AGENT FOR TREATMENT OF SCHIZOPHRENIA

Description

CROSS-REFERENCE TO RELATED APPLICATIONS

The present application is a continuation of application Ser. No. 14/471,919, filed Aug. 28, 2014, which is a continuation of application Ser. No. 10/525,021, filed Feb. 18, 2005, which is a 371 of International Application No. PCT/JP2003/010490, filed Aug. 20, 2003, which is based upon and claims the benefits of priority to U.S. Provisional Application No. 60/404,927, filed Aug. 22, 2002. The entire contents of all of the above applications are incorporated herein by reference.

TECHNICAL FIELD

The present invention relates to a novel method for treatment of schizophrenia and a novel therapeutic agent used therein. More particularly, the present invention relates to a method for improving schizophrenia without being accompanied by extrapyramidal symptoms by orally administering a prescribed dose of a specific bicycloheptane-dicarboximide derivative once a day, and a therapeutic agent used in said method.

BACKGROUND ART

Schizophrenia (split personality) is a kind of endogenous psychosis, and it is developed mainly during adolescence, and after a chronic course, the personality of patient is progressively decayed, and some of patients may culminate in a mental decay. The symptoms of this disease are, for example, positive symptoms often observed during the early stage of the disease such as hallucination, delusion, etc., or negative symptoms such as apathy and withdrawal, or cognitive dysfunction such as impairments of concentration and learning abilities, etc. Moreover, there are other symptoms such as depression, anxiety, etc. as related symptoms thereof.

Medication is mainly employed in the treatment of schizophrenia, but the treatment of schizophrenia should be continued for a long time, and even though schizophrenia is once healed, there is a large risk of reoccurring of schizophrenia after drug withdrawal so that it is necessary to continue the medication forever. Therefore, any side effects of medication may always be serious problems, and based on this perspective, it has been desired to develop a medicine being suitable for prolonged medication.

The agents for treatment of schizophrenia are various medicaments such as ones classified in the category of antipsychotic, for example, phenothiazine derivatives (e.g., chlorpromazine, methoxy-promazine, etc.), thioxanthin derivatives having a similar structure to phenothiazine (e.g., chlorprothixene, flupentixol, etc.); benzamide derivatives (e.g., sulpiride, sultopride, etc.), thienodiazepine derivatives (e.g., clotiazepam, etizolam, etc.), and further butyrophenone derivatives (e.g., haloperidol, triperidol, etc.), diphenylbutylamine derivatives (e.g., pimozide, etc.), etc.

However, phenothiazine derivatives, phenothiazine analogues, and butyrophenone derivatives may cause serious side effects of extrapyramidal symptoms showing parkinsonism such as the stiff gait of skeletal muscles, tremor of muscles, lack of facial expression, salivation, etc. Further, diphenylbutylamine derivatives may cause extrapyramidal symptoms in addition to insomnia. In addition, these conventional antipsychotics may be effective on only some of symptoms among positive symptoms, negative symptoms, cognitive dysfunctions of schizophrenia, and there has been no drug being effective on all of these symptoms.

Therefore, it has been desired to develop a safe medicament which exhibits an excellent effect on various schizophrenia as an antipsychotic without causing side effects such as extrapyramidal symptoms.

On the other hand, it has been known that the imide derivative of the following formula, which was found by the co-workers of the present inventors, may be useful as an antipsychotic (c.f., neuroleptic agent, antiaxiety, etc.), especially as an agent for treatment of schizophrenia, senile insanity, manic depressive psychoses, and nervous breakdown ( U.S. Pat. No. 5,532,372).

wherein Z is

D is a group of the formula: —(CH₂)_p-A-(CH₂)_q—, G

etc., and
Ar is an aromatic group, or an aromatic heterocyclic group, etc.

