A double-blind dose-reduction trial of fluphenazine decanoate for chronic, unstable schizophrenic patients.

OBJECTIVE: This study evaluated the feasibility and impact of gradually reducing relatively high doses of fluphenazine decanoate by one-half for chronically impaired, poor inner-city patients with schizophrenia. METHOD: Forty-three patients currently receiving an average of 23 mg (0.3 mg/kg) of fluphenazine decanoate every 2 weeks were divided alternately into a group to remain at current doses (control group) and a group to undergo stepwise 50% dose reduction over 5 months under double-blind conditions. Clinical status and side effects were assessed quarterly for a year. Relapse was determined clinically and by changes in psychopathology ratings. RESULTS: Eighty-six percent (N = 37) of the patients (control group, N = 17; reduced-dose group, N = 20) completed the study. The groups did not differ at baseline in demographic or clinical variables or neuroleptic dose. In the reduced-dose group, doses were lowered to an average of 11.5 mg every 2 weeks. The two groups did not differ throughout the year in number of relapses, and hospitalization rates fell similarly in both (overall, by about 67%). Clinical measures changed little. Extrapyramidal symptoms worsened in the control group but improved slightly in the reduced-dose group. Tardive dyskinesia worsened in both groups, but less in the reduced-dose group. CONCLUSIONS: Maintenance neuroleptic doses much lower than the conventional ones can be achieved safely in schizophrenic patients by gradual reduction, without clinical worsening and perhaps with fewer extrapyramidal symptoms and less tardive dyskinesia. The two-thirds lower hospitalization rate, with substantial financial savings, apparently was due to nonspecific effects of research intervention.

Substance use: a powerful predictor of relapse in schizophrenia.

This study examined substance use among a group of 37 schizophrenia patients participating in a year-long fluphenazine decanoate (FD; Prolixin) dosage reduction study (Inderbitzin et al. (1994) Am. J. Psychiatry 151, 1753-1759). Ten (50%) of the 20 FD dose-reduced patients, and 6 (35%) of the 17 control group patients were identified as substance users. The dose-reduced and control groups did not differ significantly in substance use. We examine here the 37 patients regrouped by substance users (n = 16) versus non-users (n = 21) to determine the effects of substance use. In addition to identifying substance users and types of substances used, we hypothesize that substance users differ demographically from non-users, have worse symptomatology, worse compliance, higher rates of relapse, and therefore, can confound studies. Clinical and demographic data were obtained. At least half of the substance users were using alcohol or cocaine. The substance use group had a significantly higher severity of illness score on the BPRS at study onset. We found no significant differences between the two groups on other rating scales. The non-use group lived more independently, and the substance use group was younger. The substance use group had nearly twice as many hospitalizations in the 2 years prior to the study, a greater rate of missed appointments in the year before and during the study, and 4 times as many relapses during the year of the study than the non-use group. The key finding was that among 9 of the 37 patients who relapsed in the year of the study, 7 of the 9 had a history of substance use. Substance use was found to be a better predictor of relapse and hospitalization than gradual 50% dosage reduction of FD in the related study. Substance use among schizophrenia patients is a major complicating factor.

Double jeopardy: schizophrenia and substance use.

OBJECTIVE: Although the clinical reality of substance dependence and/or abuse among schizophrenia patients is widely acknowledged, the interaction of these diagnoses is not well understood. Perhaps the largest study documenting the comorbidity of substance abuse is the Epidemiologic Catchment Area (ECA) study, which found the rate to be 47% in schizophrenia patients (1). The present study examined substance use and compared the broad categories of substance users versus nonusers vis-à-vis schizophrenic symptomatology, hospitalizations, compliance, and demographic variables. We further examined the two subcategories of alcohol versus other substances of abuse (hereafter called "drugs") to determine differences. METHODS: Data were collected by the same person retrospectively from the charts of schizophrenia outpatients in a public inner city mental health center. Patients must have had at least 10 outpatient visits within a 2-year period for data to be used. RESULTS: Data were compiled from 262 charts. Of the schizophrenia patients, 55% had a history of past or current substance use. Consistent with previous reports, substance-using schizophrenia patients were more likely to be younger and male than nonusers. Substance users had significantly more hospitalizations and more outpatient visits with positive symptoms. There was also a higher rate of missed appointments in the substance-using patients, and there was a correlation between missed appointments and hospitalizations. As for the differences in the two subcategories of alcohol versus drugs, drug users had notably more negative symptoms, except in those cases for which the alcohol user required treatment for alcoholism. Current drug use also correlated with higher tardive dyskinesia scores, higher incidence of cognitive deficiency, less education, and higher average neuroleptic dose than with nonuse or alcohol use. CONCLUSION: These results extend the previous findings to a large inner city group of subjects and to a population that is at high risk for relapse. Our findings further emphasize the impact of substance use on outcome in schizophrenia and the need for more research on the nature and treatment of the patient with a dual diagnosis.