Adding Psychosocial Interventions Can Improve Outcomes in Schizophrenia
Medication discontinuation is alarmingly common among patients with schizophrenia—it may range anywhere from 42% (Kahn RS et al, Lancet 2008;371(9618):1085–1097) to 74% (Lieberman JA et al, N Engl J Med 2005;353(12):1209–1223). Recently, researchers in China looked at whether adding psychosocial intervention to medication treatment of early stage schizophrenia would reduce discontinuation, as well as how it might affect relapse and remission.
In this study, 1,268 patients with early stage schizophrenia (diagnosed within the previous five years) were randomized to one of two conditions for one year: medication continuation alone (635 patients) or medication continuation combined with psychosocial intervention (633 patients). The psychosocial intervention was provided by experienced, masters or doctorate level clinicians and consisted of four one hour modules all delivered in a group setting on the same day once per month. The four topics covered were psychoeducation, family intervention, skills training, and cognitive behavioral therapy. In addition, patients in both groups had monthly visits with a study psychiatrist and an assessment phone call from a research assistant every two weeks.
Patients assigned to psychosocial intervention plus meds did significantly better on nearly all outcome measures than the medication alone group. Fewer required a discontinuation or changing of their medication (32.8% combined group vs. 46.8% meds alone), and the relapse rate was 15% for the combined group, versus 22.5% in the medication group (Guo XG et al, Arch Gen Psychiatry 2010;67(9):895–904).
TCPR’s Take: Offering a robust package of psychosocial interventions significantly boosted the effects of antipsychotic medication in this large group of schizophrenic patients. The once a month intensive sessions were designed to accommodate working families in China, who would have had difficulty traveling to the treatment center weekly. A similar arrangement would be welcome in treatment facilities here as well.
SNRIs Likely No Better than SSRIs for Depression
Due to their inhibition of both serotonin and norepinephrine reuptake, the SNRIs venlafaxine (Effexor) and duloxetine (Cymbalta) have been billed as possessing an advantage over SSRIs. Various studies have yielded inconsistent results on how SNRIs compare to SSRIs. The German Institute for Quality and Efficiency in Healthcare examined this topic in a meta-analysis.
The authors performed a thorough literature search to find published studies, and also asked the manufacturers for data from their studies on the drugs, including unpublished data. The analysis included 10 randomized controlled trials comparing Cymbalta to SSRIs, 31 trials comparing Effexor to SSRIs, and 11 trials comparing Effexor to tricyclics.
The researchers found that response rates were statistically significantly higher for Effexor than for SSRIs—but by only a small margin (66.5% vs 61.3%). There was no advantage in terms of remission rates. Effexor did not differ from TCAs on response or remission. Cymbalta did not differ from SSRIs in response or remission rates.
Both Effexor (11.8% vs 9.2%) and Cymbalta (8.4% vs. 5.8%) had higher rates of discontinuation due to adverse events than did SSRIs. Effexor’s adverse event-related discontinuation rates were not different from rates on TCAs (Schueler Y-B et al, Acta Psychiatr Scand online ahead of print).
Despite the authors’ best efforts, Effexor data was incomplete. The authors found that data from several additional unpublished studies were included in a different meta-analysis sponsored by the manufacturer of Effexor (Nemeroff CB et al, Biol Psychiatry 2008;63:424–434). The manufacturer’s meta-analysis found Effexor had a higher remission rate than SSRIs, but the manufacturer’s refusal to share data with the current researchers casts some doubt on this finding.
TCPR’s Take: With poorer tolerability than SSRIs and no efficacy advantage, Cymbalta does not look like a first-line antidepressant; its purported ability to treat pain in depressed patients is also questionable (see December 2008 issue of TCPR). Effexor fared somewhat better, but its slight efficacy advantages are counterbalanced by its poorer tolerability.
B Vitamins May Slow Brain Atrophy
High levels of homocysteine have been linked to brain atrophy in the elderly (Sachdev PS, Prog Neuropsychopharmacol Biol Psychiatry 2005;29(7):1152– 1161). Given that taking B vitamins can lower plasma homocysteine levels, a group of researchers recently examined whether supplemental B vitamins could slow the rate of brain atrophy in elderly people with mild cognitive impairment (MCI).
In this randomized, double-blind controlled trial, 168 participants over age 70 were given either a combination of high dose folic acid, vitamin B6, and vitamin B12 (n=85); or a pill placebo (n=83) for a period of two years. Participants had brain MRIs at the start and end of the trial to measure brain atrophy. The supplemental vitamins were administered as a single tablet containing 0.8 mg folic acid, 0.5 mg cyanocobalamin (vitamin B12), and 20 mg pyridoxine HCl (vitamin B6).
Treatment response was measured in relation to plasma homocysteine levels. Levels decreased by 22.5% in the active treatment group and increased by 7.7% in the placebo group. The mean rate of brain atrophy per year was 0.76% in the active treatment group vs 1.08% in the placebo group. After researchers adjusted for age, they found the rate of brain atrophy was 29.6% less in the active treatment group than the placebo group.
Participants took a number of cognitive tests at the start and finish of the study, and final cognitive test scores were related to the rate of atrophy, ie, patients who had faster rates of atrophy performed worse than those with slowed atrophy. Study authors plan to present detailed finding on cognition in a future paper (AD Smith et al, PLoS ONE 2010;5(9):e12244).
TCPR’s Take: It looks like high levels of B vitamins can slow the rate of brain atrophy. Considering there aren’t any major side effects related to taking B vitamins, suggesting supplemental folic acid, B6, and B12 to our patients with minor cognitive decline is something we can easily put into practice. Take into consideration, however, that some of the authors of this study may have a financial interest in the success of the vitamins—the main author holds a patent on a brand of folic acid to treat Alzheimer’s disease, and he and another author have received speaking honoraria from the maker of the supplemental vitamins used in the study.