DISCLOSURE OF INVENTION

The present inventor has intensively studied on a series of imide derivatives with respect to many aspects including a use and a dose thereof in order to find a novel agent for treatment of schizophrenia, which may exhibit an excellent effect in the treatment of schizophrenia and have no side effect such as extrapyramidal symptoms, which are often observed in many conventional antipsychotics, and can safely be administered for long time. As a result, the present inventors have found that (1R,2S,3R,4S)-N-[(1R,2R)-2-[4-(1,2-benzolsothiazol-3-yl)-1-piperazinylmethyl]-1-cyclohexylmethyl]-2,3-bicyclo[2.2.1]heptane-dicarboximide of the following formula:

or a pharmaceutically acceptable salt thereof such as a hydrochloride thereof is effective for relieving the wide-ranging symptoms of schizophrenia, and may treat schizophrenia quite safely without being accompanied by extrapyramidal symptoms by orally administering a prescribed dose thereof once a day.

Namely, the present invention provides a method for treatment of schizophrenia without being accompanied by extrapyramidal symptoms by orally administration of a prescribed amount of (1R,2S,3R,4S)-N-[(1R,2R)-2-[4-(1,2-benzoisothiazol-3-yl)-1-piperazinyl-methyl]-1-cyclohexylmethyl]-2,3-bicyclo[2.2.1]heptanedicarboximide of the above formula (1) or a pharmaceutically acceptable salt thereof once a day, and further provides an agent for treatment of schizophrenia which is used in said method.

BRIEF DESCRIPTION OF DRAWINGS

FIG. 1 is a graph showing the change with time in scores of Brief Psychiatric Rating Scale: BPRS, which are indexes for the effects on schizophrenia, of the active compound of the present invention, (1R,2S,3R,4S)-N-[(1R,2R)-2-[4-(1,2 benzoisothiazol-3-yl)-1-piperazinyl-methyl]-1-cyclohexylmethyl]-2,3-bicyclo[2.2.1]heptanedicarboximide hydrochloride and placebo in the double blind clinical trial.

DETAILED DESCRIPTION OF INVENTION

As shown in Examples as described hereinafter, when orally administering a prescribed dose of (1R,2S,3R,4S)-N-[(1R,2R)-2-[4-(1,2-benzoisothiazol-3-yl)-1-piperazinylmethyl]-1-cyclohexylmethyl]-2,3-bicyclo[2.2.1]heptanedicarboximide hydrochloride once a day for 6 weeks to the patients with schizophrenia in the acute exacerbation, the present inventors have found that the excellent effects on the wide-ranging symptoms were obtained, and surprisingly, any extrapyramidal symptoms as observed in the conventional antipsychotics were hardly observed, especially, abnormal electrocardiogram which progresses to sudden death is not recognized, and hence, that this compound may be quite safely used in the treatment of schizophrenia.

Namely, the present invention provides a novel method for treatment of schizophrenia improving a wide-ranging schizophrenia including positive symptoms, negative symptoms, and cognitive dysfunction, especially positive symptoms and negative symptoms, without being accompanied by extrapyramidal symptoms which comprises orally administering a prescribed dose of (1R,2S,3R,4S)-N-[(1R,2R)-2-[4-(1,2-benzoisothiazol-3-yl)-1-piperazinylmethyl]-1-cyclohexylmethyl]-2,3-bicyclo[2.2.1]heptanedicarboximide of the above formula (1) or a pharmaceutically acceptable salt thereof, especially a hydrochloride thereof, to a patient with schizophrenia once a day.

The present invention also provides a novel agent for treatment of such schizophrenia.

According to the present invention, excellent improving effects on the wide-ranging symptoms of schizophrenia may be obtained by orally administering (1R,2S,3R,4S)-N-[(1R,2R)-2-[4-(1,2-benzoisothiazol-3-yl)-1-piperazinylmethyl]-1-cyclohexylmethyl]-2,3-bicyclo[2.1.1]-heptanedicarboximide or a pharmaceutically acceptable salt thereof, for example, a hydrochloride, at a daily dose of 5 mg to 120 mg, preferably at a daily dose of 10 mg to 100 mg, more preferably at a daily dose of 20 mg to 80 mg, once a day. Further, in the therapeutic method of the present invention, side effects such as extrapyramidal symptoms such as parkinsonism, dyskinesia, akathisia, etc., abnormal electro-cardiogram, hepatic dysfunction are hardly observed, and hence, the present method may be quite safely used and suitable for a prolonged medication.

