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Pharmakotherapie bei Schizophrenie und komorbider Substanzstörung

Eine systematische Übersicht

Pharmacotherapy of schizophrenia and comorbid substance use disorder

A systematic review

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Zusammenfassung

Ein begleitender Substanzmissbrauch/-abhängigkeit ist die häufigste psychiatrische Komorbidität bei schizophrenen Patienten mit Prävalenzraten bis ca. 65%. Die Empfehlungen zur Pharmakotherapie der Schizophrenie basieren jedoch überwiegend auf Untersuchungen, in denen Patienten mit einer Doppeldiagnose ausgeschlossen waren. In der vorliegenden systematischen Übersichtsarbeit werden die pharmakotherapeutischen Studien bei dieser Patientengruppe dargestellt und hinsichtlich ihrer Evidenz bewertet. Dabei fanden sich hauptsächlich Studien mit niedrigerem Evidenzlevel und kleinen Fallzahlen. Insgesamt ergaben sich Hinweise für eine bessere Wirksamkeit von Antipsychotika der zweiten Generation (Aripiprazol, Clozapin, Olanzapin, Quetiapin, Risperidon) gegenüber konventionellen Antipsychotika hinsichtlich einiger psychopathologischer Symptome ähnlich den vorliegenden Studien mit Patienten ohne begleitenden Substanzgebrauch. In einigen Studien wurde zusätzlich über eine Reduktion des Drogenverlangens und des tatsächlichen Drogenkonsums berichtet. Trizyklische Antidepressiva zusätzlich zur neuroleptischen Erhaltungstherapie zeigten eine Wirksamkeit im Hinblick auf eine Reduktion des Substanzkonsums und des Drogenverlangens (Craving). Die Gabe von Anti-Craving-Substanzen (Naltrexon, Disulfiram) führte zu einer reduzierten Substanzeinnahme, für Acamprosat liegen keine Studien bei schizophrenen Patienten mit komorbider Alkoholabhängigkeit vor. Zusammenfassend sind bei schizophrenen Patienten mit komorbider Substanzstörung eher Antipsychotika der zweiten Generation zu präferieren und der frühzeitige Einsatz von Antidepressiva in Abhängigkeit vom psychopathologischen Befund sowie von Anti-Craving-Substanzen ist zu erwägen.

Summary

Substance use disorder is the most common psychiatric comorbidity in patients with schizophrenia, revealing prevalence rates of up to 65%. Recommendations of antipsychotic pharmacotherapy in schizophrenia are based on studies excluding patients with this double diagnosis. In this systematic review the available pharmacological studies in this subgroup of patients are summarised and discussed with regard to evidence-based medicine. Most available studies concern small sample sizes, and the level of evidence in those studies was low. Data suggest efficacy for second-generation antipsychotics (SGAs) (aripiprazole, clozapine, olanzapine, quetiapine, and risperidone) superior to orally administered conventional antipsychotics. Treatment with SGAs revealed superior improvement of distinct psychopathological symptoms, similarly to those studies excluding patients with comorbid substance abuse. In some studies reduced craving and increased reduction of substance abuse could be demonstrated. Tricyclic antidepressants (TCAs) added to antipsychotic maintenance therapy showed efficacy in reducing substance abuse and craving, whereas studies with other antidepressive agents (e.g. selective serotonin reuptake inhibitors) are lacking. Administration of the anti-craving agents naltrexone and disulfiram led to a decrease of drug intake in a few studies. Unfortunately no studies are available using acamprosate in patients with schizophrenia and comorbid alcoholism. In conclusion the preferential use of SGAs in patients with schizophrenia and comorbid substance use disorder is suggested, and the early initiation of concomitant treatment with TCAs (depending on current psychopathological status) and anti-craving agents has to be considered.

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Interessenkonflikt

Der korrespondierende Autor weist auf folgende Beziehungen hin: Dr. Wobrock und Prof. Dr. Falkai erhielten Honorare für Referententätigkeiten von den Firmen Astra Zeneca, Janssen-Cilag, Sanofi-Synthelabo, Lilly, Pfizer, Novartis und Bristol-Myers Squibb.

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  1. Klinik für Psychiatrie und Psychotherapie, Georg-August-Universität Göttingen, Von-Siebold-Straße 5, 37075, Göttingen, Deutschland

    T. Wobrock & P. Falkai

  2. Klinik für Psychiatrie und Psychotherapie, Universitätsklinikum des Saarlandes, Homburg/Saar, Deutschland

    R. D’Amelio

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Wobrock, T., D’Amelio, R. & Falkai, P. Pharmakotherapie bei Schizophrenie und komorbider Substanzstörung. Nervenarzt 79, 17–35 (2008). https://doi.org/10.1007/s00115-007-2310-4

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