CLINICAL HANDBOOK OF SCHIZOPHRENIA

192 III. SOMATIC TREATMENTAlthough the majority of the literature on the use of antidepressants in schizophreniainvolves tricyclics and SSRIs, several studies reported on the use of bupropion in schizophrenia.In a double-blind, randomized, placebo-controlled study (Evins et al., 2005) onthe use of bupropion for smoking cessation in patients with schizophrenia, subjects in thebupropion group had no worsening of clinical symptoms and had a trend toward improvementin depressive and negative symptoms, as well as increased rates of smokingcessation. Other placebo-controlled trials of bupropion for smoking cessation in schizophreniahave found that the addition of bupropion does not worsen positive symptoms,significantly reduces negative symptoms, and greatly enhances smoking abstinence ratescompared to placebo. Despite the studies showing that the use of bupropion in patientswith schizophrenia does not exacerbate psychotic symptoms, is effective for smoking cessation,and may improve depression, there is not enough evidence-based literature as yetto warrant its use for depression in this population.OBSESSIVE–COMPULSIVE DISORDER AND ANXIETY DISORDERSObsessive–compulsive symptoms (OCSs) and obsessive–compulsive disorder (OCD) frequentlyoccur in schizophrenia and appear to worsen long-term outcomes. Data suggestthat patients with schizophrenia and OCSs benefit from treatment with both anantipsychotic and an antidepressant medication. In support of this, two controlled trialsexist in the literature involving OCS treatment in schizophrenia: one with clomipramine,and the other with fluvoxamine. Both have shown positive results, but both were small,limited studies.Except for the two pharmacological studies in OCD, there are no double-blind randomizedcontrolled trials on the treatment of anxiety in schizophrenia. A review of theliterature by Braga, Petrides, and Figueira (2004) indicates that anxiety disorders such asOCD, panic disorder, social phobia, and posttraumatic stress disorder (PTSD) are prevalentin schizophrenia, and treatment for anxiety can help alleviate symptoms in those patients.Most of the literature on anxiety disorders in schizophrenia comprise case reportsand open-label trials using antidepressants such as imipramine and fluoxetine with somedegree of success. However, more studies are needed that further define evidence-based treatmentfor anxiety disorders in schizophrenia.Important ConsiderationsCare must be taken to monitor plasma levels of antipsychotics, which may rise whencombined with SSRIs or other, related antidepressants, due to their ability to inhibit variouscytochrome P450 isoenzymes. This is especially important when antidepressants arecoadministered with clozapine, because increasing levels of clozapine can lead to risk ofseizures. Since bupropion itself lowers the seizure threshold, the combination of clozapineand bupropion should be avoided.SummaryAlthough the literature is inconsistent regarding the use of antidepressants in acutely psychoticpatients with depression, evidence-based data robustly support the use of thesemedications in postpsychotic patients who have been adequately treated with anantipsychotic medication and still display depressive symptomatology. At present, datasupports the use of tricyclic medications, as well as several of the SSRIs in the treatmentof depression in schizophrenia. Bupropion has been shown to be effective in smoking ces-