Besides, when the present method is applied to a patient with schizophrenia in chronic phase, the above active compound should preferably be administered to said patient for a long time at a dose as low as possible, and in such a case, the daily dose of the active compound is in the range of 5 mg to 80 mg, preferably in the range of 5 mg to 60 mg, more preferably in the range of 10 mg to 40 mg, and it is orally administered once a day.

The therapeutic agent used in the method for treatment of schizophrenia of the present invention is in the form of an oral preparation, which contains the compound of the above formula (1) or a pharmaceutically acceptable salt thereof, especially (1R,2S,3R,4S)-N-[(1R,2R)-2-[4-(1,2-benzoisothiazol-3-yl)-1-piperazinylmethyl]-1-cyclohexylmethyl]-2,3-bicyclo[2.2.1]heptanedicarboximide hydrochloride in an amount of 5 mg to 120 mg; preferably in an amount of 10 mg to 100 mg, more preferably in an amount of 20 mg to 80 mg per a single dosage unit. The oral preparation includes, for example, tablets, granules, fine granules, powders, capsules, syrups; etc. These preparations should be in the form of a preparation for administration once a day.

The above preparations may be prepared by a conventional method by using a conventional pharmaceutically acceptable carrier which is usually used in the preparation of a conventional pharmaceutical formulation, for example, excipients such as lactose, white sugar, glucose, starch, calcium carbonate, kaolin, talc, crystalline cellulose, silicic acid, etc., binders such as water, ethanol, gelatin, carboxymethylcellulose, shellac, methylcellulose, gum arabic, tragacanth powder, polyvinylpyrrolidone, etc,, disintegrating agents such as sodium arginate, agar powder, laminaran powder, sodium hydrogen carbonate, polyoxyethylenesorbitan fatty acid esters, sodium laurylsulfate, stearic acid monoglyceride, etc., lubricants such as purified talc, stearate, boric acid powder, polyethyleneglycol, etc.

EXPERIMENTS

The method for treatment of the present invention and the effects thereof are illustrated in more detail by Experiments as described hereinafter.

The active compound SM-13496used in Experiments means (1R,2S,3R,4S)-N-[(1R,2R)-2-[4-(1,2-benzoisothiazol-3-yl)-1-piperazinyl-methyl]-1-cyclohexylmethyl]-2,3-bicyclo[2.2.1]heptanedicarboximide hydrochloride, and the meanings of the abbreviations used in Experiments are as follows.

• DSM-IV: Diagnostic and Statistical Manual of Mental Disorders, 4th ed.
• CGI-S: Clinical Global Impressions scale-Severity of Illness
• CGI-I: Clinical Global Impressions scale-Improvement
• AIMS: Abnormal Involuntary Movement Scale
• EPS: Extrapyramidal symptoms
• LOCF: Last Observation Carried Forward (LOCF Analysis: a method of using last not-missing data in cases of dropouts)
• BAS: Barnes Akathisia Scale
• SAS: Simpson-Angust Rating Scale (Rating Scale For Extrapyramidal Reactions)
• PANSS: Positive and Negative Syndrome Scale (Rating Scale For Positive Negative symptoms)

Experiment 1

First Stage Phase II Clinical Trial

(1) Test Method

According to the procedures as shown in Table 1 as described below, the placebo-controlled double blind experiment was done on 149 patients with schizophrenia in the acute exacerbation phase at 15 facilities in USA. The efficacy and safeness were studied when SM-13496 at a dose of 40 mg or 120 mg, or a placebo was orally administered once a day for 6 weeks after placebo washout.

TABLE 1
Name of	A double-blind, randomized, fixed dose, placebo-
Clinical Trial	controlled, parallel-group, 6-week, efficacy, safety, and
	tolerability study of two dose levels of SM-13496 in
	patients with schizophrenia by DSM-IV criteria who are
	experiencing an acute exacerbation of symptoms
Purpose	The efficacy and safety on patients with schizophrenia
	in the acute exacerbation phase (DSM-IV criteria) were
	studied in the placebo-controlled, parallel-group,
	double-blind test.
Subjects	Selection criteria:

