Short report: comparison of patient satisfaction and burden of adverse effects with novel and conventional neuroleptics: a naturalistic study

Converging evidence indicates that, in controlled drug trials, individuals receiving novel antipsychotic medications have fewer adverse effects than those receiving conventional antipsychotic medications. This in turn may lead to greater patient treatment satisfaction. This study examines patient satisfaction and burden of adverse effects in a county-wide epidemiologic study of first admission psychotic persons with psychosis who were receiving novel antipsychotic drugs (n = 42). Comparisons were made within this group, and between 25 of these persons and 25 others with the same diagnosis and sex, from the same epidemiologic study, who were receiving a comparable regimen of conventional antipsychotic drugs. Patients receiving novel antipsychotics were significantly more satisfied and were significantly less burdened by adverse effects than those receiving conventional antipsychotics. Among the group receiving novel antipsychotics, dosage was not related to satisfaction or burden of adverse effects. For those treated with risperidone (n = 27), there was a difference, approaching statistical significance, for greater satisfaction and less adverse effect burden among those persons with dosages less than 5 mg daily as compared to higher dosages.

Rheumatoid arthritis (RA)-associated HLA-DR alleles form less stable complexes with class II-associated invariant chain peptide than non-RA-associated HLA-DR alleles

Certain HLA-DR alleles confer strong susceptibility to the autoimmune disease rheumatoid arthritis (RA). We compared RA-associated alleles, HLA-DR*0401, HLA-DR*0404, and HLA-DR*0405, with closely related, non-RA-associated alleles, HLA-DR*0402 and HLA-DR*0403, to determine whether they differ in their interactions with the class II chaperone, invariant chain (Ii). Ii binds to class II molecules in the endoplasmic reticulum, inhibits binding of other ligands, and directs class II-Ii complexes to endosomes, where Ii is degraded to class II-associated Ii peptide (CLIP). To evaluate the interaction of Ii and CLIP with these DR4 alleles, we introduced HLA-DR*0401, *0402, and *0404 alleles into a human B cell line that lacked endogenous HLA-DR or HLA-DM molecules. In a similar experiment, we introduced HLA-DR*0403 and *0405 into an HLA-DM-expressing B cell line, 8.1.6, and its DM-negative derivative, 9.5.3. Surface abundance of DR4-CLIP peptide complexes and their susceptibility to SDS-induced denaturation suggested that the different DR4-CLIP complexes had different stabilities. Pulse-chase experiments showed CLIP dissociated more rapidly from RA-associated DR molecules in B cell lines. In vitro assays using soluble rDR4 molecules showed that DR-CLIP complexes of DR*0401 and DR*0404 were less stable than complexes of DR*0402. Using CLIP peptide variants, we mapped the reduced CLIP interaction of RA-associated alleles to the shared epitope region. The reduced interaction of RA-associated HLA-DR4 molecules with CLIP may contribute to the pathophysiology of autoimmunity in RA.

Association between nonpsychotic psychiatric diagnoses in adolescent males and subsequent onset of schizophrenia

BACKGROUND

Nonpsychotic psychiatric symptoms may occasionally herald the later development of schizophrenia. This study followed a population-based cohort of adolescents with nonpsychotic, non-major affective psychiatric disorders to ascertain future hospitalization for schizophrenia.

METHODS

Results of the medical and mental health assessments on 124 24416- to 17-year-old males screened by the Israeli draft board were cross-linked with the National Psychiatric Hospitalization case registry, which contains data on all psychiatric hospitalizations in the country, during a 4- to 8-year-long follow-up through age 25 years. In the cohort, 9365 adolescents were assigned a nonpsychotic, non-major affective diagnosis by the draft board.

