamen in patients with AHs versus patients without AHs. These findings were confirmed in the voxel-wise analysis.

Conclusion

Our findings indicate that hypoactivity in the frontal and cingulate gyri, coupled with hyperactivity in the temporal gyrus and putamen, may contribute to the pathophysiology of AHs.

Combining depot antipsychotic medications with novel antipsychotics in forensic patients: a practice in search of a principle

OBJECTIVE

We observed a pattern of combining depot antipsychotic medication with the newer ‘atypical’ antipsychotics in forensic patients. We aimed to determine the prevalence and rationale for such ‘combination therapy’.

METHOD

The medical records of forensic patients in 3 forensic hospitals in New South Wales, Australia, were reviewed and the responsible psychiatrists asked to explain the rationale for treatment of those patients on combination therapy.

Results

Twenty-two per cent of the forensic patient population were receiving combination therapy. The reasons given for combination therapy were the presence of treatment-resistant illness, to ensure adherence to at least part of the treatment and to assist transfer to lower security units.

CONCLUSIONS

Such a high prevalence of a practice that is discouraged and without theoretical justification is a cause for concern. It appeared to reflect the practical difficulties of managing forensic patients.

Functional brain networks in treatment-resistant schizophrenia

INTRODUCTION

Up to 20% of individuals with schizophrenia show minimal or no response to medication and are considered to have 'treatment-resistant' schizophrenia (TRS). Unlike early and established schizophrenia, few studies have investigated resting-state functional connectivity (rs-FC) in TRS. Here, we test for disruptions in FC and altered efficiency of functional brain networks in a well-characterized cohort of TRS patients.

METHODS

Resting-state functional magnetic resonance imaging was used to investigate functional brain networks in 42 TRS participants prescribed clozapine (30 males, mean age=41.3(10)) and 42 healthy controls (24 males, mean age=38.4(10)). Graph analysis was used to characterize between-group differences in local and global efficiency of functional brain network organization as well as the strength of FC.

RESULTS

Global brain FC was reduced in TRS patients (p=0.0001). Relative to controls, 3.4% of all functional connections showed reduced strength in TRS (p<0.001), predominantly involving fronto-temporal, fronto-occipital and temporo-occipital connections. Global efficiency was reduced in TRS (p=0.0015), whereas local efficiency was increased (p=0.0042).

CONCLUSIONS

TRS is associated with widespread reductions in rs-FC and altered network topology. Increased local functional network efficiency coupled with decreased global efficiency suggests that hub-to-hub connections are preferentially affected in TRS. These findings further our understanding of the neurobiological impairments in TRS.

Valproate for schizophrenia

BACKGROUND

Many people with schizophrenia do not achieve a satisfactory treatment response with ordinary antipsychotic drug treatment. In these cases, various add-on medications are used, and valproate is one of these.

OBJECTIVES

To examine whether:1. valproate alone is an effective treatment for schizophrenia and schizoaffective psychoses; and2. valproate augmentation of antipsychotic medication is an effective treatment for the same illnesses.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's Study-Based Register of Trials (July 2002; February 2007; July 2012; March 04, 2016). We also contacted pharmaceutical companies and authors of relevant studies in order to identify further trials.

SELECTION CRITERIA

We included all randomised controlled trials comparing valproate to antipsychotics or to placebo (or no intervention), whether as the sole agent or as an adjunct to antipsychotic medication for the treatment of people with schizophrenia or schizophrenia-like psychoses.

DATA COLLECTION AND ANALYSIS

We independently inspected citations and, where possible, abstracts, ordered papers, and re-inspected and quality-assessed these. At least two review authors independently extracted data. We analysed dichotomous data using risk ratio (RR) and its 95% confidence intervals (CI). We analysed continuous data using mean differences (MD) and their 95% CI. We assessed risk of bias for included studies and used GRADE (Grading of Recommendations Assessment, Development and Evaluation) to create a 'Summary of findings' table.

MAIN RESULTS

The 2012 update search identified 19 further relevant studies, most of which were from China. Thus the review currently includes 26 studies with a total of 2184 participants. All trials examined the effectiveness of valproate as an adjunct to antipsychotics. With the exception of two studies, the studies were small, the participants and personnel were not blinded (neither was outcome assessment), and most were short-term and incompletely reported.For this update we prespecified seven main outcomes of interest: clinical response (clinically significant response, aggression/agitation), leaving the study early (acceptability of treatment, overall tolerability), adverse events (sedation, weight gain) and quality of life.Adding valproate to antipsychotic treatment resulted in more clinically significant response than adding placebo to antipsychotic drugs (14 RCTs, n = 1049, RR 1.31, 95% CI 1.16 to 1.47, I2 = 12%, low-quality evidence). However, this effect was removed after excluding open RCTs in a sensitivity analysis. In terms of acceptability of treatment (measured by the number of participants leaving the study early due to any reason) valproate was just as acceptable as placebo (11 RCTs, n = 951, RR 0.76, 95% CI 0.47 to 1.24, I2 = 55%). Also overall tolerability (measured by the number of participants leaving the study early for adverse events) between valproate and placebo was similar (6 RCTs, n = 974, RR 1.33, 95% CI 0.90 to 1.97, I2 = 0).Participants in the valproate group were found to be less aggressive than the control group based on the Modified Overt Aggression Scale (3 RCTs, n = 186, MD -2.55, 95% CI -3.92 to -1.19, I2 = 82%, very low-quality evidence). Participants receiving valproate more frequently experienced sedation (8 RCTs, n = 770, RR 1.38, 95% CI 1.07 to 1.79, I2 = 0, low-quality evidence) but were no more likely to gain weight than those receiving placebo (4 RCTs, n = 427, RR 1.17, 95% CI 0.76 to 1.82, I2 = 0, low-quality evidence). No study reported on the important outcome of quality of life.

