A standardized psychiatric assessment scale for rating chronic psychotic patients

Sulpiride versus placebo for schizophrenia

BACKGROUND

Sulpiride is a relatively old antipsychotic drug reputed to have low incidence of adverse effects and an effect on the negative symptoms of schizophrenia. This relatively inexpensive antipsychotic drug has a similar neuropharmacological profile to several novel atypical drugs.

OBJECTIVES

To evaluate the effects of sulpiride for schizophrenia and other similar serious mental illnesses in comparison with placebo.

SEARCH STRATEGY

We searched the Cochrane Schizophrenia Group Trials Register (September 2008) and references of all identified studies for further trial citations. We contacted pharmaceutical companies and authors of trials for additional information.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) comparing sulpiride with placebo for people with schizophrenia and other types of schizophrenia-like psychoses. The primary outcome of interest was clinically significant response in global state.

DATA COLLECTION AND ANALYSIS

We independently inspected citations and abstracts, ordered papers, re-inspected and quality assessed these. IMO and JW extracted data. We analysed dichotomous data using random-effects relative risk (RR) and estimated the 95% confidence interval (CI) around this. Where continuous data were included, we analysed this data using random-effects weighted mean difference (WMD) with a 95% confidence interval.

MAIN RESULTS

Two trials of short duration compare sulpiride with placebo (total n=113). As regards mental state, there were no clear differences between groups for either positive or negative symptoms (n=18, 1 RCT, WMD Manchester scale negative subscore -0.30 CI -1.66 to 1.06; n=18, 1 RCT, WMD SANS 2.90 CI -0.14 to 5.94). Few people left these studies by three months (n=113, 2 RCTs, RR 1.00 CI 0.25 to 4.00). One subscore finding found sulpiride improved social behavior (n=18, 1 RCT, WMD -2.90 CI -5.60 to -0.20). There were no data for many important outcomes such as general functioning, service use or adverse effects.

AUTHORS' CONCLUSIONS

Sulpiride may be an effective antipsychotic drug but evidence of its superiority over placebo from randomised trials is very limited. Practice will have to use evidence from sources other than trials until better evidence is generated.

Non-motor cognitive-perceptual dysfunction associated with drug-induced parkinsonism

OBJECTIVE

The purpose of the present study was to examine the relationship between drug-induced parkinsonism (DIP) and subjective non-motor cognitive impairments in schizophrenia by performing comprehensive assessments of extrapyramidal side effects (EPS) and the subjective cognitive-perceptual functioning.

METHODS

Ninety-one outpatients with schizophrenia were evaluated for DIP and other EPS. Subjective cognitive-perceptual dysfunction was comprehensively assessed using the Frankfurt Complaint Questionnaire (FCQ). To examine the association between DIP and non-motor cognitive-perceptual dysfunction, Pearson's partial correlation analysis was performed between the FCQ scores and the severity of DIP, controlling for relevant variables.

RESULTS

The analysis revealed that the severity of DIP had a significant correlation with the total FCQ score (p < 0.05). In phenomenological subscales, the severity of DIP showed significant correlations with "deterioration of discrimination," "psychomotor disorder," "perceptual disorder," "cognitive floating," and "automatic behavior disorder" (p < 0.05).

CONCLUSIONS

The results of our study suggest that DIP is significantly associated with a wide range of subjective non-motor cognitive impairments. Clinicians should be careful of the appearance of DIP and the associated non-motor cognitive-perceptual symptoms, which may cause considerable distress and reduce the quality of life in an already vulnerable group of patients.

Expressed emotion, human agency, and schizophrenia: toward a new model for the EE-relapse association

Although there is a clear statistical association between expressed emotion (EE) and schizophrenic relapse, our understanding of the mechanisms underlying this relationship is underdeveloped. This study tested a theoretical model in which caregivers' perceptions of their ill relative's agency underlie the EE-relapse association. To evaluate this model, we completed qualitative and quantitative analyses of narratives provided by individuals caring for a relative with schizophrenia. The results indicate that high-EE caregivers perceive the expression of symptoms as stemming from their ill relative's agency more frequently than low-EE caregivers. This was true for both high-EE-criticism and high-EE-emotional overinvolvement caregivers. High-EE and low-EE caregivers did not differ in their perceptions of the role of their ill relative's agency with regard to the control of symptoms. The findings suggest that EE may be a proxy risk factor for caregivers' perceptions of their ill relative's agency.

