Guideline for the pharmacotherapy of treatment-resistant schizophrenia. Royal College of Psychiatrists of Thailand.

The authors proposed to develop an evidence-based guideline relevant to drug use for treatment-resistant schizophrenia (TRS), which will be called "Guideline for the Pharmacotherapy of Treatment-Resistant Schizophrenia or PTRS Guideline". The authors performed a MEDLINE search (between 1966 and December 1998) and classified the study designs of those trials by using the system proposed by the Agency for Health Care Policy and Research (AHCPR). The levels of evidence were graded and recommendations were made by the use of a system modified from that of the AHCPR. One hundred and sixty-three articles met the inclusion criteria for the review. For a schizophrenic patient who does not respond to a classical antipsychotic, physicians should switch from the first classical antipsychotic to the second one, which belongs to a different class. A schizophrenic patient who does not respond to at least two adequate trials of classical antipsychotics should be classified as a TRS patient. Clozapine should be considered as a first-line treatment for TRS. Risperidone should be considered in a TRS patient who refuses to have regular blood monitoring or has contraindication for clozapine. Physicians should use this guideline to accompany others that suggest the overview of treatment for schizophrenia. Appropriate application and the limitations of the guideline are also discussed.

Quetiapine for schizophrenia.

BACKGROUND: Quetiapine is a novel atypical antipsychotic with, theoretically, a low propensity for movement disorder adverse effects. It is used for treatment of schizophrenia and other psychoses. OBJECTIVES: To determine the effects of quetiapine for schizophrenia in comparison to placebo, classical and other atypical antipsychotics. SEARCH STRATEGY: Electronic searches of Biological Abstracts (1982-2000), CINAHL (1982-2000), the Cochrane Library (2000, Issue 1), the Cochrane Schizophrenia Group's Register of trials (Feb 2000), EMBASE (1980-2000), MEDLINE (1966-2000), PsycLIT (1974-2000), SIGLE on CD (1980-1997), SocioFile (1974-1997) and many conference proceedings and hand searches of specific journals were undertaken. AstraZeneca Pharmaceuticals was contacted for information regarding unpublished trials. SELECTION CRITERIA: All controlled trials where adults with schizophrenia or similar illnesses were randomised to quetiapine, placebo or other neuroleptic drugs and where clinically relevant outcomes were reported. DATA COLLECTION AND ANALYSIS: Citations and, where possible, abstracts were independently inspected by reviewers, papers ordered, re-inspected and quality assessed. Data were also independently extracted. The Relative Risk (RR) with 95% confidence intervals (CI) was used. A fixed effect model was used for a data set with non-significant heterogeneity. A random effect model was used for data sets with significant heterogeneity. In addition, as a measure of efficacy, the number needed to treat (NNT) was also calculated. For a continuous outcome, a weighted mean difference (WMD) between groups was estimated. A fixed effect model was used for a data set with non-significant heterogeneity. A random effect model was used for a data set with significant heterogeneity. MAIN RESULTS: Forty-two papers and reports (11 randomised controlled trials) were included in the review while 155 were excluded. Apart from the outcome, 'leaving the study early', all other results may be prone to bias and should be viewed with caution since dropout rates are high (36-64%) in these trials of short duration. In comparison to placebo, there are data suggesting that people allocated to quetiapine are less likely to leave the study early (RR 0.84, CI 0.73 to 0.97) particularly when the reason given was due to treatment failure. Dichotomous data relating to psychotic symptoms show a significant improvement in the quetiapine group (RR 0.79, CI 0.67 to 0.92, NNT 8). No significant difference could be found in respect of needing medication for extrapyramidal side effects, as well as for incidences of parkinsonism, akathisia and dystonia. In comparison to classical antipsychotics, the proportion of people leaving the studies early is significantly, but marginally, less for the quetiapine group (RR 0.87, CI 0.76 to 0.99). No significant difference between the two groups shows with regard to global state and mental state. Quetiapine may produce lower incidences of using medication for extrapyramidal side effects such as parkinsonism, akathisia and dystonia. Most data are very short term. In comparison to the low dose quetiapine group, the number of people leaving the three studies is significantly smaller in the high dose group (RR 0. 84, CI 0.75 to 0.94). The improvement on mental state was significantly higher in the high dose group. Incidences of akathisia, dystonia, parkinsonism and needing medication for extrapyramidal side effects were the same for both doses of quetiapine. REVIEWER'S CONCLUSIONS: High dropout rates in short quetiapine studies are a major problem, and makes interpreting any results problematic. Before quetiapine's use can be recommended, more large, well conducted trials that provide short, medium and long term outcomes relevant to carers and clinicians are necessary.

Quetiapine for schizophrenia.