	1)	Patients with scchizophrenia determined according
		to DSM-IV criteria who are experiencing an acute
		exacerbation of symptoms
	2)	Patients having 42 or more of Extracted-BPRS
		Score as well as 4 or more of CGI-S Score
	3)	Patients having less than 2 of Simpson-Angus Score
		as well as less than 3 of AIMS Score
	4)	Patients suffering from schizophrenia for more
		than 1 year
	5)	Males and females aged 18-64 years

Factors for patient exclusion:

	1)	Patients with treatment-resistant schizophrenia
	2)	Patients being taking depot injections before
		finishing the therapy cycle
	3)	Patients having a strong suicidal ideation
	4)	Patients with Parkinson's disease, Alzheimer
		disease, drug addiction, convulsive disorders,
		epilepsy
	5)	Pregnant women and any women having a
		possibility of pregnancy, and lactating women
	6)	Patients having drug hypersensitivity
	7)	Any patients who are examined not to be suitable as
		subjects by principal investigator

Design of	Placebo-controlled, randomized, comparison with
Clinical Trial	parallel-group, double-blind
Dosage and	Oral administration of the test compound at a dose of
Administration	40 mg/day, 120 mg/day or a placebo once a day for 6
route	weeks
	Washout with placebo for one week (at least for 3 day)
	Hospitalization during the washout period and two
	weeks after medication

Combined	1)	Another antipsychotic is not administered. When
Drug and		another antipsychotic is taken, then it is necessary
Combination		to set up a washout period before the trial at least 3
Therapy		days for oral drug or for one therapy cycle for depot
		injection.
	2)	In case of onset of extrapyramidal symptoms, then
		the administration of an antiparkinson agent is
		allowed.
	3)	In case of onset of insomnia, lorazepam is used.

Number of	In the planning stages: 132 subjects (each 44 subjects
subjects	for the placebo-treated group, the 40 mg-treated group
	and the 120 mg-treated group)
	After the completion of the trial: 149 subjects (50
	subjects for the placebo-treated group, 50 subjects for
	the 40 mg-treated group, and 49 subjects for the 120 mg-
	treated group)
Evaluation	Efficacy: PANSS, Extracted-BPRS, CGI-S/I
Items	Safety: EPS Rating scale (Simpson-Angus, Barnes,
	AIMS), vital signs (body temperature, blood pressure,
	pulse), 12-lead electrocardiogram, laboratory test
	[hematologic test, biochemical test of blood, prolactin,
	urine test], psychosomatic conditions, eyeground-slit-
	lamp microscopy, adverse event

(2) Test Results

1) Evaluation of Efficacy

• (i) The data by BPRS and PANSS (LOCF), and CGI-S and CGI-I at the end of the trial are shown in Table 2 and Table 3, respectively. As is shown in Table 2 and Table 3, the reductions in the scores at the end of the trial (6 weeks after the administration) from those prior to the administration in the groups treated by SM-13496 40 mg or 120 mg are statistically significant as compared to that in the placebo-treated group with respect to BPRS, CGI-I and CGI-S evaluations. With respect to PANSS evaluation, the reduction in the score at the end of the experiment in the SM-13496 120 mg-treated group is statistically significant as compared to that in the placebo-treated group, which means the psychotic manifestations are improved by SM-13496.

	TABLE 2
	Dose (No. of Subjects)

	Placebo	SM-13496 40 mg	SM-13496 120 mg
	(45)	(47)	(44)

Rating	Average	Average		Average
scale	(SD)	(SD)	p value#	(SD)	p value#

BPRS	−4.0 (8.45)	−10.0	0.014	−11.3 (8.89)	0.003
Total		(12.79)
Score
PANSS	−5.8 (14.06)	−14.1	0.063	−17.4 (15.70)	0.010
Total		(23.10)
Score
#Two-sided Dunnett's t-test (comparison between the groups treated by each dose and the placebo-treated group)
Covariance analysis using faculty and Groups as factors and the values before administration as covariate

	TABLE 3
	Dose

Placebo

SM-13496 40 mg

SM-13496 120 mg

Rating	Average	Average		Average
Scale	(SD)	(SD)	p value#	(SD)	p value#
CGI-S	(n = 41)	(n = 41)	0.004	(n = 40)	0.002
	0.0 (0.77)	−0.7 (1.12)		−0.8 (1.03)
CGI-I	(n = 45)	(n = 47)	0.013	(n = 42)	0.005
	4.0 (1.41)	3.2 (1.56)		3.0 (1.29)
#Two-sided Dunnett's t-test (comparison between the groups treated by each dose and the placebo-treated group)
Covariance analysis using faculty and Groups as factors and the values before administration as covariate

