Current hot topics in the treatment of schizophrenia - Highlights Pt 1 of 3
The symposium on Data, Discussions and Decisions in Psychiatry was held in Sydney (14 May 2022). The programme included clinically focussed sessions and expert panel discussions on treating people with schizophrenia. This is part 1of 3 part article series that presents highlights from the symposium.
“Antipsychotics differ more in tolerability than in efficacy”1 was the key take-home message from Professor Leucht’s talk. To help delegates navigate the underlying evidence, Professor Leucht started his talk describing how to read a forest plot. “Forest plots are one of the major inventions of evidence-based medicine,” he explained. Forests plots summarize the outcomes of studies comparing a treatment with a control by displaying studies’ effect sizes and 95% confidence intervals (Figure 1). The position of the effect size to the left or right of the y-axis indicates if the outcome that is being assessed (for example, an efficacy or safety outcome) favours the treatment or the control. When the confidence interval of a study does not cross the y-axis, this shows that the difference between the treatment and the control is statistically significant. Looking across studies, if there are overlapping confidence intervals, this means that differences in effect sizes between the studies are not statistically significant. and expert panel discussions on treating people with schizophrenia. This article represents some highlights from the symposium.
Figure 1. How to read a forest plot.
Adapted from Prof Stefan Leucht, personal communication
Figure 1. How to read a forest plot.
Adapted from Prof Stefan Leucht, personal communication
Network meta-analyses enable researchers to compare treatments such as antipsychotics with one another even if they have not been compared directly with each other in a clinical study, Professor Leucht explained. For example, if trial results are available for treatments “A” versus “B”, and “A” versus “C”, then results for “B” versus “C” can be obtained indirectly.
“Antipsychotics differ more in tolerability than in efficacy"1-Professor Leucht’s
Using network meta-analysis principles, Professor Leucht and colleagues were able to compare 32 oral antipsychotics in acute phase schizophrenia across 402 randomized, controlled trials that included 53 463 patients.1 The analysis, published in The Lancet, demonstrated that antipsychotics differ more in their side effects than in their efficacy.1 All of the assessed antipsychotics were shown reduce symptoms versus placebo.1 Overlapping confidence intervals between individual antipsychotics suggested that most between-treatment differences in terms of efficacy were non-significant.1 In contrast, antipsychotics showed a hierarchy in terms of their side effects, which included weight gain, sedation and antiparkinson medication use.1 Professor Leucht noted that patients differ in terms of which side effects matter most to them and that including patients in discussions around medications is likely to improve adherence.
Professor Leucht presented further examples of meta-analyses conducted by him and his team, including evidence that antipsychotics outperform not only inactive placebo but also active placebo for acute schizophrenia treatment: a meta-analysis of seven large trials that used barbiturates as active placebo, all conducted in the 1960s, showed that substantially more patients on antipsychotics than on barbiturates had a response to treatment.2
The onset of the treatment effect is early, as shown by a meta-analysis of 34 studies that found that patients who were non-responders at week 2 of treatment were unlikely to respond later.3
Other session highlights included a discussion on optimal dosing of antipsychotics. A pair of dose-response meta-analyses of antipsychotics for acute schizophrenia and relapse prevention in stable schizophrenia showed that a plateau is reached where higher doses do not provide additional efficacy.4,5
Presented by Professor Stefan Leucht, head of the Section on Evidence-Based Medicine in Psychiatry and Psychotherapy, Department of Psychiatry and Psychotherapy, Technical University Munich, Germany. Session chaired by Dr Sally Lambert.
The symposium on Data, Discussions and Decisions in Psychiatry was held in Sydney (14 May 2022). The programme included clinically focussed sessions and expert panel discussions on treating people with schizophrenia.
Our correspondent’s highlights from the Psychiatry Symposium: Data, Discussions and Decisions in Psychiatry, are meant as a fair representation of the scientific content presented. The views and opinions expressed on this page do not necessarily reflect those of Lundbeck.
Internal ID article: AU-HLU-0057. September 2022
Internal ID copy: AU-NOTPR-0559. August 2022
