Persistent infection with neurotropic herpes viruses and cognitive impairment

BACKGROUND

Herpes virus infections can cause cognitive impairment during and after acute encephalitis. Although chronic, latent/persistent infection is considered to be relatively benign, some studies have documented cognitive impairment in exposed persons that is untraceable to encephalitis. These studies were conducted among schizophrenia (SZ) patients or older community dwellers, among whom it is difficult to control for the effects of co-morbid illness and medications. To determine whether the associations can be generalized to other groups, we examined a large sample of younger control individuals, SZ patients and their non-psychotic relatives (n=1852). Method Using multivariate models, cognitive performance was evaluated in relation to exposures to herpes simplex virus type 1 (HSV-1), herpes simplex virus type 2 (HSV-2) and cytomegalovirus (CMV), controlling for familial and diagnostic status and sociodemographic variables, including occupation and educational status. Composite cognitive measures were derived from nine cognitive domains using principal components of heritability (PCH). Exposure was indexed by antibodies to viral antigens.

RESULTS

PCH1, the most heritable component of cognitive performance, declines with exposure to CMV or HSV-1 regardless of case/relative/control group status (p = 1.09 × 10-5 and 0.01 respectively), with stronger association with exposure to multiple herpes viruses (β = -0.25, p = 7.28 × 10-10). There were no significant interactions between exposure and group status.

CONCLUSIONS

Latent/persistent herpes virus infections can be associated with cognitive impairments regardless of other health status.

Comparative effectiveness of antipsychotic drugs in schizophrenia

Chlorpromazine, which was discovered in 1952, has an exhaustively characterized efficacy/safety profile comprising serious limitations: effectiveness in the field failing to match efficacy in trials, residual symptoms in 50% of patients, a 20% relapse rate in compliant patients, and worrisome extrapyramidal side effects, including tardive dyskinesia in 5% per year. Second-generation "atypical" antipsychotics bypass these effects by having less affinity for the dopamine D(2) receptor and affinities for other neuroreceptors. Clozapine, the lead atypical antipsychotic, was followed in the mid 1990s by risperidone, olanzapine, and quetiapine, which now account for over half of new antipsychotic prescriptions in North America, The debate over their relative efficacy involves the potential well-being of millions of schizophrenics and billions of dollars. Atypical antipsychotics are considerably more expensive; evidence for their superiority is highly variable and often inadequate, largely confined to short-term regulatory studies. Their effects on long-term outcome (particularly negative symptoms), relapse prevention, social and vocational functioning, suicide prevention and quality of life, and family and caregiver burden are largely unknown. The National institute of Mental Health's Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) project is a combined efficacy-effectiveness trial that aims to answer these questions in a broad range of patients with schizophrenia and Alzheimer's disease.

Heritability of functioning in families with schizophrenia in relation to neurocognition

The role of daily functioning is an integral part of the schizophrenia (SZ) phenotype and deficits in this trait appear to be present in both affected persons and some unaffected relatives; hence we have examined its heritability in our cohort of African American schizophrenia families. There is now ample evidence that deficits in cognitive function can impact family members who are not themselves diagnosed with SZ; there is some, but less evidence that role function behaves likewise. We evaluate whether role function tends to "run in families" who were ascertained because they contain an African American proband diagnosed with SZ.

METHODS

We analyzed heritability for selected traits related to daily function, employment, living situation, marital status, and Global Assessment Scale (GAS) score; modeling age, gender, along with neurocognition and diagnosis as covariates in a family based African-American sample (N=2488 individuals including 979 probands).

RESULTS

Measures of role function were heritable in models including neurocognitive domains and factor analytically derived neurocognitive summary scores and demographics as covariates; the most heritable estimate was obtained from the current GAS scores (h2=0.72). Neurocognition was not a significant contributor to heritability of role function.

CONCLUSIONS

Commonly assessed demographic and clinical indicators of functioning are heritable with a global rating of functioning being the most heritable. Measures of neurocognition had little impact on heritability of functioning overall. The family covariance for functioning, reflected in its heritability, supports the concept that interventions at the family level, such as evidenced-based family psychoeducation may be beneficial in schizophrenia.