• (ii) Further, the appended FIG. 1 shows the changes in BPRS total score (LOCF). As is shown in FIG. 1, the BPRS scores in the SM-13496-treated groups are statistically significantly reduced from those of prior to the administration as compared to that in the placebo-treated group at the 2 weeks or later (p<0.05).
• iii) The ratio of the patients of which the BPRS reduction at the end of the experiment is 20% or more, or the patients who showed 1 or 2 of CGI-I, those patients are considered as responder, is shown in Table 4. As is apparent from Table 4, there was a statistically significant difference between the SM-13496 40 mg- or 120 mg-treated group and the placebo-treated group.

	TABLE 4
	Dose (No. of Subjects)

	Placebo	SM-13496 40 mg	SM-13496 120 mg
	(45)	(47)	(44)

	Number	Number	p value#	Number	p value#

Responder	10	26	0.002	22	0.007
#Cochran-Mantel-Haenszel test adjusting the faculties (comparison between the groups treated by each dose and the placebo-treated group)

2) Evaluation of Safety

• (i) Adverse events observed in 10% or more of the patients are shown in Table 5.

	TABLE 5
	Placebo	40 mg	120 mg

Number of Subjects	50	50	49
Number of subjects showing adverse	36 (72)	40 (80)	38 (78)
events (%)
Number of subjects showing serious	3 (6)	3 (6)	3 (6)
adverse events (%)
Number of subjects who drop out from	2 (4)	6 (12)	6 (12)
the trial due to adverse events (%)

Occurrence of Adverse events (%)

Digestive disturbance	6 (12)	4 (8)	2 (4)
Nausea	2 (4)	5 (10)	11 (22)
Headache	5 (10)	8 (16)	3 (6)
Akathisia	0 (0)	4 (8)	7 (14)
Free-floating vertigo (excluding	3 (6)	6 (12)	5 (10)
rotatory vertigo)
Suppression	5 (10)	9 (18)	7 (14)
Drowsiness	2 (4)	4 (8)	5 (10)
Exacerbation of schizophrenia	5 (10)	2 (4)	1 (2)

• Subject having multiple adverse events was accounted as 1.

As is shown in Table 5, 114 subjects among 149 subjects (77%) showed adverse events, but most of them were mild or moderate ones. The number of subjects who dropped out from the trial due to the adverse events was higher in both of the groups treated by two doses of SM-13496 than in the placebo-treated group.

The main adverse events are suppression, nausea, headache, akathisia, and free-floating vertigo (excluding rotatory vertigo). The ratio of the subjects showing suppression was 10%, 18%, 14% in the placebo-treated group, the SM-13496 40 mg-treated group, and the SM-13496 120 mg-treated group, respectively. In the SM-13496 120 mg-treated group, nausea was more observed as compared to the other groups, but digestive disturbance was less observed than in the placebo-treated group. Exacerbation of schizophrenia was less observed in the SM-13496 40 mg- and 120 mg-treated groups (4% and 2%, respectively) than in the placebo-treated group (10%). Akathisia was observed only in the SM-13496 treated groups, i.e., 8% and 14% in the 40 mg-treated group and in the 120 mg-treated group, respectively. The occurrence of the adverse events in the groups treated by SM-13496 were the same as that in the placebo-treated group. Either body weight gain, bulimia, impotence, erectile dysfunction or convulsion was not observed.

• (ii) The serious adverse events observed in the above phase II clinical trial are shown in Table 6 as described below.

	TABLE 6
	Placebo	40 mg	120 mg

	Number of Subjects	50	50	49
	Total (%)	4 (8)	3 (6)	2 (4)

Occurrence of Serious Adverse Events (%)

	Exacerbation of	0 (0)	1 (2)	0 (0)
	paranoia
	Psychosis aggravated	0 (0)	1 (2)	0 (0)
	Exacerbation of	4 (8)	1 (2)	1 (2)
	schizophrenia
	Paranoid	0 (0)	0 (0)	1 (2)
	schizophrenia

As is shown in Table 6, the serious adverse events were observed in 4 cases of the placebo-treated group, 3 cases of the SM-13496 40 mg-treated group and 2 cases of the SM-13496 120 mg-treated group, but the relationship to the tested medicament was denied.

