Discontinuation vs. continuation treatment with neuroleptics for a better long-term outcome

Background

Long-term functional outcome of dose-reduction/discontinuation strategies in first-episode psychosis (FEP) has not been studied before. The present study compared 7-year outcome of an early antipsychotic dose-reduction/discontinuation (DR) strategy with maintenance treatment (MT). Primary outcome was (symptomatic and functional) recovery; relapse rates, functional and symptomatic remission were secondary outcomes.

Methods

FEP patients (n = 128) symptomatically remitted for 6 m during their first treatment year who completed an 18 months trial comparing MT and DR were followed-up at 7 years. Symptomatic remission criteria were adopted from Andreasen et al., functional remission criteria were based on a functioning scale. Recovery was defined as meeting both criteria sets. MT or DR strategy, and baseline parameters were entered in a logistic regression analysis with symptom and functional remission and recovery at 7-years follow-up as dependent variables.

Results

One hundred and three patients consented to participate. DR-patients showed twice the recovery-rate of MT-patients (40% against 18%), odds ratio 3.5 (P = .014). Symptomatic remission-rates were equal (69% and 67%). Better DR recovery-rates were attributable to higher functional remission-rates (46% vs. 20%) in DR. Predictors of recovery were DR, baseline living together and less severe negative symptoms. During the last 2 years of follow-up the mean daily dose in haloperidol equivalents was 2.20 mg in DR vs. 3.60 mg in MT (P = .031).

Relapse rates were initially higher in DR but leveled at 3 years; 61.5% relapsed in DR and 68.6% in MT in 7 years.

Conclusion

DR of antipsychotics during early stages of remitted FEP significantly improved 7-years outcome in terms of recovery and functional remission compared to maintenance treatment. Though initially relapse rates in GD were higher, these equalled those in MT from 3 years to the end of the study. While the necessity of immediate antipsychotic treatment in FEP and positive symptoms relapse is robustly demonstrated in a great number of studies, this study suggests that we are faced with a dilemma concerning the drawbacks of long-term maintenance antipsychotic treatment on functional capacity. Though antipsychotic discontinuation appears only feasible without relapse in a substantial minority of patients, guided dose-reduction as far as positive symptoms remain subsided and allow it, appears a feasible strategy in view of functional recovery, doing justice to both sides of the dilemma.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Lower prefrontal activation during emotion regulation in subjects at ultrahigh risk for psychosis: an fMRI-study

BACKGROUND

Previous research has shown that patients with schizophrenia experience difficulties with emotion regulation and activate prefrontal regions to a lesser extent during reappraisal of emotional information. It has been suggested that problems in emotion regulation might precede the onset of psychosis. Therefore, it could be hypothesized that also individuals at ultrahigh risk (UHR) for developing psychosis experience difficulties with emotion regulation.

AIMS

The aim of the current study was to investigate whether individuals at UHR for developing psychosis show abnormal brain activation during reappraisal of negative pictures.

METHODS

Using functional magnetic resonance imaging (fMRI), we scanned 15 UHR participants and 16 matched healthy controls while performing an emotion regulation task. During this task, participants had to reappraise their negative emotion elicited by International Affective Picture System pictures. Furthermore, the reported use of reappraisal was examined with the emotion regulation questionnaire (ERQ).

RESULTS

Individuals at UHR for psychosis showed less activation in the left ventrolateral prefrontal cortex during reappraisal compared with healthy controls. Furthermore, they reported less use of reappraisal in daily life (P=0.01; 95% CI (0.24-1.63)).

CONCLUSIONS

These findings indicate that dysfunctional emotion regulation may already occur in individuals at risk for psychosis. These regulation difficulties are underpinned by less ventrolateral prefrontal cortex activation, and may result in high negative affect, lower social functioning, and high rates of psychotic symptoms.

Adding evidence-based interventions to assertive community treatment: a feasibility study

OBJECTIVE

This 24-month study, conducted in The Netherlands, examined the feasibility of enhancing the effectiveness of assertive community treatment (ACT) by adding evidence-based interventions.