Olanzapine and haloperidol in first episode psychosis: two-year data

Few studies have assessed the comparative efficacy and safety of atypical and typical antipsychotic medications in patients within their first episode of psychosis. This study examined the effectiveness of the atypical antipsychotic olanzapine and the typical antipsychotic haloperidol in patients experiencing their first episode of a schizophrenia-related psychotic disorder over a 2-year treatment period. Two hundred and sixty-three patients were randomized to olanzapine or haloperidol in a doubleblind, multisite, international 2-year study. Clinical symptoms and side effects were assessed at baseline and longitudinally following randomization for the duration of the study. Olanzapine and haloperidol treatment were both associated with substantial and comparable reductions in symptom severity (the primary outcome measure) over the course of the study. However, the treatment groups differed on two secondary efficacy measures. Patients were less likely to discontinue treatment with olanzapine than with haloperidol: mean time (in days) in the study was significantly greater for those treated with olanzapine compared to haloperidol (322.09 vs. 230.38, p<0.0085). Moreover, remission rates were greater in patients treated with olanzapine as compared to those treated with haloperidol (57.25% vs. 43.94%, p<0.036). While extrapyramidal side effects were greater in those treated with haloperidol, weight gain, cholesterol level and liver function values were greater in patients treated with olanzapine. The data from this study suggest some clinical benefits for olanzapine as compared to haloperidol in first episode patients, which must be weighed against those adverse effects that are more likely with olanzapine.

Fast voltammetric studies of the kinetics and energetics of coupled electron-transfer reactions in proteins

A wealth of information on the reactions of redox-active sites in proteins can be obtained by voltammetric studies in which the protein sample is arranged as a layer on an electrode surface. By carrying out cyclic voltammetry over a wide range of scan rates and exploiting the ability to poise or pulse the electrode potential between cycles, data are obtained that are conveniently (albeit simplistically) analysed in terms of plots of peak potentials against scan rate. A simple reversible electron-transfer process gives rise to a 'trumpet'-shaped plot because the oxidation and reduction peaks separate increasingly at high scan rate; the electrochemical kinetics are then determined by fitting to Butler-Volmer or Marcus models. Much more interesting though are the ways in which this 'trumpet plot' is altered, often dramatically, when electron transfer is coupled to biologically important processes such as proton transfer, ligand exchange, or a change in conformation. It is then possible to derive particularly detailed information on the kinetics, energetics and mechanism of reactions that may not revealed clearly or even at all by other methods. In order to interpret the voltammetry of coupled systems, it is important to be able to define 'ideal behaviour' for systems that are expected to show simple and uncoupled electron transfer. Accordingly, this paper describes results we have obtained for several proteins that are expected to show such behaviour, and compares these results with theoretical predictions.

Safety and tolerability of oral loading divalproex sodium in acutely manic bipolar patients

BACKGROUND

Achieving therapeutic blood levels of a mood stabilizer as quickly as possible is desirable in patients with acute mania. We examined the feasibility and safety of an accelerated oral loading strategy (divalproex, 30 mg/kg/day, on days 1 and 2, followed by 20 mg/kg/day on days 3-10) designed to bring serum valproate concentrations to therapeutic levels (i.e., above 50 microg/mL).

METHOD

Fifty-nine patients who met DSM-IV diagnostic criteria for current manic episode and who had a Mania Rating Scale score > or = 14 were randomly assigned on a double-blind basis to receive divalproex oral loading (N = 20); divalproex nonloading (N = 20) at a starting dose of 250 mg t.i.d. on days 1 and 2, followed by standard dose titration for days 3 to 10; or lithium carbonate (N = 19) at a starting dose of 300 mg t.i.d., followed by standard dose titration for days 3 to 10.

RESULTS

Eighty-four percent of the divalproex-loading patients, but only 30% of the divalproex-nonloading patients, had valproate serum levels above 50 microg/mL at day 3 of the study. None of the lithium-treated patients had serum lithium levels above 0.8 mEq/L at study day 3. No patient was removed from the study because of an adverse event. There were no significant differences between the groups in the frequencies or types of adverse events.

CONCLUSION

Accelerated oral loading with divalproex sodium is a feasible and safe method to bring serum valproate concentrations to effective levels rapidly.

Smoking and therapeutic response to clozapine in patients with schizophrenia

BACKGROUND

Of patients with schizophrenia, 70 to 80% smoke. Nicotine corrects certain information processing and cognitive psychomotor deficits seen in many patients with schizophrenia. Clozapine, but not conventional antipsychotics, has been shown to correct some of these deficits.