RESULTS

After excluding 167 adolescents who were hospitalized before or up to 1 year after the draft board assessment, 1.03% of the adolescents assigned a nonpsychotic, non-major affective psychiatric diagnosis, compared with only 0.23% of the adolescents without any psychiatric diagnosis, were later hospitalized for schizophrenia. Of the patients with schizophrenia, 26.8%, compared with only 7.4% in the general population, had been assigned a nonpsychotic, non-major affective psychiatric diagnosis in adolescence (overall odds ratio [OR], 4.5; 95% confidence interval [CI], 3.6-5.6), ranging from OR, 21.5 (95% CI, 12.6-36.6) for schizophrenia spectrum personality disorders to OR, 3.6 (95% CI, 2.1-6.2) for neurosis.

CONCLUSION

These results reflect the relatively common finding of impaired functioning in patients later hospitalized for schizophrenia and the relatively low power of these disorders in predicting schizophrenia.

Risperidone versus haloperidol in long-term hospitalized chronic patients in a double blind randomized trial: a post hoc analysis

BACKGROUND

Patients who remain in hospital for an extended time pose a special therapeutic challenge.

OBJECTIVES

The goal of this study was to examine whether the acute response of long-term hospitalized schizophrenic patients differs between haloperidol and risperidone based on a post hoc, sub-analysis of data from a large double blind pivotal trial.

METHOD

Data on chronic schizophrenic patients who had been hospitalized for at least 60 days (median 351 days) prior to entering this 8-week randomized double blind controlled trial were examined. This included 75 patients treated with 4 mg of risperidone and 69 treated with 10mg of haloperidol. Changes in symptoms were assessed with the Positive and Negative Syndrome Scale for Schizophrenia (PANSS) and the Clinical Global Impression (CGI). Data were analyzed using analysis of variance.

RESULTS

The analyses revealed that patients receiving risperidone improved significantly more than those treated with haloperidol.

CONCLUSIONS

Results suggest that the most often prescribed dose of risperidone, 4 mg, might be more effective for long-stay chronic schizophrenic patients than haloperidol 10mg.

Rapid onset of therapeutic effect of risperidone versus haloperidol in a double-blind randomized trial

BACKGROUND

Speed of onset of therapeutic effect is an important dimension of drugs employed to treat psychosis and schizophrenia. Faster onset is desirable to reduce the anguish caused by delusions and hallucinations and to protect patients and others from the consequences of poor judgment associated with psychotic exacerbation. Although sufficient studies have demonstrated that novel antipsychotics have advantages over clinically employed doses of classic drugs in terms of tolerability and aspects of efficacy, less is known about differences in speed of onset of therapeutic effect. This report consists of a post hoc subanalysis of data from a large double-blind, randomized pivotal trial in which we compared onset of therapeutic effect between risperidone and haloperidol.

METHOD

During an 8-week period, 227 patients with DSM-III chronic schizophrenia received 4 mg/day of risperidone and 226 patients received 10 mg/day of haloperidol. Symptoms were assessed 6 times (days 0, 7, 14, 28, 42, and 56) using the Positive and Negative Syndrome Scale (PANSS) for schizophrenia and the Clinical Global Impressions-Severity of Illness scale (CGI-S). Data were analyzed using analysis of variance for multiple dependent variables and repeated-measures multivariate analysis of variance.

RESULTS

The analyses revealed that patients receiving risperidone improved more rapidly than those receiving haloperidol as measured by PANSS total and CGI-S scores. Differences were most pronounced during the first week of treatment.

CONCLUSION

Results suggest that risperidone offers a more rapid response than haloperidol, particularly during the active phase of illness when time to response can be crucial.

Elective amniocentesis in low-risk pregnancies: decision making in the era of information and uncertainty

OBJECTIVES

Rational choice theory was applied to explain women's use of amniocentesis. Variables included knowledge about prenatal diagnostics, attitudes, and emotional preferences.

METHODS

Using structured instruments at 9 to 14 and at 29 to 34 weeks' gestation, we interviewed 232 Israeli women who had low-risk pregnancies.

