The Effects of Rimonabant, on Weight and Metabolic Risk Factors

Part I will be a 2-week evaluation phase. In Part I, subjects undergo a diagnostic interview
for symptoms and treatment along with medical, side effect measures, and neuropsychological
tests (tests for memory, attention, and motor task skills). An electrocardiogram (EKG), a
urine sample, and about 3 tablespoons of blood will be taken for laboratory tests. Women will
have a pregnancy test. This part of the study is 3-4 visits. The time of the visits will be
about 8 hours.

Part II is a 16-week treatment phase subjects will be randomly assigned to either rimonabant
or placebo for a 16-week period. The medication will be given in unmarked capsules so that
subjects will not know which medication they are receiving. Only the pharmacist will know
which medications subjects are receiving. If an emergency occurs we will break the blind and
give appropriate care. This phase will require one visit every week and each visit may take
up to 2-3 hours. Subjects will be examined every week to check symptoms side effects.
Subjects symptoms will be evaluated using specially designed rating scales, to ask about
their daily experiences and feelings. Evaluations that occur every 4 weeks may take about 2
hours. At week 8 and week 16 laboratory tests will be repeated. These tests will be compared
to the baseline tests taken in Part I. The end of study tests may take up to a total of 8
hours and may require 3-4 visits. All testing is done for research purposes only and would
not be performed if subjects were not participating in this study. The total number of visits
requested for this study will be 16-20. When subjects undergo neuropsychological testing, we
will examine their ability to learn and remember numbers and words to pay attention and to
quickly perform motor tasks. A motor task is when you use your hands to perform a task such
as placing pegs into a piece of wood. These tests will take about 2 hours and are done at the
beginning of Part I and the end of Part II.

Diet and exercise counseling will be held weekly for groups and individuals. Sessions will
focus on topics such as calories, fat content, portion control and determining a healthy
weight. We will request that participants maintain a food diary and exercise approximately 30
minutes/3 times per week. Subjects will be encouraged to attend the counseling sessions.
Transportation will be available for subjects. If patients have not attended sessions, they
will be reeducated on the importance of attending sessions at the time of clinical
ratings.Subjects will not be discharged from the study if they do not attend sessions.

Randomization will be done using a permuted block randomization system, and will be
stratified by clozapine/olanzapine treatment at baseline. Treatment assignment order is
random within each block, and the total number of patients assigned to each treatment is
equal. The block sizes will vary between sizes 2 and 4 in random sequence. The unblinded
pharmacist will be notified of the treatment assignment, and will inform unblinded
pharmacists at the other sites about which study medication to dispense. In an emergency,
research staff will be able to contact the pharmacy for unblinding. Rimonabant will be
available in 20 mg capsules with matched placebo.

For outpatients study medication will be dispensed on a weekly basis plus two extra days of
medication. Inpatient subjects will receive their study medication daily from the Maryland
Psychiatric Research Center (MPRC) Treatment Research Program (TRP) central pharmacy by a
non-blind pharmacist. The blind will be broken only if a medical emergency requires this
information. If this occurs, the patient will be withdrawn from the study.

All raters, investigators and other staff will be blind to treatment assignment except for
the pharmacist. The pharmacist does not participate in assessing any of the primary symptom
or side effect dependent variables and conveys no information about treatment assignment to
patients or staff except in a medical emergency.

Patients receiving 75% of their assigned medication will be considered compliant. Outpatient
compliance will be monitored through weekly pill counts and subject interviews. Inpatient
compliance will be monitored through inpatient medication records. If a patient is observed
to be non-compliant then this will be discussed with the patient and a plan formulated to
bring the patient back within the compliance parameter. For outpatients the plan may include
contacting the patients caretaker or scheduling increased clinic visits. These monitoring
procedures have been used in other MPRC studies and have resulted in high levels of
compliance. Compliance patterns will be carefully monitored in each treatment group and will
be described as part of any presentation of study results.

Satiety is defined as the reduced willingness to eat after a meal, not due to sickness or
other extraneous factors and can be thought of as sensations of fullness. A preload and a
test meal will be used in this study. The preload is a fixed amount of food given to the
participant that is consumed in its entirety. The test meal is a food or foods served,
following the preload, in sufficient quantity so that the participant can eat as much as
desired. The amount consumed of the test meal is measured and used as an index of satiety.
Likert and Visual Analog Scales (VAS) will also be used.

