
- Vol 38, Issue 5
- Volume 05
Which Pharmacotherapies Are Most Effective for Schizoaffective Disorder?
There is debate whether schizoaffective disorder is a separate illness or is part of the continuum of schizophrenia and mood disorder spectrum.
RESEARCH UPDATE
Schizoaffective disorder includes both psychotic and affective symptoms (
Pharmacotherapy recommendations for schizoaffective disorder are generally derived from studies on schizophrenia and bipolar disorder; thus, symptoms are most commonly treated with antipsychotics, mood stabilizers, and/or antidepressants. Only paliperidone has an approved treatment indication specifically for schizoaffective disorder.
Cohorts Studied
To explore the efficacy of pharmacotherapies for schizoaffective disorder,
Lintunen et al
The main exposure was antipsychotics, based on Anatomical Therapeutic Chemical classification code N05A (except lithium); adjunctive medicine included
Analyses were conducted in each cohort separately using within-individual design and Cox regression models (hazard ratios [HRs] and 95% CIs), with P values adjusted for multiple comparisons. For antipsychotic effectiveness, the reference was antipsychotic nonuse. Nonantipsychotic medications were considered as adjunctive therapies, with antipsychotic use without adjunctive use as the reference (eg, olanzapine monotherapy was the reference for comparisons with olanzapine–mood stabilizer analyses). Data on 16 most commonly used antipsychotics were reported. Five oral antipsychotics (clozapine, olanzapine, quetiapine, risperidone, and aripiprazole) and LAIs (as a single category) were analyzed in combinations with adjunctive pharmacotherapies.
The Outcomes
In both cohorts, 60% of the study subjects were female. Mean age was 45 to 47 years. During follow-up, 13% of the Finnish cohort and 22% of the Swedish cohort were censored because of a change in diagnosis to schizophrenia. The median follow-up was 8 years in the Swedish cohort and 11 years in the Finnish cohort. During the follow-up, about half of the participants had a hospitalization for
In both groups, use of clozapine (HR, 0.49-0.50), LAIs, and polypharmacy (HR, 0.51-0.57) were consistently associated with a decreased risk of inpatient hospitalization versus antipsychotic nonuse (
Antipsychotics plus mood stabilizers were associated with a 16% to 24% decreased risk of a psychosis hospitalization (HR, 0.76-0.84). Antidepressant use was associated with a 10% decreased risk of inpatient hospitalization in the Swedish cohort (HR, 0.90), but not in the Finnish cohort (HR, 1.00). By contrast, Z-drug use was associated with a 7% to 21% increased risk of hospitalization, even after censoring the first 30 days of use. The overall pattern of findings remained similar with the broader outcome of any psychiatric hospitalization (instead of hospitalization for
The authors found that exposure to antipsychotics was associated with a decreased risk for inpatient hospitalization in patients with schizoaffective disorder. Furthermore, the combination of antipsychotics and adjunctive mood stabilizers (versus antipsychotic monotherapy) was also associated with lower risk of psychosis hospitalization. The evidence was much less robust for adjunctive antidepressants. Adjunctive use of benzodiazepines/Z-drugs was associated with an increased risk of hospitalization.
Study strengths include the use of 2 large nationwide cohorts with multiple years of follow-up and use of the within-individual model, which inherently controls for time-invariant covariates. Study limitations include the lack of availability of some clinically relevant factors and the potential diagnostic uncertainty of register-based data.
Concluding Thoughts
The use of antipsychotics, particularly clozapine and LAIs, and adjunctive mood stabilizers was associated with a decreased risk of hospitalization for psychosis among individuals with schizoaffective disorder in 2 nationwide cohorts. In contrast, benzodiazepines/Z-drugs were associated with an increased risk of psychosis-related hospitalization. Future studies of adjunctive treatments should consider the bipolar and depressive subtypes of schizoaffective disorder separately.
Dr Miller is professor in the Department of Psychiatry and Health Behavior, Augusta University, Augusta, Georgia. He is on the Editorial Board and serves as the schizophrenia section chief for Psychiatric TimesTM. The author reports that he receives research support from Augusta University, the National Institute of Mental Health, the Brain & Behavior Research Foundation, and the Stanley Medical Research Institute.
References
1. Murru A, Pacchiarotti I, Nivoli AM, et al. What we know and what we don’t know about the treatment of schizoaffective disorder. Eur Neuropsychopharmacol. 2011;21(9):680-690.
2. World Health Organization. International Statistical Classification of Diseases and Related Health Problems. 10th revision. World Health Organization; 1992.
3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Association; 2013.
4. Peterson DL, Webb CA, Keeley JW, et al. The reliability and clinical utility of ICD-11 schizoaffective disorder: a field trial. Schizophr Res. 2019;208:235-241.
5. Cheniaux E, Landeira-Fernandez J, Lessa Telles L, et al. Does schizoaffective disorder really exist? A systematic review of the studies that compared schizoaffective disorder with schizophrenia or mood disorders. J Affect Disord. 2008;106(3):209-217.
6. Lintunen J, Taipale H, Tanskanen A, et al.
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