[Antipsychotics in clinical practice. Treatment of the first schizophrenic episode]

AIM

The aim was to obtain the information regarding the choice of antipsychotic drugs in the treatment of first episode schizophrenia. In particular, the factors influencing doctors' preferences and their opinion about several antipsychotics and the availability of these drugs were evaluated.

METHODS

The anonymous questionnaire was presented to 100 psychiatrists; 50 of them were in hospital and 50 were in the out-patient practice. The questionnaire consisted of 17 questions regarding the pharmacological treatment of the first schizophrenic episode.

RESULTS

The most frequently prescribed drug was olanzapine (33%), then risperidone (26%), and perazine (25%). In hospitals, risperidone was more frequently administered than perazine (29% and 24% respectively) while in out-patient clinics perazine slightly outnumbered risperidone (25% vs 23%). Fluoxetine was prescribed to 18% of out-patients, but not to hospitalized ones. Doctors performed treatment verification mainly (in 39% of patients) after 4 weeks of therapy. The change of antipsychotics was made more frequently in 28% of those hospitalized than the out-patients (16%) and mainly due to the lack of efficacy. More psychiatrists considered the most important attribute of the drug to be the efficacy toward the negative symptoms (77%) than the positive symptoms (59% of doctors).

CONCLUSIONS

Prescription practice of psychiatrists shows the popularity of olanzapine and risperidone in the treatment of the first psychotic episode, but also indicates the strong position of perazine, which results from the current administrative regulations. Three times more psychiatrists think that patients should have an unrestricted (by the law) access to olanzapine or risperidone than to perazine. The most important attribute of an antipsychotic in the first episode schizophrenia turned out to be its efficacy toward the negative symptoms. Psychiatrists admitted that they chose an antipsychotic much more frequently on the basis of their own knowledge than on the basis of experts' opinion or the administrative regulations.

Direct effects of neuroleptics on the activity of CYP2A in the liver of rats

The aim of the present study was to investigate the influence of classic and atypical neuroleptics on the activity of rat CYP2A measured as a rate of testosterone 7alpha-hydroxylation. The reaction was studied in control liver microsomes in the presence of neuroleptics, as well as in microsomes of rats treated intraperitoneally (i.p.) for one day or two weeks (twice a day) with pharmacological doses (mg/kg) of the drugs (promazine, levomepromazine, thioridazine, perazine 10, chlorpromazine, haloperidol 0.3, risperidone 0.1, sertindole 0.05), in the absence of the neuroleptics in vitro. Most of the neuroleptics added in vitro to control liver microsomes decreased the activity of the rat CYP2A. Chlorpromazine (Ki = 11 microM) was the most potent inhibitor of the rat CYP2A among the studied drugs, whose effect was more pronounced than that of the other tested phenothiazines (Ki = 41-83 microM), haloperidol (Ki = 190 microM) or sertindole (Ki = 78 microM). Risperidone was not active in this respect. The investigated neuroleptics when given to rats in vivo for one day or two weeks--did not produce any indirect inhibitory effect on CYP2A via other mechanisms. The obtained results show direct inhibitory effects of phenothiazine neuroleptics on the activity of CYP2A in rat liver, which may be of physiological importance for the metabolism of testosterone, considering simultaneous inhibition of CYP2C11 and CYP3A by those drugs.

Antipsychotic efficacy of the antidepressant trimipramine: a randomized, double-blind comparison with the phenothiazine perazine

BACKGROUND

The tricyclic antidepressant trimipramine exhibits several features (e. g., dopaminergic effect, molecular structure similar to a neuroleptic, receptor-binding profile similar to clozapine) that suggest its potential as an antipsychotic medication. The aim of the study was to investigate the antipsychotic potential of trimipramine in a controlled clinical trial comparing its antipsychotic efficacy with that of a neuroleptic.

METHOD

In a German multi-center, randomized, double-blind trial, the antipsychotic efficacy of trimipramine was compared with that of the phenothiazine neuroleptic perazine, using the Brief Psychiatric Rating Scale (BPRS), the Positive and Negative Syndrome Scale (PANSS), and Clinical Global Impressions (CGI). Antidepressant efficacy of both agents was measured by use of the Bech-Rafaelsen Melancholia Scale (BRMES). Ninety-five patients with acute schizophrenia (DSM-III-R) and a BPRS total score > 40 at baseline were treated with either 300-400 mg trimipramine or 450-600 mg perazine for 5 weeks.

RESULTS

Therapeutic equivalence of both treatments (in the dosages used) could not be demonstrated (change in BPRS total score, per-protocol [PP] analysis, one-sided equivalence testing). However, intention-to-treat (ITT) as well as PP analysis showed a statistically significant decrease in the BPRS total scores in both treatment groups (PP: trimipramine, 56.5 +/- 9.8 to 44.1 +/- 17.9; perazine, 56.4 +/- 10.8 to 37.9 +/- 12.9). Significant decreases in all BPRS and PANSS subscores as well as CGI results and response rate support the antipsychotic efficacy of trimipramine. The BRMES total scores significantly decreased in both treatment groups without showing a significant difference between the two agents. Trimipramine was better tolerated than perazine and did not elicit extrapyramidal symptoms.