We will employ both the preload-test meal paradigm along with rating scales in the present
study to investigate the effects of rimonabant on satiety signaling. The testing will occur
at baseline, week 8, and week 16 to see if the effect changes. All three testing occasions
will be the same. Participants will arrive after skipping breakfast and given a preload of 12
oz. of Ensure (375 kcal) served chilled in a large, plastic cup. Hunger ratings will be taken
at baseline, then every 30 minutes for 90 minutes. After 60 minutes a test meal consisting of
a pre-weighed bowl each of Reduced Fat Wheat Thins and Nilla Wafers will be given. These will
be kept in separate bowls so that exact caloric consumption can be measured. The test meal
will be served with 12 oz. of water served chilled in a large plastic cup. Satiety will be
assessed by the quantity of Wheat Thins, Nilla Wafers, and water consumed and the difference
between the hunger rating score from baseline for each time point.

About 75% of subjects will be smokers. Smoking measures will be performed on those with >8
ppm CO in expired breath and who smoke at least 5 cigarettes daily. One approach to studying
tobacco craving in the laboratory is to compare smokers responses when exposed to neutral and
smoking-related in vivo cues. In vivo or "real-life" cues are either presented by the
experimenter or involve manipulation of materials by the participant. For this study, after
smoking a cigarette at baseline (15 minutes before testing begins), patients will be asked to
complete the Tobacco Craving Questionnaire (TCQ) and the Positive and Negative Affect
Schedule (PANAS). Participants will then be exposed to two experimental trials presented in
random order: 1) smoking cues, and 2) neutral cues.Each trial will last 20 minutes.
Participants will complete the TCQ and PANAS immediately and 10 and 20 minutes after cue
exposure. There will be a rest period between trials. During the rest period, the patient
will complete other study assessments lasting 30-60 minutes. After the assessments, the
patient will smoke again and then will complete the ratings and cue reactivity session for
the second random condition at the same time points (baseline, immediately after, 10 and 20
minutes).Trials will begin with the experimenter placing a tray containing an opaque cover on
a table in front of the participant. In the smoking cue condition, a pack of the participants
preferred brand of cigarettes a lighter and an ashtray will be under the tray cover. In the
neutral cue condition, a pack of unsharpened pencils and a pencil sharpener will be under the
cover. When instructed, the participant will lift the cover on the tray. In the smoking cue
condition, participants will take one cigarette out of the pack light it without puffing hold
it and look at it. At the end of the exposure period participants will extinguish the
cigarette, and replace the cover on the tray. In the neutral cue condition, participants will
take one pencil out of the pack sharpen it hold it and look at it.

The Iowa Gambling Task (IGT) is a computer-administered cognitive test that measures
risk-reward decision-making. Performance is impaired in patients with brain lesions in the
ventromedial prefrontal cortex and in people who abuse alcohol, cocaine, marijuana,
methamphetamine, opiates, or multiple illegal drugs. Patients with schizophrenia show normal
IGT performance in some studies. In particular, adolescent patients and adults with catatonic
schizophrenia show impairment. One study found that IGT performance was significantly
correlated with negative symptoms. In this study, subjects will take one of two equivalent
versions of the IGT at study entry and study completion. Each task session will take up to 30
minutes.

The Tobacco Craving Questionnaire (TCQ) is a questionnaire designed to assess current tobacco
craving. Factor analysis of the 47-item TCQ resulted in four factors: 1) emotionality,
smoking in anticipation of relief from withdrawal or negative mood; 2) expectancy,
anticipation of positive outcomes from smoking; 3) compulsivity, an inability to control
tobacco use; and 4) purposefulness, intention and planning to smoke for positive outcomes. We
will use a 12-item version of the TCQ, comprising the three items from each factor that
exhibited optimal within-factor reliability (Cronbachs coefficient alpha) and inter-item
correlation. The 12-item TCQ is as valid and reliable as the 47-item version. TCQ items are
rated on a scale from 1 strongly disagree to 7 strongly agre. Factor scale scores for each
participant are obtained by summing the three items.