• (iii) Further, the side effects observed in this clinical trial are listed in the following Table 7.

	TABLE 7
	Placebo	40 mg	120 mg

	Number of Subjects	50	50	49
	Occurrence of side	22 (44)	33 (66)	35 (71)
	effects (%)

Mental disturbance

	Restlessness	0 (0)	1 (2)	1 (2)
	Psychosis aggravated	0 (0)	0 (0)	2 (4)
	Agitation	0 (0)	0 (0)	1 (2)
	Agitation aggravated	0 (0)	0 (0)	2 (4)
	Anxiety aggravated	0 (0)	1 (2)	0 (0)
	Insomnia	0 (0)	1 (2)	1 (2)
	Exacerbation of	0 (0)	0 (0)	1 (2)
	insomnia
	Nightmare	0 (0)	0 (0)	1 (2)

Metabolic disturbances and nutritional disturbance

	Anorexia	1 (2)	1 (2)	0 (0)
	Decrease in appetite	1 (2)	1 (2)	1 (2)

Disturbance in Skin and Hypodermis

Pruritus

1 (2)

0 (0)

0 (0)

Infection and parasitosis

	Tinea pedis	0 (0)	0 (0)	1 (2)
	External otitis	0 (0)	1 (2)	0 (0)
	Parotiditis	1 (2)	0 (0)	0 (0)
	Urinary tract	0 (0)	1 (2)	0 (0)
	infection

Vascular diseases

	Flushing	1 (2)	0 (0)	0 (0)
	Hot flashes	0 (0)	0 (0)	1 (2)

Disturbance in respiratory organ, chest and mediastinum

	Laryngopharynx pain	0 (0)	1 (2)	0 (0)
	Breathing difficulty	0 (0)	0 (0)	1 (2)

Heart problems

	Sinus tachycardia	0 (0)	0 (0)	1 (2)
	Palpitation	0 (0)	0 (0)	1 (2)

Gastroenteric disturbance

	Nausea	2 (4)	4 (8)	9 (18)
	Vomiting	0 (0)	2 (4)	3 (6)
	Constipation	1 (2)	2 (4)	0 (0)
	Diarrhea	3 (6)	3 (6)	0 (0)
	Loose stools	0 (0)	0 (0)	1 (2)
	Tongue disturbance	0 (0)	1 (2)	0 (0)
	Dyspepsia	2 (4)	3 (6)	2 (4)
	Flatulence	0 (0)	1 (2)	0 (0)
	Dry mouth	1 (2)	0 (0)	0 (0)
	Salivary	1 (2)	0 (0)	0 (0)
	hypersecretion
	Abdominal pain	2 (4)	0 (0)	0 (0)

Total disability and local condition

	Fatigue	3 (6)	3 (6)	1 (2)
	Fatigue aggravated	0 (0)	1 (2)	0 (0)
	Hot sensation	1 (2)	0 (0)	0 (0)
	Sleepiness	1 (2)	1 (2)	2 (4)

Nervous system disorder

	Suppression	3 (6)	9 (18)	7 (14)
	Akathisia	0 (0)	4 (8)	7 (14)
	Free-floating vertigo	0 (0)	5 (10)	5 (10)
	(excluding rotatory
	vertigo)
	Drowsiness	2 (4)	4 (8)	5 (10)
	Headache	3 (6)	6 (12)	1 (2)
	Extrapyramidal	0 (0)	1 (2)	3 (6)
	disease
	Tremor	0 (0)	3 (6)	3 (6)
	Akathisia aggravated	0 (0)	1 (2)	0 (0)
	Dystonic reaction	0 (0)	1 (2)	0 (0)
	Anarthria	0 (0)	0 (0)	1 (2)
	Glossoplegia	1 (2)	0 (0)	0 (0)
	Cogwheel rigidity	0 (0)	0 (0)	1 (2)
	Trismus	0 (0)	0 (0)	1 (2)

