Off-Label Anticonvulsants Useful in Schizophrenia

Article excerpt

One of the drugs most often prescribed for schizophrenia-valproate--has never been approved by the Food and Drug Administration for that indication. In fact, it hasn't even been subjected to randomized controlled trials.

A survey of New York state mental health facilities reported that in 1998, 35% of schizophrenic inpatients were given the anticonvulsant adjunctively during their stay. This represents a near tripling in the use of the drug since 1994, noted Dr. Leslie Citrome, director of the clinical research and evaluation facility at Nathan S. Kline Institute for Psychiatric Research, Orangeburg, N.Y. The use of other anticonvulsants for schizophrenia also appear to be on the rise.

"There's very little literature to back up this use," Dr. Citrome said. "But psychiatrists are pretty desperate to help patients any way they can." He sees the rise in anticonvulsant prescribing as part of a more global trend toward coprescription--for which the data are generally "quite sparse."

The increased use of drugs such as anticonvulsants also reflects a greater awareness of diverse symptoms in schizophrenia (including negative symptoms, cognitive dysfunction, depression, and aggression) that can be approached through specific therapy, he suggested.

"I use these drugs even though there's a lack of data [supporting their use]," Dr. Citrome said. "I follow patients longitudinally, using rating scales rather than depending on general impression. If they don't show evidence of improvement, I discontinue [the drugs]."

Aggression, a fairly well-accepted indication for anticonvulsants across diagnostic categories, is perhaps the most common reason for the use of these drugs in schizophrenia. Dr. Jean Pierre Lindenmeyer, director of psychopharmacology research at Manhattan Psychiatric Center, New York, is likely to prescribe valproate for "intermittent violence, aggression, hostility, and irritability," he said. In a retrospective chart review of 72 patients with schizophrenia treated with the drug for these indications displayed a significant decrease verbal and physical aggression.

But he also adds valproate as adjunctive therapy for patients who do not respond adequately to an antipsychotic--particularly when residual symptoms are positive. …