METHODS

We assessed psychopathology and smoking in 70 patients with treatment refractory schizophrenia (55 smokers and 15 nonsmokers) at baseline when they were receiving conventional antipsychotics and again after they were switched to clozapine.

RESULTS

Smokers showed significantly greater therapeutic response to clozapine than nonsmokers. Smokers smoked less when treated with clozapine than when treated with conventional antipsychotics.

CONCLUSIONS

Certain patients with schizophrenia have contributing pathophysiologic mechanisms that respond favorably to either nicotine or clozapine.

Neurotrophin-3 levels in the cerebrospinal fluid of patients with schizophrenia or medical illness

Neurotrophin-3 (NT-3) may have a potential role in the pathogenesis of schizophrenia, given evidence of abnormal neurodevelopment in schizophrenia, as well as a potential association of an NT-3 gene polymorphism with schizophrenia. Cerebrospinal fluid NT-3 protein was assayed using an enzyme-linked immunosorbent assay in five patients with schizophrenia and 49 patients with medical illness. None of the patients with schizophrenia had detectable levels of NT-3 (above 4.7 pg/ml). Eleven samples from 10 different patients with medical or neurological illness had detectable levels of NT-3, associated with surgery for hydrocephalus or central nervous system infection.

Clozapine-induced electroencephalogram changes as a function of clozapine serum levels

Specific electroencephalogram (EEG) changes during clozapine therapy were prospectively studied in a cohort of 50 chronic state hospital patients with schizophrenia who were randomly assigned to one of three nonoverlapping clozapine serum level ranges (50-150 ng/mL, 200-300 ng/mL, and 350-450 ng/mL). EEGs were obtained before clozapine was instituted, and after 10 weeks of treatment. Fifty-three percent of patients showed EEG changes during the 10-week study period. We observed three seizures (6%), one in a patient on 900 mg (serum level 320 ng/mL) clozapine, and two in patients with lower clozapine serum levels (200-300 ng/mL) who had prior histories of seizures and inadequate valproate coverage. Thirteen percent of patients developed spikes with no relationship to dose or serum level of clozapine. Fifty-three percent of patients developed slowing on EEG. Compared to plasma levels below 300 ng/mL, a clozapine serum level between 350 and 450 ng/mL led to more frequent and more severe slowing. The EEG slowing correlated with observed sleepiness, although this factor was not sufficient to explain the severity of high-dose effects.

A double-blind comparison of abecarnil and diazepam in the treatment of uncomplicated alcohol withdrawal

Treatment of the alcohol withdrawal syndrome is best accomplished using pharmacologic agents that have minimal interaction with alcohol, have limited adverse effects, and are without abuse potential. The partial benzodiazepine receptor agonist beta-carboline compound, abecarnil, has been shown in animal and human studies to possess a number of these characteristics and to be useful in the reduction of alcohol withdrawal convulsions in mice. In this study, 49 alcohol-dependent inpatients who exhibited at least moderate symptoms of uncomplicated alcohol withdrawal were treated over a 5-day detoxification period with abecarnil or diazepam and rated daily for alcohol withdrawal symptoms and adverse events. Both the abecarnil and diazepam treatment groups exhibited a similar marked reduction in withdrawal symptoms over time. In addition, similar rates of successful treatment and improvement were observed after 1 day of treatment and at termination in alcoholics treated with either medication. Overall, rates of adverse events and changes in liver enzymes were similar in both treatment groups and were generally benign. Because of the unique pharmacologic profile of abecarnil in animal and in non-clinical human studies, including anticonvulsant action, low abuse liability, and a favorable side effect profile, further study of compounds of the partial benzodiazepine receptor agonist type in the treatment of alcohol withdrawal syndromes seems warranted.

A study of the potential confounding effects of diet, caffeine, nicotine and lorazepam on the stability of plasma and urinary homovanillic acid levels in patients with schizophrenia

Ten men inpatients who met DSM-III-R criteria for schizophrenia participated. On five occasions at least one week apart, each subject had an intravenous line placed at 0730 after an overnight fast. On each occasion blood samples were drawn at 0800 and hourly thereafter through 1200 noon for measurement of plasma homovanillic acid (HVA). Total four-hour urine collections were obtained for measurement of urinary HVA. Subjects received five experimental conditions, in randomized sequence: no intervention, smoking one cigarette per hour, drinking one caffeinated cola per hour, lorazepam 2 mg IV push, or a high monoamine meal. Baseline (0800) plasma HVA measures showed only minor intrinsic variability. The average standard deviation in baseline plasma HVA over five occasions of measurement was low relative to the changes in HVA produced during treatment with antipsychotic medications. The high monoamine meal significantly elevated plasma HVA, with a similar trend for urinary HVA. Neither caffeine, nicotine, nor lorazepam significantly affected plasma or urinary HVA.