The PANAS is a 20-item scale in which 10 items describe positive mood (enthusiastic,
interested, determined, excited, inspired, alert, active, strong, proud, attentive) and 10
items describe negative mood (scared, afraid, upset, distressed, jittery, nervous, ashamed,
guilty, irritable, hostile). Each item is rated on a 5-point scale (not at all, a little,
moderately, quite a bit, extremely). The PANAS shows high internal consistency and
test-retest reliability. Subjects can leave the study at any point. If a participant
experiences worsening of psychotic symptoms (relative to the baseline BPRS, an increase of 3
points or more OR an increase from a 5 to 7 on any one of the following BPRS items: somatic
concern, conceptual disorganization, hostility, suspiciousness, hallucinatory behavior, or
unusual thought content OR an increase of 2 or more on the CGI global severity OR the subject
is judged to be entering an exacerbation of his/her illness by the treating clinician), the
patient will be discontinued from the study. Other reasons for study termination include
evidence of suicidal thinking or behavior, or the development of or worsening of significant
depressive symptoms (score at any point in the study of >10 on the CDS or a 3 on the suicidal
item), complete cessation of eating and drinking for > 24 hours, pregnancy, or blood pressure
> 165/95 on three consecutive readings. Once a participant is discontinued from the study for
whatever reason, completion ratings will be performed. This includes laboratory tests rating
scales and neurocognitive assessments.

If a patient is prematurely terminated from the study, they will resume their standard
treatment. At the end of the study patients will not have the option of continuing rimonabant
because it is not FDA approved in the US. Other interventions to improve weight and metabolic
profiles will be discussed with the patients.

Inclusion Criteria:

1. Any gender

2. Any race,

3. Age range of 18-55.

4. Meet DSM-IV (APA, 1994) criteria for either schizophrenia or schizoaffective disorder.

5. Have a BMI greater than or equal to 27 with treated or untreated hyperlipidemia/
hypertriglyceridemia or a BMI greater than or equal to 30 regardless of concurrent
risk factors

6. Be treated with the same SGA for at least 8 weeks and to have received a constant
therapeutic dose for at least 30 days

7. Be clinically stable (for inpatients: at least one month post admission).
Hyperlipidemia and hypertriglyceridemia are defined by ATP III guidelines such that
borderline high and high will be considered as criteria for these disorders (ATP III
2001).

Exclusion Criteria:

1. Subjects with significant recent depressive symptoms will be excluded from the study,
defined as any history of a suicide attempt or suicidal ideation or hospitalization
for depressive symptoms within the last 6 months; or a high level of current
depressive symptoms (Calgary Depression Scale of > 7) (Addington 1993, Kim et al
2006).

2. Subjects with intermittent alcohol or substance use will not be excluded unless they
have met DSM-IV criteria for current alcohol or substance dependence within the last 6
months or DSM-IV criteria for alcohol or substance abuse within the last month.

3. Subjects with nicotine use or dependence will not be excluded.

4. Subjects with daily marijuana use will be excluded because of the possibility of
physical dependence on cannabis. Those with with marijuana use no more than once a
week will not be excluded because such subjects will not be physically dependent on
marijuana and so not at risk for rimonabant-elicited acute cannabis withdrawal.
Experimental studies of human cannabis physical dependence and withdrawal suggest that
high-dose, multiple times a day administration is needed to produce physical
dependence (Jones et al., 1976; Haney et al., 1999)

5. Subjects with a history of Crohn's Disease or Irritable Bowel Syndrome

6. Subjects with a organic brain disorder

7. A DSM-IV eating disorder

8. Subjects with mental retardation will be excluded to exclude subjects with cognitive
impairment not related to schizophrenia. Mental retardation will be determined by
chart review for a mental retardation diagnosis or a history of an IQ <70 and
functional disability noted before the age of 18 (DSM-IV criteria for mental
retardation).

9. Subjects with a medical condition, whose pathology or treatment could alter the
presentation or treatment of schizophrenia or significantly increase the risk
associated with the proposed treatment protocol will be excluded.

10. Subjects with a history of surgical procedures for weight loss .

11. Subjects who are currently in the process of trying to quit cigarette smoking will be
excluded.

12. Female subjects of childbearing potential must agree to use medically accepted means
of contraception. Pregnant and lactating female subjects will be excluded. People with
a diagnosis of diabetes will only be included if their diabetes is currently treated
and under control and have been on their current medication regimen for at 3 months.

13. People with a blood pressure reading of 165/95 or greater at baseline will be excluded
from the study.

14. The concomitant use of medications that are known to alter weight or appetite,
including anti-obesity drugs; corticosteroids; or nicotine substitutes will not be
allowed (see Appendix 2: Medication Exclusion List). 15. Additionally, patients
treated with a form of valproate will not be included in the study.

16. Subjects must be judged competent to participate in the informed consent process (by
passing the ESC with a score of 10/12) and provide voluntary informed consent.