AUTHORS' CONCLUSIONS

There is limited evidence, based on a number of trials, that the augmentation of antipsychotics with valproate may be effective for overall clinical response, and also for specific symptoms, especially in terms of excitement and aggression. However, this evidence was entirely based on open RCTs. Moreover, valproate was associated with a number of adverse events among which sedation and dizziness appeared significantly more frequently than in the control groups. Further randomised studies which are blinded are necessary before any clear recommendation can be made. Ideally these would focus on people with schizophrenia and aggression, on those with treatment-resistant forms of the illness and on those with schizoaffective disorders.

Positive Allosteric Modulation of the Muscarinic M1 Receptor Improves Efficacy of Antipsychotics in Mouse Glutamatergic Deficit Models of Behavior

Current antipsychotics are effective in treating the positive symptoms associated with schizophrenia, but they remain suboptimal in targeting cognitive dysfunction. Recent studies have suggested that positive allosteric modulation of the M₁ muscarinic acetylcholine receptor (mAChR) may provide a novel means of improving cognition. However, very little is known about the potential of combination therapies in extending coverage across schizophrenic symptom domains. This study investigated the effect of the M₁ mAChR positive allosteric modulator BQCA [1-(4-methoxybenzyl)-4-oxo-1,4-dihydroquinoline-3-carboxylic acid], alone or in combination with haloperidol (a first-generation antipsychotic), clozapine (a second-generation atypical antipsychotic), or aripiprazole (a third-generation atypical antipsychotic), in reversing deficits in sensorimotor gating and spatial memory induced by the N-methyl-d-aspartate receptor antagonist, MK-801 [(5R,10S)-(+)-5-methyl-10,11-dihydro-5H-dibenzo[a,d]cyclohepten-5,10-imine]. Sensorimotor gating and spatial memory induction are two models that represent aspects of schizophrenia modeled in rodents. In prepulse inhibition (an operational measure of sensorimotor gating), BQCA alone had minimal effects but exhibited different levels of efficacy in reversing MK-801-induced prepulse inhibition disruptions when combined with a subeffective dose of each of the three (currently prescribed) antipsychotics. Furthermore, the combined effect of BQCA and clozapine was absent in M₁^-/- mice. Interestingly, although BQCA alone had no effect in reversing MK-801-induced memory impairments in a Y-maze spatial test, we observed a reversal upon the combination of BQCA with atypical antipsychotics, but not with haloperidol. These findings provide proof of concept that a judicious combination of existing antipsychotics with a selective M₁ mAChR positive allosteric modulator can extend antipsychotic efficacy in glutamatergic deficit models of behavior.

Bilateral Repetitive Transcranial Magnetic Stimulation for Auditory Hallucinations in Patients with Schizophrenia: A Randomized Controlled, Cross-over Study

Objective

A randomized double-blind cross-over trial was conducted in patients with persistent auditory hallucinations (AHs) to investigate whether bilateral repetitive transcranial magnetic stimulation (rTMS) at the temporoparietal area or Broca's area is more effective at high- or low-frequencies compared to a sham condition.

Methods

Twenty three patients with persistent AHs who remained stable on the same medication for 2 months were enrolled. They were randomized to one of four conditions: low-frequency (1 Hz)-rTMS to the temporoparietal area (L-TP), high-frequency (20 Hz)-rTMS to the temporoparietal area (H-TP), high-frequency (20 Hz)-rTMS to Broca's area (H-B), or sham.

Results

All the four rTMS conditions resulted in significant decrease in the scores under the auditory hallucination rating scale and hallucination change scale over time. However, there were no significant treatment effects or interaction between time and treatment, suggesting no superior effects of the new paradigms over the sham condition.

Conclusion

Our findings suggest that bilateral rTMS at the temporoparietal area or Broca's area with high- or low-frequency does not produce superior effects in reducing AHs compared to sham stimulation.

Carbamazepine for schizophrenia

BACKGROUND

Many people with schizophrenia do not achieve a satisfactory treatment response with just antipsychotic drug treatment and various adjunct medications are used to promote additional response. The antiepileptic carbamazepine is one such drug.

OBJECTIVES

To examine whether carbamazepine or oxcarbazepine alone is an effective treatment for schizophrenia and schizoaffective psychoses and whether carbamazepine or oxcarbazepine augmentation of neuroleptic medication is an effective treatment for the same illnesses.

SEARCH METHODS

For the original version we searched The Cochrane Schizophrenia Group's Register of Trials (December 2001), The Cochrane Library (Issue 3, 2001), MEDLINE (1966-2001), EMBASE (1980-2001), Biological Abstracts (1980-2001), PsycLIT (1886-2001) and PSYNDEX (1974-2001). For the most recent update we searched the Cochrane Schizophrenia Group's Register of Trials in July 2012. We also inspected references of all identified studies for further trials and contacted relevant pharmaceutical companies and authors for additional data.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) comparing carbamazepine or compounds of the carbamazepine family with placebo or no intervention, whether as sole treatment or as an adjunct to antipsychotic medication for the treatment of schizophrenia and/or schizoaffective psychoses.

DATA COLLECTION AND ANALYSIS

We extracted data independently. For homogenous dichotomous data we calculated fixed-effect, risk ratio (RR), with 95% confidence intervals (CIs) on an intention-to-treat basis. For continuous data, we calculated mean differences (MD). We assessed the risk of bias for included studies and created a 'Summary of findings' table using GRADE.