Cognitive effects of neonatal hippocampal lesions in a rat model of schizophrenia

Lesioning the ventral hippocampus of neonatal rats has been proposed as an experimental model of schizophrenia. This lesion causes a syndrome of hyperresponsivity to the stimulant effects of amphetamine, impaired grooming and disrupted social interactions, effects that emerge during adolescence, much like schizophrenia. Persisting cognitive effects of neonatal ventral hippocampal lesions were assessed in the current study, because the hippocampus is critically important for a variety of cognitive functions and cognitive impairment and because it is an important feature of schizophrenia. Spatial learning and working memory were assessed in the radial-arm maze, which is sensitive to the adverse effects of hippocampal lesions made in adults. Lesioned rats showed pronounced deficits in radial-arm maze choice accuracy that persisted throughout training. Deficits were seen during the prepubertal period as well as in adulthood. Even though the lesioned rats performed more poorly, they were significantly less sensitive to the amnestic effects of the nicotinic antagonist mecamylamine and the muscarinic antagonist scopolamine. No significant effects of nicotine or amphetamine were seen in either the lesioned or control groups. The long-lasting deficits in spatial learning and working memory resulting from neonatal ventral hippocampal lesions show that, unlike frontal cortical lesions during the same age, the effects of hippocampal lesions are not overcome during development. The resistance to the amnestic effects of nicotinic and muscarinic acetylcholine (ACh) antagonists suggests that the hippocampus is a critical site for the action of these drugs. Neonatal hippocampal lesions may provide a good model of the cognitive impairments of schizophrenia and may be useful to assess novel drug effects to counteract the cognitive deficits in schizophrenia.

Response of patients with treatment-refractory schizophrenia to clozapine within three serum level ranges

OBJECTIVE

This study sought to determine the relationships between serum clozapine levels and therapeutic response.

METHOD

Fifty-six inpatients who met the DSM-III-R criteria for chronic schizophrenia and who had not responded to extended treatment with classical antipsychotics were randomly assigned to 12 weeks of double-blind treatment with clozapine at one of three serum level ranges: low (50-150 ng/ml), medium (200-300 ng/ml), or high (350-450 ng/ml). Baseline clinical assessments were completed before the patients' regular antipsychotic and anticholinergic drugs were discontinued. During clozapine treatment, serum levels were ascertained weekly to allow adjustment of clozapine doses so as to maintain each patient near the midpoint of his or her assigned serum level range. Clinical assessments were completed after 6 and 12 weeks of treatment.

RESULTS

The analyses of the results of treatment supported the superior efficacy of the 200-300 ng/ml and 350-450 ng/ml serum clozapine level ranges over the 50-150 ng/ml range, with no advantage for 350-450 ng/ml over 200-300 ng/ml. Sleepiness increased with increasing serum levels.

CONCLUSIONS

Serum clozapine levels per unit of daily dose were at the lower end of the range noted in previous reports, possibly reflecting the current study's dosing schedules of twice or three times a day, the 11- to 13-hour postdose sampling time, and the moderate doses given. Serum clozapine levels, if interpreted in relation to daily clozapine dosing schedules, postdose sampling time, and total daily dose, may help to guide dosing to provide adequate opportunities for therapeutic response and to limit certain side effects of clozapine treatment.

A randomized, controlled, dose-ranging trial of sertindole in patients with schizophrenia

Sertindole is a novel antipsychotic agent with high selectivity for the mesolimbic dopaminergic pathway and nanomolar affinities for dopamine D2, serotonin 5-HT2, and norepinephrine NE alpha 1 receptors. This 40-day randomized, placebo-controlled, dose-ranging multicenter study was designed to assess the effect of sertindole on previously neuroleptic-responsive, hospitalized schizophrenic patients (n = 205). Sertindole doses began at 4 mg/day and were increased to 8, 12, or 20 mg/day, depending on randomization. Efficacy measures included the Positive and Negative Syndrome Scale (PANSS), Brief Psychiatric Rating Scale (BPRS), and Clinical Global Impression (CGI). Extrapyramidal symptoms (EPS) were assessed by movement rating scales, EPS-related adverse events, and use of anti-EPS medications. A dose-related improvement was observed for PANSS, BPRS, and CGI, with statistically significant mean differences (P < 0.05) between placebo and 20-mg/day sertindole (decreases from baseline of -5.8 versus -16.9 for PANSS, -4.8 versus -10.4 for BPRS, respectively). The differences in CGI final improvement score between placebo and 20-mg/day sertindole were 3.8 versus 2.9, respectively. EPS-related events were comparable in the placebo and sertindole groups. In conclusion, sertindole 20 mg/day was effective, well tolerated, and not associated with significant motor system abnormalities.