CONCLUSION

Trimipramine failed to exhibit therapeutic equivalence to perazine in the dosages used. However, there was evidence of a substantial antipsychotic effect of trimipramine. It may be a useful medication if depressive symptoms in psychotic patients require antidepressant treatment or if other antipsychotics cannot be administered.

Valproate as an adjunct to neuroleptic medication for the treatment of acute episodes of mania: a prospective, randomized, double-blind, placebo-controlled, multicenter study. European Valproate Mania Study Group

To compare the efficacy of sodium valproate administered as adjunct to neuroleptic medication for patients with acute mania with the efficacy of neuroleptics alone, the authors conducted a 21-day, randomized, double-blind, parallel-group, placebo-controlled trial. The study design closely reflected a clinical psychiatric setting in Europe where patients with acute mania commonly receive neuroleptic medication. In this trial, 136 hospitalized patients met the ICD-10 criteria for acute manic episodes; these patients received a fixed dose of 20 mg/kg of body weight of sodium valproate (Orfiril, Desitin Arzneimittel GmbH, Hamburg, Germany) orally, in addition to basic neuroleptic medication, preferably haloperidol and/or perazine. The primary outcome measure was the mean dose of neuroleptic medication (after conversion into haloperidol-equivalents) for the 21-day study period. Severity of symptoms was measured using the Young Mania Rating Scale (YMRS), the Global Assessment Scale, and the Clinical Global Impression Scale. Intent-to-treat analysis was based on 69 patients treated with valproate and 67 patients who received placebo. Groups were comparable with regard to demographic and clinical baseline data. Premature discontinuations occurred in only 13% of the patients. The mean neuroleptic dose declined continuously in the valproate group, whereas only slight variations were observed in the placebo group; the difference was statistically significant (p = 0.0007) for study weeks 2 and 3. The combination of neuroleptic and valproate proved superior to neuroleptics in attempts to alleviate manic symptoms. The proportion of responders (a 50% improvement rate shown on the YMRS) was higher for the combination with valproate than for the group receiving only neuroleptics (70% vs. 46%; p = 0.005). Adverse events consisted of those known for valproate or neuroleptics; the only adverse event was asthenia, which occurred more frequently with the combination therapy. Valproate represents a useful adjunct medication for the treatment of acute manic symptoms. Valproate is beneficial because it allows the administration of fewer neuroleptic medications and produces improved and quicker remission of manic symptoms.

Pharmacokinetics of phenothiazine neuroleptics after chronic coadministration of carbamazepine

The aim of the present study was to assess the influence of carbamazepine on the pharmacokinetics of the two phenothiazine neuroleptics thioridazine and perazine in rats. The obtained results are compared with the results of analogical experiments concerning promazine. Thioridazine or perazine (10 mg/kg i.p.) were administered twice a day for two weeks alone or jointly with carbamazepine (15 mg/kg i.p. during the 1st week, and 20 mg/kg i.p. during the 2nd week of treatment). Concentrations of the neuroleptics and their main metabolites in the plasma and brain were measured at 30 min, 6 and 12 h after the last dose of the drugs. Carbamazepine decreased the concentrations of thioridazine and its metabolites (especially mesoridazine and sulforidazine) in plasma at 30 min and 6 h after the last dose of the drugs. Similar changes in the concentrations of thioridazine and its metabolites were observed at 6 h in the brain. Carbamazepine did not significantly influence the pharmacokinetics of perazine. In vitro studies with liver microsomes of control rats revealed that carbamazepine added to the incubation mixture inhibited N-demethylation of thioridazine via mixed mechanism, but it did not influence significantly 2- or 5-sulfoxidation of the neuroleptic. In the case of perazine, no distinct inhibition of its N-demethylation or sulfoxidation by carbamazepine was observed. Neither carbamazepine nor the neuroleptics, administered separately or jointly for two weeks, significantly influenced the concentrations of cytochromes P-450 and b-5 in the liver. Carbamazepine++ given chronically decreased the rate of N-demethylation and had a tendency to accelerate 2-sulfoxidation of thioridazine, both when given alone (as compared to the control) and when coadministered with thioridazine (as compared to the thioridazine-treated group). In contrast, chronic treatment with carbamazepine alone, significantly increased the rate of perazine N-demethylation. When carbamazepine was coadministered with perazine, the effect was less pronounced. In conclusion, carbamazepine given jointly with thioridazine or promazine at pharmacological doses to rats accelerates the metabolism of the neuroleptics, which is not the case with perazine. The observed induction proceeds by metabolic pathways other than N-demethylation or sulfoxidation. The different effect of carbamazepine on the N-demethylation of thioridazine and perazine in liver microsomes of control and carbamazepine-treated rats implicates that the two reactions are not catalyzed by the same enzyme. Such an induction of neuroleptic metabolism by carbamazepine in patients may worsen psychotic symptoms.