MAIN RESULTS

The updated search did not reveal any further studies that met our inclusion criteria. The number of included studies therefore remains at 10 with the number of participants randomised still 283.One study comparing carbamazepine with placebo as the sole treatment for schizophrenia was abandoned early due to high relapse rate with 26 out of 31 participants relapsing by three months. No effect of carbamazepine was evident with no difference in relapse between the two groups (1 RCT n = 31, RR 1.07 CI 0.78 to 1.45). Another study compared carbamazepine with antipsychotics as the sole treatment for schizophrenia. No differences in terms of mental state were found when comparing 50% reduction in Brief Psychiatric Rating Scale (BPRS) scores (1 RCT n = 38, RR 1.23 CI 0.78 to 1.92). A favourable effect for carbamazepine was found when more people who received the antipsychotic (perphenazine) had parkinsonism (1 RCT n = 38, RR 0.03 CI 0.00 to 0.043). Eight studies compared adjunctive carbamazepine versus adjunctive placebo, we were able use GRADE for quality of evidence for these results. Adding carbamazepine to antipsychotic treatment was as acceptable as adding placebo with no difference between the numbers leaving the study early from each group (8 RCTs n = 182, RR 0.47 CI 0.16 to 1.35, very low quality evidence). Carbamazepine augmentation was superior compared with antipsychotics alone in terms of overall global improvement, but participant numbers were low (2 RCTs n = 38, RR 0.57 CI 0.37 to 0.88). There were no differences for the mental state outcome of 50% reduction in BPRS scores (6 RCTs n = 147, RR 0.86 CI 0.67 to 1.12, low quality evidence). Less people in the carbamazepine augmentation group had movement disorders than those taking haloperidol alone (1 RCT n = 20, RR 0.38 CI 0.14 to 1.02). No data were available for the effects of carbamazepine on subgroups of people with schizophrenia and aggressive behaviour, negative symptoms or EEG abnormalities or with schizoaffective disorder.

AUTHORS' CONCLUSIONS

Based on currently available randomised trial-derived evidence, carbamazepine cannot be recommended for routine clinical use for treatment or augmentation of antipsychotic treatment of schizophrenia. At present large, simple well-designed and reported trials are justified - especially if focusing on people with violent episodes and people with schizoaffective disorders or those with both schizophrenia and EEG abnormalities.

Cognitive Behavioral Therapy for Psychosis - Training Practices and Dissemination in the United States

OBJECTIVE

Cognitive-Behavioral Therapy for psychosis (CBTp) is an evidence-based treatment for psychosis-related disorders. However, despite the strong evidence-base and inclusion in national treatment guidelines, CBTp remains poorly disseminated in the US. It is proposed that this state is a product of lack of CBTp knowledge among clinical training leaders along with limited availability of training opportunities.

METHOD

We surveyed training directors in US psychiatry residency and clinical psychology doctoral programs to characterize the penetration of CBTp training and to assess their familiarity with basic CBTp facts.

RESULTS

Directors displayed limited knowledge of CBTp effectiveness, with only 50% of psychiatry and 40% of psychology directors believing that CBTp is efficacious. Only 10% of psychiatry and 30% of psychology directors were aware that the CBTp evidence-base is based on meta-analyses. While 45% of all directors reported that their program offer CBTp training, trainees received limited training - 4 hours of didactics, 21 hours of treatment, and 12 hours of supervision.

CONCLUSIONS

CBTp dissemination in the US is characterized by training directors' minimal awareness of the CBTp evidence-base along with training opportunities that are so limited, as to be unlikely to be adequate to provide CBTp effectively, hence unlikely to improve patients' psychoses.

Insights into hallucinations in schizophrenia: novel treatment approaches

Novel strategies are needed in the treatment of hallucinations as a subgroup of patients with pathological hallucinations (>30%) do not respond to antipsychotics or are not compliant with medication. We review recently developed biological and cognitive treatments. Repetitive transcranial magnetic stimulation concerns neuromodulation targeted at aberrant activity in regions shown to be hyperactive in neuroimaging studies. Repetitive transcranial magnetic stimulation has been shown to reduce auditory hallucinations in several studies. However, not all studies have confirmed such effects, and a number of questions remain. With regard to cognitive therapeutic approaches, new proposals include attention training, acceptance and commitment therapy, and competitive memory training. After a brief discussion of these approaches, we take stock of recent advances and discuss avenues for future research.

A review of hearing voices groups: evidence and mechanisms of change

As a heavily stigmatized group, voice hearers often value the chance to meet others with similar experiences. As a result, Hearing Voices Groups (HVGs) are becoming increasingly common in both inpatient and outpatient settings. Where resources are constrained, HVGs are frequently viewed as a desirable alternative to individual therapy and are often preferred by service users themselves. HVGs often vary in their content and structure, with four common approaches: CBT, skills-training, mindfulness and unstructured support groups. This review evaluates the evidence for HVGs and the mechanisms of change for successful interventions. CBT was the only approach with evidence from well-controlled studies. However, several evidence-based treatments share 'key ingredients' which evidence suggests help reduce distress. Successful groups supply a safe context for participants to share experiences, and enable dissemination of strategies for coping with voices as well as considering alternative beliefs about voices. Future research should focus on isolating mechanisms of change and predictors of outcome in order to refine HVG approaches, rather than polarizing them and setting them against one another in efficacy trials.

Review: The biological basis of antipsychotic response in schizophrenia

Schizophrenia is a severe mental illness affecting approximately 1% of the population worldwide. Antipsychotic drugs are effective in symptom control in up to two-thirds of patients, but in at least one-third of patients the response is poor. The reason for this is not clear, but one possibility is that good and poor responders have different neurochemical pathologies, and may therefore benefit from different treatment approaches. In this selective review we summarise research findings investigating the biological differences between patients with schizophrenia who show a good or a poor response to treatment with antipsychotic drugs.

Sulpiride augmentation for schizophrenia

BACKGROUND

Sulpiride may be used in combination with other antipsychotic drugs in the hope of augmenting effectiveness - especially for those whose schizophrenia has proved resistant to treatment.

OBJECTIVES

To evaluate the effects of sulpiride augmentation versus monotherapy for people with schizophrenia.