Common sense, insight, and neuropsychological test performance in schizophrenia patients

We report an exploratory study examining the interrelationships among common sense, insight into psychosis, and performance on a battery of neuropsychological tests in 32 patients with schizophrenia evaluated at the time of discharge from involuntary hospitalization at a State psychiatric hospital. Common sense, as measured by the Social Knowledge Questionnaire, was associated with better performance across tests measuring parietal lobe functioning and vocabulary. In addition, patients with more common sense were more likely to say that they were ill and needed treatment. A global measure of insight, the Insight and Treatment Attitudes Questionnaire (ITAQ), was related to performance on a test of left parietal lobe function. However, the responses to the ITAQ item that may best reflect current awareness of mental illness in patients at the time of discharge ("After you are discharged, is it possible you may have mental problems again?") were related to performance on tests of the functioning of the prefrontal lobes and the right and left parietal lobes. These results add to the growing evidence that some of the deficits in awareness of illness among patients with schizophrenia are related to the neuropsychological dysfunction commonly seen in patients with this disorder.

Insight in schizophrenia and mania

We administered a series of 12 brief vignettes depicting examples of positive, negative, and manic psychopathology in everyday language to 21 patients with schizophrenia and 20 patients with mania. We asked patients to rate, first, how similar they were to the individual depicted in each vignette, and, second, the degree to which the experiences or behaviors depicted in each vignette reflected mental illness. Psychiatrists also rated how similar each patient was to each vignette. At admission, patients with schizophrenia rated themselves as significantly less similar to the positive symptom vignettes than the psychiatrists rated them. Patients with mania did not differ from the psychiatrist in rating their similarity to the vignettes, but they strongly denied that the vignettes reflected mental illness.

Haloperidol increases smoking in patients with schizophrenia

Ten patients with schizophrenia participated in 120-min free-smoking sessions when actively psychotic and free of antipsychotic medications, and again after the initiation of haloperidol treatment. During these free-smoking sessions they had access to cigarettes ad libitum. Their expired air carbon monoxide (CO) and plasma nicotine and cotinine levels were measured at the end of the 120-min free-smoking sessions. These patients smoked more after starting haloperidol treatment, relative to their baseline rate of smoking when free of antipsychotic medications, as evidenced by significantly higher expired CO and plasma nicotine levels.

Pharmacotherapy of impaired affect in recovering schizophrenic patients

BACKGROUND

Prominent and persistent anxiety, depression, and/or negative features characterize a substantial minority of recovered or residually psychotic schizophrenic outpatients and contribute to poor outcome. Because extrapyramidal side effects of typical neuroleptic medications often resemble such features, we first systematically studied the contribution of extrapyramidal side effects to these problems and their treatment. For patients who remained distressed, controlled trials of supplemental thymoleptics were undertaken.

METHODS

In trial 1, 92 distressed (depressed and/or anxious) patients and 36 patients in a defect state (patients with negative symptoms) participated in a double-blind, intramuscular challenge that compared centrally acting benztropine mesylate with peripherally acting glycopyrrolate. In trial 2, 57 distressed patients and 22 patients in a defect state were randomly assigned to a double-blind, neuroleptic medication dose-reduction group. In trial 3, 57 chronically distressed patients who were maintained on a low dose of fluphenazine decanoate were randomly assigned to a supplemental desipramine hydrochloride, lithium carbonate, or placebo group under double-blind conditions for 12 weeks.

RESULTS

For patients who were already maintained on antiparkinsonian medication, impaired affect was not resolved by additional benztropine. Only distressed patients with a family history of severe mental disorder (often affective) showed improvement with neuroleptic medication dose reduction. Patients in the defect-state group reported less dysphoria on a reduced neuroleptic medication dose, but negative symptoms persisted. Desipramine improved diverse aspects of mood and residual psychoticism, possibly as a prophylaxis against minor affective exacerbations. Depression improved in women only. Lithium positively affected multiple indexes of anxiety and anxious depression.