RESULTS

Women who had elective amniocentesis (n = 39) were more knowledgeable about prenatal diagnostics, risks of invasive procedures, and probability of fetal abnormality in high maternal age; had fewer children; and had less favorable attitudes toward parenthood than those who had medically indicated amniocentesis (n = 57) and those who did not have amniocentesis (n = 136).

CONCLUSIONS

The use and possible overuse of amniocentesis were associated with having more information about prenatal diagnostics and definite emotional preferences.

Post-traumatic stress disorder in primary-care settings: prevalence and physicians' detection

BACKGROUND

Little is known about the prevalence of PTSD in primary-care settings and regarding the ability of primary-care physicians to detect PTSD. The current study examines prevalence of PTSD in a national sample of primary-care attenders and primary-care physicians' detection of PTSD and general psychological distress in PTSD patients.

METHODS

Data are from a national study of 2975 primary-care attenders in Israel. Demographic data, responses to the GHQ-28, PTSD Inventory and physicians' diagnoses were examined.

RESULTS

Twenty-three per cent of all patients who attended clinics (N = 684) reported traumatic events, 39% of whom (males 37%, females 40%) met criteria for PTSD on the PTSD Inventory. Eighty per cent of the males and 92% of the females with PTSD were distressed according to the GHQ. According to physicians, 37% of persons who reported trauma (40% of the women, 32% of the men) suffered from psychological distress. Only 2% of patients meeting PTSD criteria on the self-report measure were given a diagnoses of PTSD by physicians.

CONCLUSIONS

Many primary-care patients suffer from PTSD, which is usually accompanied by major psychological distress. Attention by primary-care physicians to a history of trauma could improve physicians' detection of this disabling disorder.

Rehospitalization rates of chronically ill schizophrenic patients discharged on a regimen of risperidone, olanzapine, or conventional antipsychotics

OBJECTIVE

The purpose of this study was to compare the rehospitalization rates of patients discharged from the hospital while being treated with risperidone, olanzapine, or conventional antipsychotics.

METHOD

By using Israel's National Psychiatric Hospitalization Case Registry, rehospitalization status was monitored for all patients with schizophrenia who were discharged from any inpatient psychiatric facility in Israel while taking risperidone (N=268) or olanzapine (N=313) between Jan. 1, 1998, and Dec. 31, 1998, and a group of patients discharged during that time who were treated with conventional antipsychotics (N=458). Time to readmission over the course of 2 years was measured by the product-limit (Kaplan-Meier) formula.

RESULTS

The readmission rate for patients discharged while taking conventional antipsychotics was higher than the rates for patients treated with either risperidone or olanzapine. At 24 months, 67% of the risperidone-treated patients and 69% of the olanzapine-treated patients remained in the community, as compared to 52% of the patients treated with conventional antipsychotics.

CONCLUSIONS

This study suggests that the rehospitalization rates of patients taking the novel antipsychotics risperidone and olanzapine are not different from each other and are considerably lower than the rate for patients treated with conventional antipsychotics. The results confirm findings of previous studies suggesting that the levels of overall effectiveness of risperidone and olanzapine are not very different and offers evidence that these drugs are more effective in preventing rehospitalization than conventional antipsychotic drugs.

Changes in insurance coverage and extent of care during the two years after first hospitalization for a psychotic disorder

OBJECTIVE

This study examined changes in insurance coverage during the 24 months after first admission for a psychotic disorder and the relationship of insurance type to the extent of care.

METHODS

The sample consisted of 443 persons who were enrolled in the Suffolk County (New York) Mental Health Project. Information about coverage-private insurance, Medicaid-Medicare, or no insurance-was obtained from hospital records and interviews. The insurance status groups were compared to examine differences in the percentage of days they received inpatient, outpatient, and day hospital care.