METHODS

A total of 159 patients were randomly assigned to two ACT teams, one providing standard ACT (N585) and an ACT Plus team that also provided evidence-based interventions (N574): psychoeducation, family interventions, individual placement and support, and cognitive behavioral therapy. The interventions were conducted by psychologists and nurse practitioners working independently from the ACT team.

RESULTS

Although most patients were judged eligible for each of the four interventions (range 65% to 89%), only 12 of the 74 patients (16%) successfully completed an intervention. Outcomes, such as use of inpatient care, for ACT Plus and standard ACT patients did not differ significantly.

CONCLUSIONS

Guidelines for the treatment of schizophrenia should consider the feasibility of delivering evidence-based interventions to difficult-to-engage patients.

Induction of cytochrome P450 isoenzymes after toxicokinetic interactions between 2,3,7,8-tetrachlorodibenzo-p-dioxin and 2,2',4,4',5,5'-hexachlorobiphenyl in the liver of the mouse

One group of male C57BL/6J mice received a single oral dose of 1 nmol 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD)/kg. Six other groups received single oral doses of 100, 300, or 1000 mumol 2,2',4,4',5,5'-hexachlorobiphenyl (HxCB)/kg, alone or in combination with 1 nmol/kg TCDD. Liver deposition of both compounds was studied at Day 3 after dosage. Hepatic CYP1A1 and CYP1A2 protein levels and related 7-ethoxyresorufin-O-deethylation (EROD) and acetanilide 4-hydroxylation (ACOH) activities were also studied. A significant increase in the hepatic deposition of TCDD was observed in all three mixed dose groups but TCDD did not influence hepatic HxCB deposition. TCDD did increase both CYP1A1 and CYP1A2 protein levels. In the HxCB-treated groups, CYP1A2 levels were also increased in a dose-dependent way but CYP1A1 levels were not increased. CYP1A2 activities (ACOH), but not protein levels, in the TCDD groups cotreated with HxCB were higher than those in the group treated with TCDD alone. CYP1A1-dependent EROD activity and CYP1A2-dependent ACOH activity were induced in all treated dose groups. It is concluded that the present results do not confirm a direct role of CYP1A2 induction in the increase of hepatic TCDD levels by HxCB cotreatment in the mixed HxCB/TCDD dose groups. However, in this aspect, the discrepancy between CYP1A2 activities and protein levels remains to be explained.

Toxicokinetic mixture interactions between chlorinated aromatic hydrocarbons in the liver of the C57BL/6J mouse: 2. Polychlorinated dibenzo-p-dioxins (PCDDs), dibenzofurans (PCDFs) and biphenyls (PCBs)

Six groups of C57BL/6J mice received single oral doses of 1.5-10.6 nmol/kg 1,2,3,7,8-pentachlorodibenzo-p-dioxin (PnCDD), 1,2,3,6,7,8-hexachlorodibenzo-p-dioxin (HxCDD) or 2,3,4,7,8-pentachlorodibenzofuran (PnCDF) as single compounds or in combination with 300 mumol/kg 2,2',4,4',5,5'-hexachlorobiphenyl (HxCB). Two other groups of mice received a mixture of the first three compounds, either with or without HxCB. The hepatic deposition and elimination of the compounds and their CYP1a dependent 7-ethoxyresorufin-O-deethylation (EROD) activity were studied until day 175. Interactive effects on the hepatic deposition of PnCDD were observed in most of the mixed dose groups. For HxCDD and PnCDF interactive effects were either very small or absent. No interactive effects were observed on hepatic elimination rates of PnCDD, HxCDD or PnCDF. No evidence was found for the influence of HxCB cotreatment on the hepatic concentration-response curves of the three compounds or their mixture. Based on the results from the present study it is concluded that PCDDs, PCDFs and PCBs may influence each other's, toxicokinetics when administered in mixtures.