CONCLUSION

Most often, persistent affective impairments are neither resistant extrapyramidal side effects nor characterological traits. Thymoleptics improve the nonphasic, chronic types of anxiety and depression in contrast to the acute, episodic forms, for which little support can be found in the literature.

Efficacy of risperidone on positive features of schizophrenia

Dopaminergic hyperactivity mediated via D2 receptors is implicated in the etiology of positive symptoms of schizophrenia, but selective D2 antagonists provide imperfect therapy. This article describes a subanalysis of a trial of risperidone, a combined 5-HT2A/D2 antagonist, in 513 patients with DSM-III-R chronic schizophrenia. Risperidone at 2, 6, 10, and 16 mg/day was compared with placebo and haloperidol 20 mg/day. All doses of risperidone and the 20-mg dose of haloperidol were superior to placebo (mean change from baseline on the PANSS positive and general psychopathology subscales). The 6-mg dose of risperidone also produced significantly more improvement than haloperidol 20 mg. We conclude that risperidone is an effective drug for patients with positive features of schizophrenia.

A pilot study of a structured interview addressing sexual function in men with schizophrenia

Twenty physically healthy men with schizophrenia responded to a 15-item questionnaire inquiring about their usual and their present (on medications) sexual functioning. Two summary measures of present impairment (the average of items 7-13 that detail the patients' specific complaints of impairment, and item 15, the interviewer's global judgment of impairment) were significantly correlated with each other and with the differences between usual and present reported frequencies of erection and masturbation. More severe impairment on these summary measures was significantly associated with greater biological evidence of dopamine blockade (more severe extrapyramidal side effects and higher serum prolactin levels).

Use of psychopathology vignettes by patients with schizophrenia or schizoaffective disorder and by mental health professionals to judge patients' insight

OBJECTIVE

The goal of this study was to clarify more precisely where patients with psychotic disorders and the mental health professionals who care for them disagree regarding whether the patient is ill or needs treatment.

METHOD

The authors prepared brief vignettes in everyday descriptive language that provided examples of the classical positive and negative psychopathological features of schizophrenia. Fifteen men and 11 women diagnosed as having schizophrenia or schizoaffective disorder and one physician used these vignettes as a common frame of reference to rate 1) the degree to which the patients demonstrated the features described in each vignette and 2) the degree to which the features signified the presence of mental illness.

RESULTS

Disagreements between the physician's and patients' ratings, indicating deficits in insight, were associated with the recognition of the presence of conceptual disorganization, avolition-apathy, and affective blunting in the patients by the physician but not the patients and with the conceptualization of hallucinatory behavior and suspiciousness as signs of mental illness by the physician but not the patients.

CONCLUSIONS

The authors conclude that the failure to acknowledge conceptual disorganization, avolition-apathy, and affective blunting and the failure to view hallucinatory behavior and suspiciousness as signs of mental illness, which proved to be additive in this study, contribute to deficits in insight.

An open study of the pharmacokinetics and the tolerability of raclopride extended release capsules in psychiatric patients

Following a 4-7 day drug-free washout period, eight male inpatients took an extended-release (ER) formulation of raclopride. After the initial 8 mg dose on day 1 of the study, repeated plasma samples were collected over the ensuing 36 h. Subsequently, patients received raclopride 8 mg b.i.d. through day 7, 12 mg b.i.d. through day 14, and, if tolerated, 16 mg b.i.d. through day 21. On days 7, 14, and 21, repeated plasma samples were drawn over the 12 h following the morning dose. Relative to the previously studied immediate release form of raclopride, the ER formulation delayed and extended the absorption of raclopride, and produced lower maximum raclopride concentrations. Linear kinetics were preserved across the dose range studied. Two patients could not tolerate the highest raclopride dose because of extrapyramidal side effects.

