Antidepressant Controlled Trial For Negative Symptoms In Schizophrenia (ACTIONS): a double-blind, placebo-controlled, randomised clinical trial

Abstract

BackgroundNegative symptoms of schizophrenia represent deficiencies in emotional responsiveness, motivation, socialisation, speech and movement. When persistent, they are held to account for much of the poor functional outcomes associated with schizophrenia. There are currently no approved pharmacological treatments. While the available evidence suggests that a combination of antipsychotic and antidepressant medication may be effective in treating negative symptoms, it is too limited to allow any firm conclusions.ObjectiveTo establish the clinical effectiveness and cost-effectiveness of augmentation of antipsychotic medication with the antidepressant citalopram for the management of negative symptoms in schizophrenia.DesignA multicentre, double-blind, individually randomised, placebo-controlled trial with 12-month follow-up.SettingAdult psychiatric services, treating people with schizophrenia.ParticipantsInpatients or outpatients with schizophrenia, on continuing, stable antipsychotic medication, with persistent negative symptoms at a criterion level of severity.InterventionsEligible participants were randomised 1 : 1 to treatment with either placebo (one capsule) or 20 mg of citalopram per day for 48 weeks, with the clinical option at 4 weeks to increase the daily dosage to 40 mg of citalopram or two placebo capsules for the remainder of the study.Main outcome measuresThe primary outcomes were quality of life measured at 12 and 48 weeks assessed using the Heinrich’s Quality of Life Scale, and negative symptoms at 12 weeks measured on the negative symptom subscale of the Positive and Negative Syndrome Scale.ResultsNo therapeutic benefit in terms of improvement in quality of life or negative symptoms was detected for citalopram over 12 weeks or at 48 weeks, but secondary analysis suggested modest improvement in the negative symptom domain, avolition/amotivation, at 12 weeks (mean difference –1.3, 95% confidence interval –2.5 to –0.09). There were no statistically significant differences between the two treatment arms over 48-week follow-up in either the health economics outcomes or costs, and no differences in the frequency or severity of adverse effects, including corrected QT interval prolongation.LimitationsThe trial under-recruited, partly because cardiac safety concerns about citalopram were raised, with the 62 participants recruited falling well short of the target recruitment of 358. Although this was the largest sample randomised to citalopram in a randomised controlled trial of antidepressant augmentation for negative symptoms of schizophrenia and had the longest follow-up, the power of statistical analysis to detect significant differences between the active and placebo groups was limited.ConclusionAlthough adjunctive citalopram did not improve negative symptoms overall, there was evidence of some positive effect on avolition/amotivation, recognised as a critical barrier to psychosocial rehabilitation and achieving better social and community functional outcomes. Comprehensive assessment of side-effect burden did not identify any serious safety or tolerability issues. The addition of citalopram as a long-term prescribing strategy for the treatment of negative symptoms may merit further investigation in larger studies.Future workFurther studies of the viability of adjunctive antidepressant treatment for negative symptoms in schizophrenia should include appropriate safety monitoring and use rating scales that allow for evaluation of avolition/amotivation as a discrete negative symptom domain. Overcoming the barriers to recruiting an adequate sample size will remain a challenge.Trial registrationEuropean Union Drug Regulating Authorities Clinical Trials (EudraCT) number 2009-009235-30 and Current Controlled Trials ISRCTN42305247.FundingThis project was funded by the NIHR Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 20, No. 29. See the NIHR Journals Library website for further project information.

A systematic review of the indirect costs of schizophrenia in Europe

“…cost borne by caregivers) has been shown to be higher than the cost of productivity loss borne by schizophrenic patients themselves. In the study of Barnes et al, 22 cost of informal care was much higher than the cost of absenteeism, even though study results were not statistically significant. Frey validated the direction of the findings with high statistical significance, however, the magnitude of the difference was not as high.…”

Efficacy and safety of antidepressant augmentation of continued antipsychotic treatment in patients with schizophrenia

“…Altogether, 42 studies ( n = 1934) were included . About 40.5% of the studies focused on negative symptoms, 28.6% on total symptoms, 23.8% on depressive symptoms, and 7.1% on cognition.…”

“…In most studies, patients continued their previous antipsychotic (78%), whereas in seven studies (14%) patients started using a study‐defined antipsychotic prior to randomization. Information was insufficient for categorization in two studies . Additional details are displayed in Table .…”

The relationship between negative symptoms and depression in schizophrenia: a systematic review

“…Distinguishing between these two domains may provide clinical benefit through targeted therapy, which can be directed at either anticipatory or consummatory anhedonia and has been shown to be effective when applying psychological therapy . To date, there have been relatively few studies assessing the use of antidepressants to treat depression in schizophrenia and those that have been reported yielded mixed results, possibly the result of poor understanding of the core symptoms of depression therein Furthermore, to understand the relationship between depression and negative symptoms in schizophrenia, highly sensitive measures and thorough longitudinal studies, which chart symptom development and course, are required.…”