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Systematic review and exploratory meta-analysis of the efficacy, safety, and biological effects of psychostimulants and atomoxetine in patients with schizophrenia or schizoaffective disorder

  • Marco Solmi (a1) (a2), Michele Fornaro (a3) (a4), Kuniyoshi Toyoshima (a5), Andrè F. Carvalho (a6), Cristiano A. Köhler (a6), Nicola Veronese (a7), Brendon Stubbs (a8) (a9), Andrea de Bartolomeis (a3) and Christoph U. Correll (a10) (a11) (a12)...



Our aim was to summarize the efficacy and safety of atomoxetine, amphetamines, and methylphenidate in schizophrenia.


We undertook a systematic review, searching PubMed/Scopus/ for double-blind, randomized, placebo-controlled studies of psychostimulants or atomoxetine in schizophrenia published up to 1 January 2017. A meta-analysis of outcomes reported in two or more studies is presented.


We included 22 studies investigating therapeutic effects of stimulants (k=14) or measuring symptomatic worsening/relapse prediction after stimulant challenge (k=6). Six studies of these two groups plus one additional study investigated biological effects of psychostimulants or atomoxetine. No effect resulted from interventional studies on weight loss (k=1), smoking cessation (k=1), and positive symptoms (k=12), and no improvement was reported with atomoxetine (k=3) for negative symptoms, with equivocal findings for negative (k=6) and mood symptoms (k=2) with amphetamines. Attention, processing speed, working memory, problem solving, and executive functions, among others, showed from no to some improvement with atomoxetine (k=3) or amphetamines (k=6). Meta-analysis did not confirm any effect of stimulants in any symptom domain, including negative symptoms, apart from atomoxetine improving problem solving (k=2, standardized mean difference (SMD)=0.73, 95% CI=0.10–1.36, p=0.02, I2=0%), and trending toward significant improvement in executive functions with amphetamines (k=2, SMD=0.80, 95% CI=−1.68 to +0.08, p=0.08, I2=66%). In challenge studies, amphetamines (k=1) did not worsen symptoms, and methylphenidate (k=5) consistently worsened or predicted relapse. Biological effects of atomoxetine (k=1) and amphetamines (k=1) were cortical activation, without change in β-endorphin (k=1), improved response to antipsychotics after amphetamine challenge (k=2), and an increase of growth hormone–mediated psychosis with methylphenidate (k=2). No major side effects were reported (k=6).


No efficacy for stimulants or atomoxetine on negative symptoms is proven. Atomoxetine or amphetamines may improve cognitive symptoms, while methylphenidate should be avoided in patients with schizophrenia. Insufficient evidence is available to draw firm conclusions.


Corresponding author

*Address for correspondence: Marco Solmi, Department of Neurosciences, University of Padua, via Giustiniani, 2, 35128 Padua, Italy. (Email:


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MS and MF contributed equally to the article. All authors contributed equally to all stages of the article preparation.

No funding was directly involved in this paper’s preparation.



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Systematic review and exploratory meta-analysis of the efficacy, safety, and biological effects of psychostimulants and atomoxetine in patients with schizophrenia or schizoaffective disorder

  • Marco Solmi (a1) (a2), Michele Fornaro (a3) (a4), Kuniyoshi Toyoshima (a5), Andrè F. Carvalho (a6), Cristiano A. Köhler (a6), Nicola Veronese (a7), Brendon Stubbs (a8) (a9), Andrea de Bartolomeis (a3) and Christoph U. Correll (a10) (a11) (a12)...


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