Can the Hospital Anxiety and Depression Scale be used in patients with schizophrenia?

RATIONALE, AIMS, OBJECTIVES: The Hospital Anxiety and Depression Scale (HADS) was developed explicitly for use in non-psychotic populations, yet is routinely used for screening patients with psychotic illness. The utility of the HADS as a screening instrument for use in patients with schizophrenia was investigated.

METHOD

Exploratory factor analysis and confirmatory factor analysis were conducted on the HADS to determine its psychometric properties in 100 patients with a primary ICD-10 diagnosis of schizophrenia.

RESULTS

Three distinct factors were identified within the HADS. Support was found for the clinical use of the HADS anxiety subscale to assess anxiety in patients with schizophrenia; however, evidence was also found that the HADS depression subscale may not be a unidimensional measure of depression in this clinical group.

CONCLUSIONS

Caution should be used when using the HADS depression subscale in this clinical group. The direction of future research in this area is indicated, in particular comparison of HADS anxiety and depression measures to determine further the validity or otherwise of these subscale domains.

Predictors of PTSD symptoms in response to psychosis and psychiatric admission

The experiences of psychosis and psychiatric admission have the potential to act as events precipitating posttraumatic stress disorder (PTSD) symptoms. Known risk factors for the development of PTSD symptoms in adults were identified. These included childhood trauma, current psychiatric symptoms, perceived coercion, and relationships with mental health service providers. These factors were analyzed to determine if they were important in the development of PTSD symptoms in response to psychosis and admission. We used a cross-sectional design with a sample of 47 participants recruited from a service in Northern Ireland who had experienced psychosis and been discharged from inpatient treatment within 12 months of data collection. The main outcome measure was the impact of events scale-revised. Data was subject to correlation analyses. A cut-off point of r = +/- 0.25 was used to select variables for inclusion in hierarchical regression analyses. Forty-five percent and 31% of the sample had moderate to severe PTSD symptoms related to psychosis and admission, respectively. The majority of participants identified positive symptoms and the first admission as the most distressing aspects of psychosis and admission. Childhood sexual and physical traumas were significant predictors of some PTSD symptoms. Strong association was found between current affective symptoms and PTSD symptoms. A reduced sense of availability of mental health service providers was also associated with PTSD symptoms and depression. Awareness of risk factors for the development of PTSD symptoms in response to admission and psychosis raises important issues for services and has implications for interventions provided.

The compatibility of psychosocial interventions (PSI) and assertive outreach: a survey of managers and PSI-trained staff working in UK assertive outreach teams

In recent years, there has been an increased emphasis on providing psychosocial interventions (PSI) and assertive outreach (AO) for people with severe and enduring mental illness living in the UK. This paper presents the findings of a telephone survey conducted with managers and PSI-trained staff working for AO teams in the Northwest of England. The aim of the study was to gain an insight into staff attitudes regarding the compatibility of PSI and AO. The survey also gathered more general information about the nature of the AO teams and the number of PSI-trained staff working within them. The results indicate that, although PSI-trained staff believe that PSI and AO are compatible, AO is not immune to the barriers to PSI implementation that exist in other service areas. There also appears to be a question regarding the extent to which teams are maintaining fidelity to the original AO model that was outlined by Stein and Test.

Blood levels of flupenthixol in patients with acute and chronic schizophrenia

Plasma levels of flupenthixol were estimated by three methods in 30 patients with acute schizophrenia and 29 patients with chronic schizophrenia. These levels were related to clinical response, anterior pituitary hormone secretion, platelet monoamine oxidase activity, the effects of the concurrent administration of anticholinergic drugs, and body weight. No clearcut relationships between plasma flupenthixol levels and any of these variables were demonstrated. The practical clinical value of the estimation of plasma flupenthixol is limited at the present time.