BACKGROUND: Quetiapine is a novel atypical antipsychotic with low propensity for movement disorder adverse effects. It is used for treatment of schizophrenia and other psychoses. OBJECTIVES: To determine the effects of quetiapine for schizophrenia in comparison to placebo, classical and other atypical antipsychotics. SEARCH STRATEGY: Electronic searches of Biological Abstracts (1982-1997), CINAHL (1982-1997), the Cochrane Library (1998, Issue 1), the Cochrane Schizophrenia Group's Register of trials (1998), EMBASE (1980-1998), MEDLINE (1966-1998), PsycLIT (1974-1997), SocioFile (1974-1997) and many conference proceedings and hand searches of specific journals were undertaken. Zeneca Pharmaceuticals was contacted for information regarding unpublished trials. SELECTION CRITERIA: All controlled trials where adults with schizophrenia or similar illnesses were randomised to quetiapine, placebo or other neuroleptic drugs and where clinically relevant outcomes were reported. DATA COLLECTION AND ANALYSIS: Citations and, where possible, abstracts were independently inspected by reviewers, papers ordered, re-inspected and quality assessed. Data were also independently extracted. For homogeneous dichotomous data the Peto odds ratio (OR), 95% confidence interval (CI) and, where appropriate, the number needed to treat (NNT) was calculated on an intention-to-treat basis. MAIN RESULTS: Seven trials of short duration are included (31 reports) and seven are excluded (15 reports). Apart from that of 'leaving the study early', all other results may be prone to bias and should be viewed with caution since dropout rates are high (48-61%) in each arm of all studies. There are data suggesting less people allocated quetiapine leave the study early (53%) than those in the placebo group (61%) (OR 0.67 CI 0.48-0. 95). Data incorporating considerable assumptions about the many people who left early suggest that global state and psychotic symptoms - both positive and negative - may be more helped by quetiapine than placebo. Although some of these data reach statistical significance their clinical importance is difficult to interpret. While the incidences of extrapyramidal side effects are not different between quetiapine and placebo, side effects such as dizziness and dry mouth are more prevalent in the quetiapine treated group. High proportions of trial participants also leave when quetiapine is compared to chlorpromazine or haloperidol (57% by six weeks). Quetiapine is as potent as chlorpromazine and haloperidol as regards global and mental state but it may cause higher incidences of dry mouth and sleepiness. Extrapyramidal side effects are the same as those of chlorpromazine but may be less than haloperidol. High dose quetiapine is better than low dose quetiapine with regard to leaving the study early, and limited data suggest that the higher dose is also better at marginally improving global state (n = 1, OR 0.70, CI 0.50-0.99, NNT 11). There are no clear differences between high and low dose groups in respect of extrapyramidal side effects. REVIEWER'S CONCLUSIONS: The high dropout rates are a large problem in interpreting any results other than 'leaving the study early' since about half the data were not available at the end of studies. Before quetiapine's use can be recommended, we need more large, well conducted trials that provide short, medium and long term outcomes relevant to carers and clinicians.

Zopiclone in the treatment of insomnia: an open clinical trial.

The purpose of this study was to examine the efficacy and adverse effects of zopiclone in Thai psychiatric patients. Thirty-two insomniac outpatients with a variety of diagnoses participated in this study. Zopiclone at the dose of 7.5-15 mg was administered 15 minutes before bedtime. The sleep-questionnaire items included: 1) sleep induction; 2) duration of sleep; 3) number of awakenings, 4) sleep quality; 5) dream incidence; and 6) condition in the morning. The mean scores of each item were compared by using pair t-test. One week after treatment, significant improvement was found in all items, except item 5. In comparison between sleep at 1 week and 3 weeks after treatment, further improvement was still found in the first three items. The adverse effects found were bitter taste, drowsiness, and headache. In conclusion, zopiclone is an effective hypnotic with few adverse effects.

Introduction of the treatment method of Thai traditional medicine: its validity and future perspectives.

Thai traditional medicine is one of the most valuable heritages handed down from Thai ancestors. In spite of increasing popularity of Western modern medicine, Thai traditional medicine is still widely used in taking care of health in daily life especially among the rural Thais. For the past decade, the government and private organizations have worked in collaboration to restore the values and popularity of Thai traditional medicine. Recently, the Ministry of Public Health has promoted the use of herbal medicine, and the Center for Herbal Information has collected data and performed scientific studies on this matter. Thai Massage Restoration Project has also revised the text on Thai traditional massage, which is now widely practised. The future prospects of Thai traditional medicine are rather positive because the Foundation for Restoring Thai Traditional Medicine and the College of Ayurvedic Medicine have the program and curriculum to produce personnel on traditional medicine. They have also attempted to integrate the basic knowledge of Western medicine into the study and practice of Thai traditional medicine.