Tag Archives: anti-psychotic

Is CBT really ineffective for schizophrenia? – 2 rounds: Marquis of Queensbery Rules

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CBT-for-Psychosis-Final-Poster399x282In the UK the National Institute of Clinical & Health Excellence (NICE) has recommended that the treatment of psychosis should include cognitive behavioural therapy (CBT). As a result CBT has been ‘rolled out’ for people suffering schizophrenia and other psychotic disorders.

But the efficacy of CBT in schizophrenia has been challenged. A recent paper in the British Journal of Psychiatry has argued that the returns of CBT are small, and if the highest standards of the clinical trial are applied, any benefits disappear into nothingness. Not surprisingly – given the stakes – there has been a robust counter argument in favour of CBT for schizophrenia.

Ahead of a forthcoming Maudsley debate, the protagonists have made their case in a ‘head to head’ article published in the British Medical Journal [available here]. This is the preamble to the main event, a tag-match involving two rounds of ‘live action’, between…

in the Blue corner: CBT critics

Peter McKenna, Research Psychiatrist, Barcelona &                                                         Keith Laws, Professor of Cognitive Neuropsychology, University of Hertfordshire

& in the red corner: CBT defenders

David Kingdon, Professor of Mental Health Care Delivery, University of Southampton Peter Kinderman, Professor of Clinical Psychology, University of Liverpool

(& your match referee: Professor Sir Robin Murray FRS)                                                                    

Psychosis Research. Where have we been & where are we going?

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phenotype and genotype

The Institute of Psychiatry at The Maudsley is the largest centre for psychiatric research in Europe. Recently a group of leading researchers were tasked with summarising an area of research as it pertains to psychosis and psychopharmacology.

The outcome was a series of short lectures, delivered to a lively audience of psychiatrists, mental health workers and psychologists at The Maudsley. The lecture slides and audio are now available below and constitute a unique training resource for those who treat patients.

1. Sir Robin Murray,
“Psychosis research: Deconstructing the dogma“
2. David Taylor,
“Current Psychopharmacology: Facts & Fiction“
3. Oliver Howes,
“How can we Treat psychosis better?“
4. Marta DiForti,
“An idiot's guide to psychiatric genetics“
5. Sameer Jauhar,
“Ten psychosis papers to read before you die!”
6. Paul Morrison,
“Future antipsychotics“

 

Dopamine & psychosis: Old fashions, new findings.

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Dopamine is the archetypal late '60s, early '70s transmitter, famous for it's involvement in schizophrenia. Like much else from this era, the dopamine story is discovered anew by successive generations. That story – that the dramatic symptoms of schizophrenia are caused by too much dopamine – has survived as fashions have come and gone.

dopamine terminal

Dopamine is synthesised in pre-synaptic boutons from the amino-acid tyrosine (TYR), via DOPA. Patients who respond well to anti-psychotics appear to have increased synthesis of dopamine (DA).

A recent paper from researchers in London adds a new twist. It appears that those patients who respond well to anti-psychotic drugs (which block dopamine receptors) have elevated pre-synaptic dopamine. In contrast, the (thankfully small) group of patients who don't do so well on anti-psychotics appear to be no different from healthy controls in regard to pre-synaptic dopamine.

Further work, including replication of the findings, will be necessary. But these results suggest that there are dopamine and non-dopamine forms of psychosis.

Hopefully, in time, there will be technological improvements allowing prospective testing of individual patients prior to initiating drug therapy. New, non-dopamine based anti-psychotics are also a priority.

The abstract can be read here

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Major mental illness and the Love hormone

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Oxytocin for schizophrenia – More positive news

Oxytocin is a hypothalamic peptide which is involved in social cognition and social behaviour. It is sometimes colloquially referred to as the 'love hormone', given it's involvement in bonding, empathy and trust. In recent years, oxytocin has been proposed as a possible new treatment for psychiatric disorders in which inter-personal relationships are problematic. The list of candidate conditions has included social anxiety disorder, autism and schizophrenia.

In the case of schizophrenia, clinical trials have begun to appear in the last few years. Two American groups have reported promising findings in small-scale studies. New findings from a trial carried out by researchers based in Tehran are also positive. The Iranian trial has the advantage in that patients were followed up for 8 weeks, compared to 2-3 weeks in the US studies. It was also slightly larger in size.