SEARCH STRATEGY

We searched the Cochrane Schizophrenia Group Trials Register (July 2009) which is based on regular searches of CINAHL, EMBASE, MEDLINE and PsycINFO.

SELECTION CRITERIA

All relevant randomised clinical trials (RCTs).

DATA COLLECTION AND ANALYSIS

We extracted data independently. For dichotomous data we calculated relative risks (RR) and their 95% confidence intervals (CI) based on a fixed-effect model. For continuous data, we calculated weighted mean differences (WMD) again based on a fixed-effect model.

MAIN RESULTS

We included three short-term and one long-term trial (total N=221). All participants had schizophrenia that was either treatment-resistant or with prominent negative symptoms. All studies compared sulpiride plus clozapine with clozapine (+/- placebo), were small and at considerable risk of bias.Short-term data of 'no clinically significant response' in global state tended to favour sulpiride augmentation of clozapine compared with clozapine alone (n=193, 3 RCTs, RR 0.58 CI 0.3 to 1.09).People allocated to sulpiride plus clozapine had more movement disorders (n=70, 1 RCT, RR 48.24 CI 3.05 to 762.56) and an increase in serum prolactin (skewed data, 1 RCT), but less incidence of hypersalivation (n=162, 3 RCTs, RR 0.49 CI 0.29 to 0.83) and less weight gain (n=64, 1 RCT, RR 0.30 CI 0.09 to 0.99). The augmentation of clozapine by sulpiride also caused less appetite loss (n=70, 1 RCT, RR 0.09 CI 0.01 to 0.70, NNT 4 CI 4 to 12, Z=2.31, P=0.02) and less abdominal distension (n=70, 1 RCT, RR 0.10 CI 0.01 to 0.78, NNT 5 CI 4 to 19, Z=2.20, P=0.03).Long-term data showed no significant difference in global state (n=70, 1 RCT, RR 0.67 CI 0.42 to 1.08) and relapse (n=70, 1 RCT, RR 0.85 CI 0.5 to 1.3).

AUTHORS' CONCLUSIONS

Sulpiride plus clozapine is probably more effective than clozapine alone in producing clinical improvement in some people whose illness has been resistant to other antipsychotic drugs including clozapine. However, much more robust data are needed.

Multimodal cognitive therapy: combining treatments that bypass cognitive deficits and deal with reasoning and appraisal biases

The process of recovery in schizophrenia involves resolving persistent symptoms, addressing cognitive impairments, and improving functional outcomes. Our research group has demonstrated the efficacy of cognitive adaptation training (CAT)--a home-based psychosocial treatment utilizing environmental supports such as medication containers, signs, checklists, and the organization of belongings to bypass deficits in cognitive functioning and cue and sequence adaptive behavior) for improving adherence to medications and functional outcomes in schizophrenia. Early CAT pilot studies utilizing some therapists with training in cognitive behavior therapy (CBT) techniques for psychosis found significant improvements in positive symptoms. More recent larger scale randomized clinical trials failed to replicate this finding with CAT therapists not trained in CBT techniques. Persistent psychotic symptoms substantially impair patients' ability to adapt to life in the community. Cognitive behavior therapy for psychosis (CBTp) is an evidence-based practice for addressing persistent positive symptoms and the distress associated with them. CBTp decreases symptomatology and minimizes the negative effect of persisting symptoms upon individuals with this disorder. We now describe a home-delivered, multimodal cognitive treatment targeting functional outcomes and persistent positive symptoms for individuals with schizophrenia by utilizing both CAT and CBT techniques. We discuss the advantages and challenges of combining these 2 interventions, present a small retrospective data analysis to support their combination into a multimodal treatment, and describe the design of an ongoing randomized trial to investigate efficacy.

A randomized controlled trial of group cognitive-behavioral therapy vs. enhanced supportive therapy for auditory hallucinations

There has been little research examining group cognitive-behavioral therapy (CBT) for schizophrenia, especially compared to an active control treatment. The purpose of this study was to investigate the effectiveness of group CBT for auditory hallucinations compared to an enhanced supportive therapy (ST). Sixty five participants with schizophrenia spectrum disorders and persistent hallucinations were randomly assigned to group CBT or enhanced group ST. Primary outcomes focused on beliefs about voices and global auditory hallucinations severity. Secondary outcomes included psychotic symptoms, self-esteem, social functioning, insight, depression, and hospitalization. Controlling for baseline levels, these outcomes were evaluated across post-treatment, 3 month and 12 month follow-ups. Participants who received enhanced ST were less likely to both resist voices and to rate them as less malevolent through 12-month follow-up relative to participants who received CBT. Group CBT was associated with lower general and total symptom scores on the PANSS through 12-month-followup relative to participants who received enhanced ST. Outcomes improved through 12-month follow-up in both therapy groups, with enhanced ST having more specific impact on auditory hallucinations, and CBT impacting general psychotic symptoms.

Muscarinic receptors: do they have a role in the pathology and treatment of schizophrenia?

The high affinity of antipsychotic drugs for the dopamine D2 receptor focused attention onto the role of these receptors in the genesis of psychoses and the pathology of schizophrenia. However, psychotic symptoms are only one aspect of the complex symptom profile associated with schizophrenia. Therefore, research continues into other neurochemical systems and their potential roles in key features associated with schizophrenia. Modulating the cholinergic system in attempts to treat schizophrenia predates specific neurochemical hypotheses of the disorder. Cholinergic modulation has progressed from the use of coma therapy, through the use of anti-cholinergic drugs to control side-effects of older (typical) antipsychotic medications, to the development of drugs designed to specifically activate selected muscarinic receptors. This review presents data implicating a decrease in muscarinic receptors, particularly the M1 receptor, in the pathology of schizophrenia and explores the potential physiological consequences of such a change, drawing on data available from muscarinic receptor knockout mice as well as clinical and pre-clinical pharmacology. The body of evidence presented suggests that deficits in muscarinic receptors are associated with some forms of schizophrenia and that targeting these receptors could prove to be of therapeutic benefit to patients with the disorder.