Dysmorphophobia: differential-diagnostic aspects

The case of a patient presenting with a depressive-suicidal syndrome and dysmorphophobia, which also showed a delusional character, is discussed concerning the differential-diagnostic difficulties. The nosology of the disorder is discussed especially regarding the variants in the new classification systems.

[A case report of cyclic psychosis]

Cycloid psychoses have a special position in psychiatric classification. Usually they are listed among atypical psychoses, located between the group of schizophrenias and affective psychoses. Nevertheless, there are indications for nosological differentiation of cycloid psychoses from other psychotic conditions. The case of cycloid psychosis of a 38 year old woman with two severe psychotic episodes of mixed, paranoid and affective symptomatology is described. Among the characteristic features of psychotic episodes were acute onset, severe but short course of the episodes and the lack of residual/defect symptoms at outcome. On the basis of this case the differential diagnosis of cycloid psychoses is discussed.

Schizophrenic patients treated with high dose phenothiazine or thioxanthene become deficient in polyunsaturated fatty acids in their thrombocytes

Total fatty acids were analysed in thrombocytes of schizophrenic patients treated with a "high dose" or "low dose" monotherapy of neuroleptic drugs phenothiazine or thioxanthene. The ratio of the very long chain fatty acid hexacosanoic acid to the long chain fatty acid docosanoic acid (C26:0/C22:0) increased in the "high dose" and "low dose" groups as compared to healthy untreated controls (P less than 0.05). The polyunsaturated fatty acid arachidonic acid decreased in the "high" and "low dose" groups (P less than 0.01 and P less than 0.05). The polyunsaturated fatty acids alpha-linolenic acid, eicosapentaenoic acid and docosahexaenoic acid were not detectable in most of the "high dose" schizophrenic patients, however, they were found in the "low dose" group and in the controls. There was a negative correlation between the daily dosage of phenothiazine and the percentages of the polyunsaturated fatty acids arachidonic acid and alpha-linolenic acid+eicosapentaenoic acid+docosahexaenoic acid in thrombocytes (r = -0.87, P less than 0.01 and r = -0.81, P less than 0.01). Two patients of the "high dose" group with an especially high and long lasting monotherapy of neuroleptics were nearly devoid of polyunsaturated fatty acids in their thrombocytes. Untreated schizophrenic patients exhibited a fatty acid pattern in their thrombocytes not markedly different from that of the healthy untreated control group. We conclude that neuroleptic drugs phenothiazine or thioxanthene can alter the fatty acid pattern of thrombocytes.

[Psychotic episode caused by prevention of malaria with mefloquine. A case report]

We report on a 41 year old woman, who after 750 mg mefloquine, a newer antimalarial agent, developed a psychosis with dizziness, confusion and delusions. The symptoms were more intensive and remained longer than hitherto reported in the literature. A total of 23 patients are known to have had psychiatric adverse effects under mefloquine. Psychotic episodes are undoubtedly though rarely associated with the intake of mefloquine.

[Comparative studies of various clinical and psychopharmacological parameters of schizoaffective psychosis and paranoid schizophrenia]

Two groups of male patients were investigated: 19 subjects with diagnosis of paranoid schizophrenia and 13 with schizoaffective psychosis (8 with both depressive and paranoid symptoms, 5 with manic and paranoid). All patients were treated with perazine in this same manner. During the consecutive stages of therapy the following parameters were examined and compared: clinical symptoms, DBH activity, plasma prolactin concentration and the simple reaction time task to auditory and visual stimuli. The noticeable changes, similarities and differences were described.

Reliable routine method for determination of perazine in serum by thin-layer chromatography with an internal standard

The use of a high-performance thin-layer chromatography linear chamber and of thioridazine as internal standard increases the performance of thin-layer chromatography (TLC) with direct densitometric scanning, and allows the rapid determination of serum levels of the neuroleptic drug perazine under usual therapeutic conditions. TLC is superior to gas-liquid chromatography in so far as the main metabolite desmethylperazine can be easily separated and detected by the same procedure.

[Correlation between plasma concentration and clinical effect of neuroleptics and antidepressants]

Results of investigations concerning the correlation between plasma concentrations and clinical effect of neuroleptics and antidepressives are summarised. In the case of neuroleptics there is in general no relationship between clinical parameters of activity and plasma concentration. For antidepressives there is, in most cases, a correlation between side-effects and plasma concentrations. Whether the therapeutic effect is dependent on the plasma concentration or not, is however open to some doubt. The practical value of plasma concentration estimations during therapy with the above mentioned drugs is therefore limited. Inadequate efficacy and/or poor tolerance can occasionally be explained by estimating plasma concentrations which alone, however, scarcely allow one to make prophecies. In determination of the optimal individual dosage must continue to be an empirical process based on clinical observations and experience.