Optimal dose of neuroleptic in acute schizophrenia. A controlled study of the neuroleptic threshold and higher haloperidol dose

After individual determination of neuroleptic threshold (NT) doses of haloperidol, 106 patients with schizophrenia or schizoaffective disorder (Research Diagnostic Criteria) were treated openly at such doses (mean, 3.7 +/- 2.3 mg/d) for 2 weeks. Ten responding patients were discharged and unavailable for follow-up or refused subsequent randomization, and one non-responding patient refused randomization. The remaining 95 responding or nonresponding patients were then randomly assigned, double-blind, to a dosage of haloperidol two to 10 times higher (mean, 11.6 +/- 4.7 mg/d) or to a continuing NT dosage (mean, 3.4 +/- 2.3 mg/d) for another 2 weeks. Of the 58 patients exposed only to NT dosages of haloperidol, 72% clinically recovered within the 5-week trial. Higher dosages given to 47 patients did not lead to greater improvement in measures of psychosis, but did produce slightly greater declines in measures of hostility. Higher dosages did regularly lead to significant increases in distressing extrapyramidal side effects.

Hospitalized schizophrenic patient views about seclusion

Twenty-six of 100 consecutively admitted schizophrenic or schizoaffective patients required seclusion during their hospital stays. Seclusion episodes usually involved involuntarily committed, severely ill patients and occurred early in their hospitalizations. The recollections of the personal seclusion experiences of 17 patients were generally factually accurate, except for a tendency to play down disruptive aggressive behavior on their part. Patients described seclusion as a painful experience associated with feelings of helplessness, fear, sadness, and anger. However, patients also stated that seclusion rooms were necessary on inpatient psychiatric units and that the rooms were used for the control of disruptive aggressive patient behaviors. This study highlights not only the need for staff to clarify for patients what behavior has led to seclusion and what behavior will lead to release, but also the need for staff to acknowledge patients' distress at the experience.

The dose-response relationship for memory impairment by anticholinergic drugs

Twelve stabilized chronic schizophrenic outpatients receiving maintenance treatment with fluphenazine decanoate plus anticholinergic antiparkinsonian drugs underwent two challenge sessions receiving, in random sequence and double-blind, injections of either benztropine or glycopyrrolate (a peripherally active anticholinergic agent that penetrates the CNS poorly, used as an active placebo). Performance on free recall testing was significantly worse after benztropine than after glycopyrrolate. It has previously been shown that routine clinical doses of anticholinergic antiparkinsonian drugs impair verbal learning relative to a drug-free baseline. Our results suggest that memory impairment continues to further increase as anticholinergic drugs are pushed to the upper limit of the acceptable clinical range.

Insight and the clinical outcome of schizophrenic patients

At the time of discharge from their index hospitalizations, 52 schizophrenic patients initially admitted for acute psychotic episodes were assessed on an Insight and Treatment Attitudes Questionnaire. When these patients were followed up 2 1/2 to 3 1/2 years later, adequate information on their clinical courses and outcomes was available in 46 cases. A global assessment of aftercare environment was made in each case, reflecting the degree to which individuals other than the patient were helpfully invested in maintaining the patient in treatment, whether these individuals were in the patient's living or treatment situations. Five factual outcome variables were also assessed: a) compliance with treatment 30 days after discharge; b) long-term compliance; c) whether or not patients were readmitted; d) readmissions per year; and e) percent of time spent in the hospital. As expected, aftercare environment was significantly related to outcome (p = .039). The overall relationship between insight and the outcome variables closely approached statistical significance (p = .053). Patients with more insight were significantly less likely to be readmitted over the course of follow-up. There was a trend for patients with more insight to be compliant with treatment 30 days after discharge. No significant interaction between aftercare environment and insight was found, suggesting that insight may influence outcome independently of aftercare environment.

Insight in schizophrenia. Its relationship to acute psychopathology

The relationship between insight and acute psychopathology was explored in a group of 52 acutely psychotic, schizophrenic patients. A measure of insight, reflecting patients' recognition of their illness and need for care, was validated against ratings from a semi-structured interview and against assessments of patients' compliance with medication. Contrary to expectations, degree of insight was not consistently related to the severity of acute psychopathology, as measured on two structured scales. Nor did changes in insight during hospitalization vary consistently with changes in acute psychopathology. These data suggest that very little of the deficiency in insight seen in schizophrenic patients is explainable on the basis of acute psychopathological features. The mechanism that accounts for impairment in insight in schizophrenia may be relatively resistant to treatment with neuroleptic medication.