Cognitive-behavioral therapy for medication-resistant schizophrenia: a review

Research meta-analyses have found that cognitive-behavioral therapy (CBT) is beneficial for persistent symptoms of schizophrenia. This review describes and updates the evidence base for this statement. A review of the existing literature (Medline, PsychInfo, and Embase) was carried out according to the guidelines for systematic reviews. Based on the findings of this review, the updated conclusion is that CBT has emerged as an effective adjuvant to antipsychotic medication in the treatment of persistent symptoms of schizophrenia. Studies of the use of CBT in the prodromal phase of psychosis and in combination with family therapy are currently underway.

Carbamazepine for schizophrenia

BACKGROUND

Many people with schizophrenia do not achieve a satisfactory treatment response with just antipsychotic drug treatment and various adjunct medications are used to promote additional response. The antiepileptic carbamazepine is one such drug.

OBJECTIVES

To evaluate the effects of carbamazepine and its derivatives for the treatment of schizophrenia and related psychoses.

SEARCH STRATEGY

For the original version we searched Biological Abstracts (1980-2001), The Cochrane Library (Issue 3, 2001), The Cochrane Schizophrenia Group's Register of Trials (December 2001), EMBASE (1980-2001), MEDLINE (1966-2001), PsycLIT (1886-2001) and PSYNDEX (1974-2001). For the current update we searched the Cochrane Schizophrenia Group's Register of Trials in March 2005 and in December 2006. We also inspected references of all identified studies for further trials and contacted relevant pharmaceutical companies and authors for additional data.

SELECTION CRITERIA

We included all randomised controlled trials comparing carbamazepine or compounds of the carbamazepine family to placebo or no intervention, whether as sole treatment or as an adjunct to antipsychotic medication for the treatment of schizophrenia and/or schizoaffective psychoses.

DATA COLLECTION AND ANALYSIS

We extracted data independently. For homogenous dichotomous data we calculated random effects, relative risk (RR), 95% confidence intervals (CI) and, where appropriate, numbers needed to treat (NNT) on an intention-to-treat basis. For continuous data, we calculated weighted mean differences (WMD).

MAIN RESULTS

The update search did not reveal any further studies that met our inclusion criteria. The number of included studies therefore remains at ten with the number of participants randomised still 258. One study comparing carbamazepine with placebo as the sole treatment for schizophrenia was abandoned early due to high relapse rate with 26 out of 31 participants relapsing by three months. No effect of carbamazepine was evident with no difference in relapse between the two groups (1 RCT n=31, RR 4.1 CI 0.8 to 1.5). Another study compared carbamazepine with antipsychotics as the sole treatment for schizophrenia. No differences in terms of mental state were found when comparing 50% reduction in BPRS scores (1 RCT n=38, RR 1.2 CI 0.8 to 1.9). A favourable effect for carbamazepine was found when more people who received the antipsychotic (perphenazine) had parkinsonism (1 RCT n=38, RR 0.03 CI 0.00 to 0.04, NNH 1 CI 0.9 to 1.4). Eight studies compared adjunctive carbamazepine versus adjunctive placebo. Adding carbamazepine to antipsychotic treatment was as acceptable as adding placebo with no difference between the numbers leaving the study early from each group (8 RCTs n=182, RR 0.5 CI 0.2 to 1.4). Carbamazepine augmentation was superior compared with antipsychotics alone in terms of overall global improvement, but participant numbers were low (2RCTs n=38, RR 0.6 CI 0.4 to 0.9, NNT 2 CI 1 to 5). There were no differences for the mental state outcome of 50% reduction in BPRS scores (6 RCTs n=147, RR 0.9 CI 0.7 to 1.1). Less people in the carbamazepine augmentation group had movement disorders than those taking haloperidol alone (1 RCT n=20, RR 0.4 CI 0.1 to 1.0). No data were available for the effects of carbamazepine on subgroups of people with schizophrenia and aggressive behaviour, negative symptoms or EEG abnormalities or with schizoaffective disorder.

AUTHORS' CONCLUSIONS

Based on currently available randomised trial-derived evidence, carbamazepine cannot be recommended for routine clinical use for treatment or augmentation of antipsychotic treatment of schizophrenia. At present large, simple well-designed and reported trials are justified especially if focusing on those with violent episodes and people with schizoaffective disorders or those with both schizophrenia and EEG abnormalities.

Lamotrigine for schizophrenia

BACKGROUND

Treating the 20-30% of people with schizophrenia whose symptoms are resistant to treatment can be problematic. Adding lamotrigine to ongoing antipsychotic treatment has shown to be of benefit in preliminary studies.

OBJECTIVES

To evaluate the effects of adjuvant lamotrigine for people with schizophrenia and schizophrenia-like psychoses.

SEARCH STRATEGY

We searched the Cochrane Schizophrenia Group's Register (February 2006) and inspected references of all identified studies for further trials. We contacted relevant authors of trials for additional information.

SELECTION CRITERIA

We included all clinical randomised trials comparing lamotrigine with placebo or other antipsychotic augmentation strategies.

DATA COLLECTION AND ANALYSIS

We extracted data independently. For homogenous dichotomous data we calculated random effects relative risk (RR), 95% confidence intervals (CI) and, where appropriate, numbers needed to treat (NNT) on an intention-to-treat basis. For continuous data, we calculated weighted mean differences (WMD).