Musculoskeletal system and connective tissue disorder

	Muscle stiffness	1 (2)	2 (4)	1 (2)
	Myalgic pain	0 (0)	0 (0)	1 (2)
	Cervical rigidity	0 (0)	1 (2)	0 (0)
	Articular rigidity	0 (0)	1 (2)	0 (0)
	Melalgia	0 (0)	0 (0)	1 (2)
	Heavy feeling	0 (0)	1 (2)	0 (0)

Laboratory assay

	Increase in prolactin	0 (0)	1 (2)	1(2)
	level in the blood
	Increase in creatine	0 (0)	1 (2)	0 (0)
	phosphokinase level
	in the blood
	Abnormal	1 (2)	0 (0)	0 (0)
	electrocardiogram
	Weight loss	1 (2)	1 (2)	2 (4)
	Increase in total	0 (0)	1 (2)	0 (0)
	protein
	Abnormal liver	0 (0)	0 (0)	1 (2)
	function tests

Renal Injury and urinary disorder

	Polyuria	1 (2)	0 (0)	0 (0)
	Frequent urination	1 (2)	0 (0)	0 (0)

Ocular disturbance

	Blurred vision	0 (0)	1 (2)	1 (2)
	Dry eye	1 (2)	0 (0)	0 (0)

As is shown in Table 7, among the adverse events, the main side effects, a relationship of which to the SM-13496 cannot be denied, was suppression, nausea, akathisia, free-floating vertigo (excluding rotatory vertigo), sleepiness, headache. The occurrence of dystonic reaction was low (less than 4%) in the SM-13496-treated groups. There was no clinically significant change in 12-lead electrocardiogram. There was no significant difference in the ratio of the patients having an abnormal change in laboratory values among the groups. In the SM-13496-treated groups, the moderate increase in the prolactin level in the blood was observed, but there was no clinically significant change in the body temperature, respiration rate, funduscopic examination and slit-lamp microscopy.

• (iv) Further, the results of the evaluation for dyskinesia (by AIMS), akathisia (by BAS), parkinsonism (by SAS), those symptoms being extrapyramidal symptoms, are shown in Table 8.

	TABLE 8
	SM-13496	SM-13496
	40 mg*	120 mg*

	Placebo*	Average		Average
Rating Scale	Average (SD)	(SD)	p value#	(SD)	p value#
AIMS	0.7 (2.63)	0.7 (2.88)	0.978	0.2 (2.21)	0.467
BAS**	0.0 (0.97)	0.1 (1.04)	0.687	0.4 (0.94)	0.352
SAS	−0.1 (0.96)	0.1 (1.08)	0.588	0.1 (1.11)	0.808
#Two-sided Dunnett's t-test (comparison between the groups treated by each dose and the placebo-treated group)
Covariance analysis using faculty and Groups as factors and the values before administration as covariate
*n = 44-47 for each rating score
**BAS Global score

As is apparent from the results in Table 8, there was no significant difference in the changes in the score prior to the treatment or in the total score between the treated groups. The ratio of the patients requiring benztropine was 24% in the SM-13496-treated groups and 18 in the placebo-treated group.

INDUSTRIAL APPLICABILITY

The method for treatment of schizophrenia and the agent intended to be used therein of the present invention exhibit an excellent effect on the improvement of wide-ranging schizophrenia including positive symptoms, negative symptoms, cognitive dysfunctions, especially positive symptoms and negative symptoms, without accompanied by extrapyramidal symptoms by orally administering a prescribed amount of (1R,2S,3R,4S)-N-[(1R,2R)-2-[4-(1,2-benzoisothiazol-3-yl)-1-piperazinylmethyl]-1-cyclohexylmethyl]-2,3-bicyclo-[2.2.1]heptanedicarboximide or a pharmaceutically acceptable salt thereof, especially a hydrochloride thereof once a day to a patient with schizophrenia. Besides, since the present method and the agent used therein do not cause an abnormal electrocardiogram which may progress to sudden death, or do not show excessive suppression effects, they may be quite safely employed and may be suitable even to a prolonged medication, and further they may be applied safely to even elder patients, and hence, the present method and the agent used therein are extremely excellent.