TERZA GIORNATA - GIOVEDI' 27 FEBBRAIO 2003
LE INTERVISTE - INTERVIEW WITH PROF. P BUCKLEY, GEORGIA (USA)

As you highlighted in your talk, adherence to treatment and compliance in patients with Schizophrenia are important issues. Which do you think is the way forward to deal with both issues?
I think it is a very complex issue, and there is a lag between what we know about this and how frequent this is. About 80% of patients are non compliant with their treatment and specifically with medication, so given that it is so frequent we don't actually have a lot of information, and the premise on newer antipsychotics is that they may lead to better compliance for one or two reasons or perhaps a combination of them.
One is that patients may have better efficacy, two that they may tolerate the medication better, and the idea is that substantial numbers of patients are not complying either because the drugs don't work, or because of side effects. So if we have medications that work a little better or are better tolerated, the supposition is that this will translate into better compliance. Even though study of that to date has been very sparse, there is some information to suggest that compliance is improved with newer antipsychotics. A further aspect of this will be the development of long-acting newer antipsychotics, of which one is already available in Europe and that may be another part of addressing this issue. So I think that as we gain more understanding of working and optimizing the treatment with oral forms of newer antipsychotics and the emergence of newer formulations of newer antipsychotics, we will focus more on treatment compliance as an outcome in itself.

The question that has also been around, in the UK in particular, has been about how we can help patients to participate in deciding about their own treatment, however this, as we know, is quite difficult considering the lack of insight in this patient group. What are your views about this?
We've done a little bit of work looking at the issue of insight in schizophrenia and lack of insight is the most common symptom amongst those suggested by the WHO. It's the core issue and we've done a bit of work looking at whether newer antipsychotics translate and cause improvement of insight, we've shown some effect in that area but it's very early days yet and that gets back into the issue of what's driving non-adherence and whether it's due to lack of symptomatic relief and therefore persistence of positive symptoms. Positive symptoms are very strongly correlated with insight, although not absolutely correlated; you can have patients that have poor insight even with low positive symptoms, but it is a very significant contributor to this. So, if our treatments are a bit more efficatious and can therefore improve the insight in patients that may be another mechanism. Again we haven't yet zeroed in well enough on the relationship between insight and course of treatment with atypical antipsychotics.

We've heard you talk about your SPECTRUM study and the fact that it is not the usual RCT but a naturalistic study, how does it fit into your and your department's research?
Our work with respect to schizophrenia is with a number of ongoing studies and we are looking at a very critical issue within the field which is using atypical antipsychotics at the beginning of treatment, at the first episode. We are part of a national US study comparing Quetiapine, Olanzapine and Risperidone in patients with first-episode schizophrenia. We've also been doing some very interesting work on first onset psychosis that I am going to talk about tomorrow, in terms of looking at the biology and interaction with medication treatment at the beginning of the illness, because there is some data that using atypical antipsychotics as first line treatment may translate into superior outcomes in terms of cognition and this might actually be associated with brain changes. This is very early work but our department is contributing to that at the preclinical level in the area of looking at neurochemistry and cell membranes, and we are also doing MRI work related to that.

There is however a debate about using atypical antipsychotics and uniforming treatment across Europe and across the whole world. How do you think that could be best done?
I will be talking about that tomorrow, so you'll have to come to my talk to hear about this!