MAIN RESULTS

We found five relevant trials (total n=537), but no usable data on service outcomes, general functioning, behaviour, engagement with services, satisfaction with treatment or economic outcomes. Overall, reporting of data was poor. Those data we were able to use suggested that equal proportions of people allocated lamotrigine or placebo had no global response (n=208, 1 RCT, RR 1.06 CI 0.73 to 1.54). There was no significant difference between groups in the proportions of people whose mental state did not improve (n=297, 3 RCT, RR 1.26 CI 0.81 to 1.97). There was, however, a significant reduction in the PANSS total scores (n=67, 2 RCT, WMD -16.88 CI -8.57 to -25.18, p=0.0001), positive symptom sub-scale scores (n=65, 2 RCTs, WMD -5.10 CI -8.86 to -1.34) and negative symptom sub-scale scores (n=67, 2 RCTs, WMD -5.25, CI -7.07 to -3.43). Most cognitive measures showed no differences (n=329, 2 RCTs, RR not attaining BACS composite score of 0.5 1.10 CI 0.59 to 2.04). The proportion of participants leaving studies was about 25% at 12 weeks (n=537, 5 RCTs, RR 0.96 CI 0.71 to 1.29). The lamotrigine group did experience the outcome of any adverse effects significantly more frequent than people allocated placebo (n=429, 2 RCTs, RR 1.19 CI 1.02 to 1.38, NNH 10 CI 5 to 90). Among the many effects listed, only nausea was found to be significantly more (9%) in the lamotrigine group compared with placebo (n=465, 3 RCTs, RR 2.26 CI 1.05 to 4.88).

AUTHORS' CONCLUSIONS

Evidence for use of lamotrigine as an adjuvant for people with schizophrenia is not robust and large well-designed, conducted and reported real-world randomised trials are needed to determine its place in everyday clinical practice.

A pilot study of functional Cognitive Behavioral Therapy (fCBT) for schizophrenia

BACKGROUND

The feasibility and preliminary efficacy of a novel cognitive behavioral treatment for decreasing psychotic symptoms and improving social functioning was evaluated in a pilot study. This represents the first treatment outcome study of CBT for psychosis with a manualized, active comparison condition.

METHODS

Thirty outpatients with schizophrenia or schizoaffective disorder, depressed type with residual psychotic symptoms were randomly assigned to either 16 weekly sessions of functional cognitive behavioral therapy (fCBT) or psychoeducation (PE) with assessments conducted at baseline and post-treatment by blind evaluators.

RESULTS

Attrition was only 7% and did not differ between fCBT and PE, indicating good tolerability of both treatments. For this sample with persistent symptoms, between groups effects were not significantly different, but within group effect sizes indicated greater treatment benefit for fCBT on positive symptoms, particularly for the PSYRATS voices subscale.

CONCLUSION

The results suggest that fCBT is well tolerated and holds promise for reducing persistent positive symptoms.

Augmentation With Amisulpride for Schizophrenic Patients Nonresponsive to Antipsychotic Monotherapy

Despite the effectiveness of antipsychotic medications in treatment of schizophrenia, about 30% of patients who receive an adequate treatment have significant persisting symptoms. The problem of treatment-resistant psychosis is an important and difficult one. The aim of this study was to retrospectively evaluate the efficacy and safety of amisulpride augmentation in treatment-resistant schizophrenic patients. To the best of our knowledge, this is the first report about resistant schizophrenic and schizoaffective patients treated with the combinations of risperidone and amisulpride and ziprasidone and amisulpride. Data were collected from patient records. A total of 15 resistant schizophrenic patients (7 men, 8 women, 54.0 +/- 16.9 years old) were included in the study. Before addition of amisulpride, the patients were treated with monotherapy by atypical neuroleptics (clozapine, olanzapine, risperidone, or ziprasidone). The mean amisulpride dose was 693.3 +/- 279.6 mg/d. The mental state of 12 (80%) patients treated with combination was improved. Three (20%) patients showed no change in their mental state. Only 2 patients treated with a combination of risperidone and amisulpride had mild side effects. The results are preliminary and require confirmation in a randomized controlled trial. The authors suggest that amisulpride may be a promising option as an augmentation strategy in treatment-resistant schizophrenic patients.

Is there evidence that cognitive behaviour therapy is an effective treatment for schizophrenia? A cautious or cautionary tale?

Schizophrenia is a severe and disabling disorder with considerable psychological, social and economic costs. Over the last 15 years there has been a significant development in the use of cognitive behaviour therapy for psychosis (CBTp) in the treatment of schizophrenia, with 20 randomised controlled trials having been published. The majority of this work has been with alleviating medication resistant symptoms in chronic patients, but preliminary work has also been carried out with speeding recovery in acute schizophrenia and in relapse prevention and early intervention. A review of these studies indicates modest effect sizes, with the strongest evidence available for chronic patients. There is evidence that the effect size of the trials is significantly and negatively correlated to their methodological quality. We conclude cautiously that overall there is good evidence for the efficacy and effectiveness of CBTp in the treatment of schizophrenia.

Should CBT Target the Social Impairments Associated With Schizophrenia?

Adjunctive cognitive behavior therapy (CBT) has been found to reduce the impact of symptoms among individuals with schizophrenia; however, CBT has not been used to address the social deficits in this clinical population. The current article elaborates the rationale for targeting social functioning with CBT. These reasons include the following: (a) Social dysfunction is a core feature of schizophrenia that is not directly improved with medication; (b) Improved social functioning is a treatment goal of many patients with schizophrenia, and thus treatments designed to improve social functioning may increase treatment motivation and reduce attrition; (c) Adaptive social functioning is a critical component of mental and physical health; and (d) Social dysfunction appears to be responsive to psychosocial intervention. This article concludes with a description of functional cognitive behavior therapy (FCBT), a CBT intervention that has been developed with enhanced focus on social impairments.