In the Iranian study, the addition of oxytocin to risperidone led to improvements in the intensity of positive psychotic symptoms (hallucinations, delusions and suspiciousness). There were also improvements in negative symptoms (apathy, amotivation, reduced sociability), although this was less pronounced.

The authors concluded: “Oxytocin as an adjunct to risperidone tolerably and efficaciously improves positive symptoms of schizophrenia. In addition, effects on negative and total psychopathology scores were statistically significant, but likely to be clinically insignificant. The interesting findings from the present pilot study need further replication in a larger population of patients.“

The paper is available here

 

New treatments for schizophrenia?

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The 1st generation anti-psychotics

It is sometimes said that all the treatments in psychiatry were discovered by chance (or serendipity, to use the technical term), rather than by planning. This is not strictly true. In fact many of our treatments for schizophrenia were discovered by design. The rationale was to start with a molecule which could induce a transient psychosis, even in healthy people – a molecule like amphetamine or LSD.

Thereafter the task was to find a drug which could block the effects of the psychosis-inducing compound. Such a drug, it was reasoned, could be an effective medicine for schizophrenia.

A Belgian researcher called Paul Janssen used this approach to great effect. He observed the effects of amphetamine in professional cyclists, who were using the drug to combat fatigue. Many of the cyclists developed an acute psychosis which was identical to paranoid schizophrenia. Janssen was the owner of a private research facility and was in an ideal position to search for medicines which could block amphetamine.

Progress was rapid and the compound haloperidol was discovered. And it turned out that haloperidol was a highly effective medicine for schizophrenic psychoses. Used in small doses, without interruption, haloperidol is a powerful treatment against hallucinations, delusions and agitation. But high doses are best avoided, as they can cause movement disorder.

The 2nd generation anti-psychotics

With this success of haloperidol, attention focused on other psychosis inducing drugs. This time LSD was taken as the psychosis-inducing agent. Numerous reports had shown that LSD (or 'acid') could transform consciousness in a way which was similar to the experience of people with schizophrenia. What was needed was a compound to block LSD, followed by a trial of the new compound in people with schizophrenia. Again the approach worked, giving us the medicine risperidone.

Olanzapine, sertindole, quetiapine and others followed. This class of anti-psychotic has become the first-line treatment in many countries and carries much less propensity to cause movement disorder as a side effect. However, careful attention is needed to avoid problems of weight gain and high cholesterol. Haloperidol acts on the dopamine system whereas second generation anti-psychotics like risperidone work on dopamine, but also target another brain transmitter called serotonin.

The next generation anti-psychotics

Two other drugs of abuse are associated with psychotic reactions. The first of these is ketamine, which has become popular on the club scene. Ketamine can elicit bizarre changes in consciousness which resemble the picture of schizophrenic psychosis. Ketamine can also induce the so-called negative symptoms. (Apathy, loss of drive and a reduced capacity for emotions, along with a rigid, concrete style of thinking).

The glutamate NMDA channel. Ketamine blocks the channel. Drugs which counteract ketamine may be useful antipsychotic medicines.

 

Ketamine works on the glutamate signalling system. As before the task was to find a compound which blocked the effects of ketamine. This has now been done, and in fact there are several different types of molecule available (Bitopertin, AMG747).

Now the challenge is to assess if any of these new compounds are good treatments for schizophrenia. At this time, several clinical trials in schizophrenic patients are underway, including some at The Institute of Psychiatry in London.

The other promising lead involves compounds which can block the effects of cannabis. About a dozen recent studies have shown that repeated use of cannabis is a risk factor for the development of schizophrenia. Skunk cannabis is known to be particularly hazardous for mental health. (Skunk contains high THC).

THC acts at cannabinoid receptors. Drugs which block the effects of THC are showing promise as medicines for schizophrenia.

 

Our research group and others have shown that a natural molecule called CBD can oppose the effects of THC in humans. CBD therefore becomes a candidate anti-psychotic medicine. Already one trial in Germany has found CBD to be as effective as a second generation anti-psychotic in people with schizophrenia. A number of larger studies are now underway. For an svg image click here.

 

Summary

There is an ongoing search for new medicines in schizophrenia. The first compounds such as haloperidol led to a fundamental change in psychiatric practice. The second generation medicines 'solved' the problem of motor side-effects, but at the cost of obesity and other metabolic complications. Hopefully a new generation of effective anti-psychotics will emerge in the next few years. Like their predecessors, the roots of their development may well be in design rather than by chance.