RESULTS AND CONCLUSIONS

The proportion of persons with no insurance decreased from baseline to 24 months, from 42 percent to 21 percent. The proportion of persons with private insurance remained similar, 42 and 37 percent. The proportion of those with Medicaid-Medicare increased from 15 percent to 42 percent. Of those with Medicaid-Medicare at baseline (67 persons), 88 percent had such coverage 24 months later. Of those with private insurance at baseline (188 persons), 73 percent had the same coverage 24 months later. Of those with no insurance at baseline (188 persons), 35 percent had no insurance at 24 months, 54 percent had Medicaid-Medicare, and 11 percent had private insurance. Over the 24 months, the Medicaid-Medicare group had the most days of care, the private insurance group had the least inpatient care, and those with no insurance were least likely to receive outpatient care. There was a linear relationship between receiving more outpatient care and spending less time in the hospital and the day hospital.

Comparison of cost, dosage and clinical preference for risperidone and olanzapine

BACKGROUND

Because risperidone and olanzapine have similar efficacy and tolerability in the treatment of schizophrenia, costs, physician experience, and preference become relevant considerations in making treatment decisions. The purpose of this paper is to compare daily treatment costs of risperidone and olanzapine, and to examine psychiatrists' clinical preferences.

METHOD

Dosage information was obtained from a national Ministry of Health registry and a national survey of psychiatrists. In addition, psychiatrists' clinical preference of antipsychotic medication and dosage for patient subtypes were examined by the national survey.

RESULTS

Data from the registry and national survey estimated the mean daily dose of risperidone to be one-third that of olanzapine, irrespective of patient subtype. Taking into account drug costs and dosage requirements, the average daily retail price was US $6.85 for risperidone and US $13.60 for olanzapine. Psychiatrists preferred risperidone for first-episode psychosis and elderly psychosis, and olanzapine for patients sensitive to EPS. They rated the drugs equally effective on positive and negative symptoms, for chronic patients, for treatment-refractory patients and relapse prevention.

CONCLUSIONS

Risperidone has a substantial cost advantage over olanzapine, and was preferred by psychiatrists for more indications.

Several log increase in therapeutic transgene delivery by distinct adeno-associated viral serotype vectors

We previously demonstrated that rAAV vectors carrying human and canine factor IX (FIX) cDNA can infect, stably persist, and secrete functional human and canine FIX following direct intramuscular injection. In an attempt to improve FIX protein secretion for eventual therapeutic use, we set out to determine if alteration of the AAV capsid would affect skeletal muscle transduction and factor IX secretion. Two reasons to pursue this question were (1) the persistence of high-titer neutralizing antibody (NAB) to AAV2 and (2) our previous study that supported a restricted tropism of muscle fiber types to AAV2 transduction. Using an identical CMV/canine factor IX (cFIX) expression cassette, we cross-packaged this genome into virions generated from each of the five AAV serotypes. In a dose-response assay, equivalent amounts of rAAV/cFIX serotypes were tested in vitro and in vivo. In tissue culture cells, FIX antigen levels secreted into the supernatant varied depending on the AAV serotype used; type 2 transduced maximally, with serotypes 3, 1, 5, and 4, respectively, expressing lower levels. However, when the same viruses were tested in vivo using immunodeficient NOD/SCID animals, we obtained surprisingly different results. While the time to onset of detectable serum levels appeared the same for all serotypes, types 1, 3, and 5 produced 100- to 1000-fold more cFIX than type 2. In fact, 12 weeks after transduction, type 1 continued to express levels of cFIX on average at 80 microg/ml followed by type 5 (6.52 microg/ml), type 3 (3.27 microg/ml), type 4 (258 ng/ml), and finally type 2 (90 ng/ml). Coagulant activity of cFIX as measured by aPTT supported the circulating levels measured by ELISA demonstrating the secreted protein was functional, and RT-PCR of injected tissue correlated with the serotype-specific transduction data. In summary, we found significant differences in cFIX expression upon introducing various rAAV serotypes into mouse muscle. These data have direct bearing on the design of AAV gene therapy clinical trials for hemophilia and should also extend to most therapeutic transgenes.