Managing patients with "treatment-resistant" schizophrenia

Patients who fail to respond adequately to pharmacological treatment present an ongoing therapeutic challenge. The term "incomplete recovery" (IR) is preferred to the current term "treatment resistance" to describe these patients. IR should be considered from a multidimensional perspective that includes a broad range of symptoms and functional disabilities that are relevant to schizophrenia. The approach to the incompletely recovered patient needs to be systematic, with consideration given to the factors that may hamper recovery. "Atypical" (second-generation) antipsychotic drugs target various domains of symptoms relevant to IR. Adjunctive treatment strategies (eg, mood stabilisers, antidepressants, combinations of antipsychotics) may be useful, but should be undertaken in specialist psychiatric settings. Although pharmacological treatment is a necessary first step in managing incompletely recovered patients, adjunctive psychosocial interventions are needed to optimise treatment success.

Use of healthcare services by patients treated with risperidone versus conventional antipsychotic agents

OBJECTIVE

To determine whether the use of risperidone in a US managed-care environment is associated with a reduction in the use of mental healthcare services.

METHODS

Mental health service use and costs for patients with psychoses treated with risperidone versus those treated with conventional antipsychotic agents were compared by both between-group and within-group comparisons. The study controlled for differences between the groups. Only direct medical costs were considered. All costs were for the years 1994 to 1996.

PERSPECTIVE

US managed care plan.

RESULTS

Costs (excluding antipsychotic drug costs) per member per month (PMPM) were 180 US dollars lower with risperidone (p < 0.05); per member per year (PMPY) costs were 2160 US dollars lower. In patients who received both risperidone and conventional treatments, PMPM costs were 212 US dollars (2544 US dollars PMPY) lower during risperidone treatment. Total costs (including antipsychotic drug costs) were 624 US dollars PMPY lower with risperidone by between-group comparisons and 1008 US dollars PMPY lower by within-group comparisons.

CONCLUSIONS

These results show that higher risperidone acquisition costs are offset by reductions in other mental healthcare costs, particularly inpatient hospitalisation costs. This indicates that risperidone may be a more economical choice than traditional antipsychotics for the treatment of psychoses.

Carbamazepine for schizophrenia and schizoaffective psychoses

BACKGROUND

Many people with schizophrenia do not achieve a satisfactory treatment response with ordinary antipsychotic drug treatment and various additional medications are used to promote additional response. The antiepileptic carbamazepine is one such drug.

OBJECTIVES

To review the effects of carbamazepine and its derivatives for the treatment of schizophrenia and schizoaffective psychoses.

SEARCH STRATEGY

We searched Biological Abstracts (1980-2001), The Cochrane Library (Issue 3, 2001), The Cochrane Schizophrenia Group's Register of Trials (December 2001), EMBASE (1980-2001), MEDLINE (1966-2001), PsycLIT (1886-2001) and PSYNDEX (1974-2001). Citations from included trials were also inspected and relevant companies and authors contacted for additional data.

SELECTION CRITERIA

All randomised controlled trials comparing carbamazepine or compounds of the carbamazepine family to placebo or no intervention, whether as sole treatment or as an adjunct to antipsychotic medication for the treatment of schizophrenia and/or schizoaffective psychoses.

DATA COLLECTION AND ANALYSIS

Citations and, where possible, abstracts were independently inspected by reviewers, papers ordered, re-inspected and quality assessed. Data were extracted independently by at least two reviewers. Dichotomous data were analysed using Peto odds ratio (OR) and the 95% confidence interval (CI) estimated. Where possible the number needed to treat (NNT) or number needed to harm statistics were calculated.

MAIN RESULTS

Ten studies with a total of 258 participants were included. One study comparing carbamazepine with placebo as the sole treatment for schizophrenia (n=31) was stopped early due to high relapse rate. No effect of carbamazepine was evident (OR relapse 1.5 CI 0.2 to 9.7). Another study (n=38) compared carbamazepine with antipsychotics as the sole treatment for schizophrenia. No differences in terms of mental state were found (OR 50% BPRS reduction 1.9 CI 0.5 to 7.2). More people who received the antipsychotic (perphenazine) had parkinsonism (OR 0.03 CI 0.01 to 0.1, NNH 1 CI 0.9 to 1.4). Eight studies compared adjunctive carbamazepine plus antipsychotics versus placebo plus antipsychotics. Adding carbamazepine was as acceptable as adding placebo (n=182, OR leaving the study early 0.4 CI 0.1 to 1.4). Carbamazepine augmentation of antipsychotics was superior compared with antipsychotics alone, but participant numbers were low (n=38, OR 0.1 CI 0.02 to 0.4, NNT 2 CI 1 to 5). There were no differences for mental state outcomes (6 RCTs, n=147, OR 50% BPRS reduction 0.99 CI 0.2 to 6.0). Less people in the carbamazepine augmentation group had movement disorders than those taking haloperidol alone (1 RCT, n=20, OR 0.15 CI 0.03 to 0.8). The effects of carbamazepine on subgroups of people with schizophrenia and aggressive behaviour, negative symptoms or EEG abnormalities or with schizoaffective disorder are unknown.

REVIEWER'S CONCLUSIONS

Based on currently available evidence from randomised trials, carbamazepine cannot be recommend for routine clinical use for sole treatment, or augmentation of antipsychotic treatment, of schizophrenia. Large, simple well-designed and reported trials are justified especially if focusing on those with violent episodes and people with schizoaffective disorders or on those with both schizophrenia and EEG abnormalities.