Why must some schizophrenic patients be involuntarily committed? The role of insight

Twenty-four of 52 (46%) schizophrenic patients hospitalized because of acute psychotic episodes associated with preadmission medication noncompliance required involuntary commitment. Committed patients were rated as significantly more severely ill than voluntary patients and were significantly more likely to be transferred to extended treatment facilities after acute care. However, committed patients were significantly less likely than were voluntarily admitted patients to acknowledge that they were psychiatrically ill and in need of treatment, i.e., to demonstrate insight. Although psychopathology diminished significantly in both committed and voluntary patients over the course of hospitalization, only in voluntary patients did insight increase significantly. Over a 21/2 to 31/2 year follow-up, those patients who had been involuntarily committed at the index hospitalization were significantly more likely to require involuntary admissions than were the initially voluntary patients. Inability to see the self as ill seems to be a persistent trait in some schizophrenic patients.

Dose of fluphenazine, familial expressed emotion, and outcome in schizophrenia. Results of a two-year controlled study

Issues regarding the side effects of antipsychotic medication and the possible contribution of the environment to dose requirements led to a two-year controlled dosage study of maintenance antipsychotic medication and familial environment among recently discharged schizophrenic patients. Seventy stable patients, living in high- or low-expressed emotion (EE) households, were randomized, double blind, to receive a standard dose of fluphenazine decanoate (average, 25 mg every two weeks) or a minimal dose representing 20% of the dose prescribed (average, 3.8 mg every two weeks). No differences in relapse were observed among dose, EE, or dose and EE. Patients in the minimal dose/high-EE condition experienced more minor but aborted episodes in year 2. Side effects were fewer on the minimal dose after one year, and low-EE patients were better adjusted than high-EE patients. Over time, minimal-dose recipients were significantly more improved in their instrumental and interpersonal role performance than were standard-dose recipients.

A double-blind crossover comparison of antiparkinson drug therapy: amantadine versus anticholinergics in 90 normal volunteers, with an emphasis on differential effects on memory function

Anticholinergic antiparkinson drugs administered orally at standard clinically prescribed doses impaired new memory acquisition and mood in normal volunteer subjects, based on tests of free recall, recognition memory, and time production, self-rating of memory function, and an evaluation of mood states. Elderly subjects were more severely impaired than were young adults. Amantadine did not impair new memory acquisition, and on self-report measures, it was significantly better tolerated than were anticholinergics. Among patients being treated for psychotic illness, there are two groups in which an effort to avoid anticholinergic therapy is especially worthwhile because of the severe consequences of memory dysfunction. These individuals are young neuroleptic-responsive patients who are in an early stage of their disease and elderly patients. For these two groups, amantadine should be considered as the initial mode of treatment, with low-dose anticholinergics being used for those patients who do not achieve adequate relief from extrapyramidal side effects with amantadine.

Effects of amantadine and trihexyphenidyl on memory in elderly normal volunteers

Anticholinergic drugs impair one's ability to learn new material, even at routine clinically used doses. During the trihexyphenidyl phase of this double-blind crossover trial, elderly normal subjects complained of confusion and memory impairment and demonstrated a pattern of deficits in memory function compatible with that previously reported to result from anticholinergic drugs. The subjects neither complained of nor demonstrated memory impairment while taking amantadine, which is believed to exert its pharmacological effects upon extrapyramidal disorders via dopaminergic mechanisms and does not appear to be associated with memory impairment. Anticholinergic drugs should be avoided whenever possible in the elderly and especially in those suffering dementia.

Plasma haloperidol levels drawn at neuroleptic threshold doses: a pilot study

The daily haloperidol doses of 33 newly admitted, acutely psychotic schizophrenic patients were rapidly adjusted to a point at which slight hypokinesia-rigidity first appeared on clinical examination (the neuroleptic threshold). The mean daily haloperidol dose at which the neuroleptic threshold was crossed was 4.2 +/- 2.4 mg/day. The plasma haloperidol levels obtained at these neuroleptic threshold doses clustered around a mean of 4.9 +/- 2.9 ng/ml. This plasma haloperidol level distribution extensively overlaps the proposed lower boundaries for the therapeutically effective range of plasma haloperidol levels, but it is below the range in which coarse extrapyramidal side effects appear in high frequency (greater than 10 ng/ml). Sixty-seven percent of our patients demonstrated moderate or greater therapeutic improvement within 3 weeks of treatment at neuroleptic threshold doses, a therapeutic efficacy rate identical to that expected with standard neuroleptic doses. The authors propose that the neuroleptic threshold is a readily available clinical marker which identifies a range of plasma haloperidol levels capable of producing therapeutic response with minimal associated coarse extrapyramidal side effects.