Gender differences in premorbid cognitive performance in a national cohort of schizophrenic patients

Despite significant research, there are still inconsistent findings regarding gender differences in cognitive performance in individuals already diagnosed with schizophrenia; studies have found that males suffering from schizophrenia are more, less or equally impaired compared with females. Gender differences in cognitive performance in individuals suffering from schizophrenia may be influenced by gender differences in premorbid cognitive performance; the very few and very small N studies published indicated that males have a poorer pre-morbid cognitive performance than females. This study examined the gender differences in premorbid cognition, utilizing cognitive assessments performed on female and male adolescents before induction into military service. The Israeli Draft Board Registry, which contains cognitive assessments equivalent to IQ scores on 16-18 year old Israeli adolescents, was linked with the Israeli National Psychiatric Hospitalization Case Registry, which records all psychiatric hospitalizations in the country. Scores on premorbid cognitive performance in schizophrenia were examined in 90 female-male case pairs matched for school attended as a proxy for socio-economic status. The mean age of first hospitalization was 20. 1+/-1.8 years of age for males and 19.6+/-1.8 years of age for females. A repeated-measures ANCOVA with age of first hospitalization and years of formal education as covariates, and controlling for gender differences in cognitive performance in healthy adolescents, revealed a significant difference in pre-morbid cognitive performance between males and females on all four cognitive measures [F(1,87)=8.07, P=0.006] with females scoring lower (worse) than males. In this national cohort, pre-morbid cognition was poorer in female, compared with male, adolescents who will suffer from schizophrenia in the future, a result consistent with some, but not all, similar studies. These results may be valid only for patients with first hospitalization around age 20. Hence, gender differences in premorbid cognition should be taken into account when assessing gender differences in cognition in schizophrenia.

Premorbid functioning in a national population of male twins discordant for psychoses

OBJECTIVE

The goal of the current study was to compare premorbid behavioral and cognitive functioning between co-twins discordant for psychotic disorder and between these pairs of twins and pairs of twins with no psychotic disorders.

METHOD

The authors linked data from the Israeli Draft Board Registry, which contains cognitive and behavioral assessments of all 16-17-year-old male Israeli twins, with data from the National Psychiatric Hospitalization Case Registry. Pairs of male twins who were healthy at the time of testing but discordant for psychoses later on were compared with one another and with pairs of healthy male twins.

RESULTS

The affected twins performed significantly worse than healthy twins on measures of individual autonomy, social functioning, and physical activity and nonsignificantly worse on measures of abstract reasoning. There were no significant differences in cognitive or behavioral scores between the co-twins who did or did not develop psychotic disorders.

CONCLUSIONS

The authors conclude that these findings underscore the familial nature of behavioral and cognitive deficits antecedent to psychoses.

Cognitive and behavioural functioning in men with schizophrenia both before and shortly after first admission to hospital. Cross-sectional analysis

BACKGROUND

The extent of premorbid changes associated with the onset of schizophrenia are debated.

AIMS

The study examined cognitive and behavioural functioning prior to, and after, first hospitalisation for schizophrenia.

METHOD

Data from the Israeli Draft Board Register of intelligence, social functioning and behaviour testing for all Israeli males aged 16-17 was linked with data from the National Psychiatric Hospitalisation Case Register. This identified 692 men who had been admitted to hospital for schizophrenia. Cases and non-cases matched on age and school were compared, as were cases aggregated by the time that had elapsed between testing and first admission to hospital.

RESULTS

Cases performed worse than non-cases on all measures. On Social Functioning and on Raven's Progressive Matrices-R, differences between cases and non-cases were progressively greater for cases admitted closer to the time of testing. These differences were greatest for persons tested after first psychiatric hospitalisation.

CONCLUSIONS

The results confirm premorbid deficits associated with schizophrenia and support the hypothesis that decline is progressive.