Ziprasidone, a new atypical antipsychotic drug

Although the introduction of antipsychotic drugs in 1954 was a breakthrough in the treatment of patients with schizophrenia, these agents have a number of adverse effects that limit effectiveness and compliance. The atypical antipsychotic drugs provide an improved tolerability profile, particularly in minimizing extrapyramidal side effects; however, they are associated with significant weight gain, which may be related to growing evidence linking the atypical agents with diabetes and hyperlipidemia. Ziprasidone, a new atypical antipsychotic drug, was demonstrated in clinical trials to be more efficacious than placebo and similar in efficacy to haloperidol in the treatment of schizophrenia. Like the existing atypical agents, ziprasidone has a rate of extrapyramidal side effects similar to that of placebo and does not cause significant elevations in prolactin levels. In contrast, ziprasidone has a low propensity for causing weight gain. For patients requiring an antipsychotic drug, ziprasidone represents a new treatment option with a limited adverse effect profile.

Evidence for progression of brain structural abnormalities in schizophrenia: beyond the neurodevelopmental model

OBJECTIVE

Clinical, neuroimaging, neuropathological and neuropsychological evidence suggests that, in schizophrenia, there is structural and functional disturbance of the hippocampus. The purpose of this paper is to present published findings concerning the nature, timing and course of these putative disturbances of hippocampal function and the pathophysiological mechanisms involved, and to explore whether schizophrenia is a disorder of neurodevelopment, neurodegeneration or a combination of both processes.

METHOD

The available cross-sectional and longitudinal evidence for hippocampal involvement in schizophrenia is reviewed and a model of hippocampal involvement in this disorder, which derives from our own cross-sectional and longitudinal hippocampal imaging data, is described.

RESULTS

We propose a three-hit model in which an early neurodevelopmental lesion renders the hippocampus vulnerable to further insult later in life during the transition phase to active illness. The available evidence suggests that the left hippocampus is particularly vulnerable during these early stages, while further insult involving the hippocampus bilaterally occurs in those who develop a chronic form of the illness.

CONCLUSIONS

Intervention strategies should target the most vulnerable stages of the illness, in particular the transition phase to psychosis, when novel treatments may prevent the illness or ameliorate its effects.

The effect of carbamazepine on the steady-state pharmacokinetics of ziprasidone in healthy volunteers

AIMS

To evaluate the effect of steady-state carbamazepine administration on the steady-state pharmacokinetics of ziprasidone in healthy young adults, in an open, randomised, parallel-group study.

METHODS

Twenty-five subjects were randomized to one of two treatment groups. Group 1 received 20 mg ziprasidone twice daily on days 1 and 2, and a single dose on day 3. A single 100 mg dose of carbamazepine was given once daily on days 5 and 6 and twice daily on days 7 and 8, followed by 200 mg twice daily until day 28 and on the morning only on day 29. Ziprasidone 20 mg was also administered twice daily on days 26 and 27 and in the morning only on day 28. Group 2 received the same treatment regimen with carbamazepine replaced by placebo. Pharmacokinetic data were obtained on days 3 and 28.

RESULTS

Nine subjects in group 1 and 10 in group 2 completed all three treatment periods (ziprasidone, carbamazepine or placebo; and ziprasidone plus carbamazepine or placebo). Carbamazepine administration to group 1 was associated with modest reductions in ziprasidone exposure, with mean decreases in ziprasidone AUC(0,12 h) and Cmax values of 36% and 27%, respectively, on day 28 compared with day 3 (P<0.03). The mean differences between day 28 and day 3 ziprasidone AUC(0,12 h) and Cmax values were also statistically significantly greater in the carbamazepine group than in the placebo group. The mean half-life of ziprasidone decreased by 1 h from day 3 to day 28 in the subjects receiving carbamazepine, compared with virtually no change in the placebo group. All adverse events were mild or moderate in severity and there were no serious adverse events, or clinically significant changes in ECGs and vital signs throughout the study.

CONCLUSIONS

Induction of CYP3A4 with carbamazepine led to a modest reduction (<36%) in steady-state exposure to ziprasidone that is believed to be clinically insignificant.

Cognitive-behavioural therapy for psychosis: a status report

OBJECTIVE

To review the nature of cognitive-behavioural interventions for psychosis and to evaluate evidence of their effectiveness.

METHOD

Electronic (Medline and Psychinfo) and bibliography-based searches were carried out to locate descriptions and evaluations of cognitive-behavioural interventions for psychosis.

RESULTS

Various cognitive-behavioural interventions have been used for reducing psychosis. These have usually been applied to auditory hallucinations and/or delusions in otherwise treatment-resistant patients. Most evaluations comprise case studies or simple pre-post designs. Controlled trial evaluations are few, and although the results are promising, methodological problems limit the conclusions that can be drawn concerning the clinical utility of such approaches.

CONCLUSIONS

More and better controlled trial evaluations of cognitive-behavioural interventions are needed in this area. If further research supports the efficacy of these techniques, issues related to clinical effectiveness, mediators of treatment effects, risks, and cost-effectiveness will also need to be addressed.

Treatment with haloperidol or clozapine causes changes in dopamine receptors but not adenylate cyclase or protein kinase C in the rat forebrain

The effect of treating rats with daily injections of haloperidol (1 mg/kg/day) or clozapine (20 mg/kg/day) for four weeks on second messengers and dopamine receptors was studied. The binding of [3H]forskolin to adenylate cyclase (AC), [3H]phorbol 12,13-dibutyrate (PDBu) to protein kinase C (PKC), [3H]SCH23390 binding to the dopamine D1 (DA-D1) receptor and [3H]spiperone binding to the dopamine D2 (DA-D2) receptor were measured using quantitative autoradiography. The density of AC was greatest in the caudate-putamen, nucleus accumbens and olfactory tubercle, a distribution resembling that of DA-D1 receptor. The distribution of PKC was relatively homogeneous in the forebrain. Neither haloperidol nor clozapine administration significantly altered the levels of AC or PKC in the caudate-putamen. By contrast treatment with haloperidol, but not clozapine, significantly increased the density of DA-D2 receptors in the caudate-putamen without affecting the density of DA-D1 receptors. By contrast, both haloperidol and clozapine increased the density of DA-D1 receptors in the olfactory tubercle.