Errorless learning and memory performance in schizophrenia

There is evidence that patients with schizophrenia have impaired explicit memory and intact implicit memory. The present study sought to replicate and extend that of O'Carroll et al. [O'Carroll, R.E., Russell, H.H., Lawrie, S.M. and Johnstone, E.C., 1999. Errorless learning and the cognitive rehabilitation of memory-impaired schizophrenic patients. Psychological Medicine 29, 105-112.] which reported that for memory-impaired patients with schizophrenia performance on a (cued) word recall task is enhanced using errorless learning techniques (in which errors are prevented during learning) compared to errorful learning (the traditional trial-and-error approach). Thirty patients with a DSM-IV diagnosis of schizophrenia and fifteen healthy controls (HC) participated. The Rivermead Behavioural Memory Test was administered and from their scores, the schizophrenic patients were classified as either memory-impaired (MIS), or memory-unimpaired (MUS). During the training phase two lists of words were learned separately, one using the errorless learning approach and the other using an errorful approach. Subjects were then tested for their recall of the words using cued recall. After errorful learning training, performance on word recall for the MIS group was impaired compared to the MUS and HC groups. However, after errorless learning training, no significant differences in performance were found between the three groups. Errorless learning may play an important role in remediation of cognitive deficits for patients with schizophrenia.

Measuring psychosis proneness in a nonclinical Korean population: is the Peters et al Delusions Inventory useful for assessing high-risk individuals?

OBJECTIVES

We examined the psychometric properties of the Korean version of the Peters et al Delusions Inventory (PDI) 40 and investigated the distribution of delusional ideation in a nonclinical population. We also used the item response theory to evaluate the usefulness of the PDI in measuring the risk for psychosis.

METHODS

A total of 310 nonclinical individuals completed the Korean PDI-40, the Magical Ideation Scale (MIS), and the Schizotypal Personality Scale (STA). In addition, 60 psychotic inpatients with delusions completed the PDI-40. Among 310 individuals, 124 participated in a follow-up study 6 months after completing their original questionnaire.

RESULTS

The PDI-40 revealed a slightly skewed distribution, but the score range was similar to that of the British population. Scores were negatively correlated with age, but no sex differences were found. The Korean PDI-40 exhibited good internal consistency and test-retest reliability. The PDI was significantly correlated with the MIS and the STA. Ten components were extracted through a principal component analysis with varimax rotation. The test results using item response theory revealed 39 items as the items which individuals with very high level of psychosis proneness will answer as "yes." Moreover, all items yielded "above moderate" discrimination in terms of psychosis proneness.

CONCLUSIONS

We confirmed the reliability and validity of the Korean PDI-40. The usefulness of the PDI-40 in a nonclinical population was replicated in the Korean sample. The PDI-40 can be used as an informative device when investigating "psychosis proneness" in a group at high risk for psychosis.

Empirical evidence for using subjective quality of life as an outcome variable in clinical studies A meta-analysis of correlates and predictors in persons with a major mental disorder living in the community

This paper presents data from a systematic review and meta-analysis of published quality of life (QOL) studies on the subjective general well-being (GWB) of persons with major mental disorder (MMD) who live in the community. Four research questions were addressed: (1) What is the subjective QOL in persons with MMD who live in the community? (2) Are any specific subjective subdomains of QOL superior predictors of subjective GWB? (3) Is there an association between measures of psychopathology and subjective GWB? (4) Is there an association between sociodemographic variables and subjective GWB? We initially considered 134 potentially relevant articles, but only 42 studies reporting on 49 study units (N=6774 persons with MMD) met criteria of acceptable quality or relevance to be included in the meta-analysis. First, we found that measures of subjective GWB were relatively high. Second, certain subdomains such as Leisure and Social relations were strong predictors of subjective GWB, while the links between both Personal safety and Work, and GWB were weak. Third, we found that the empirical basis for using subjective QOL as an outcome variable in clinical research is scant. In particular, the relationship between changes in measures of psychopathology and subjective QOL appears to be obscure. Finally, the present study failed to confirm any stable relationship between sociodemographic factors and subjective GWB in persons with MMD who live in the community. Consequences of the findings for clinical practice and research are discussed. Limitations inherent in the meta-analytic approach in general, and the lack of homogeneity in the reviewed studies, need to be considered when interpreting the results of this meta-analysis.

Cognitive-behavioral therapy for medication-resistant schizophrenia: a review

Research meta-analyses have found that cognitive-behavioral therapy (CBT) is beneficial for persistent symptoms of schizophrenia. This review describes and updates the evidence base for this statement. A review of the existing literature (Medline, PsychInfo, and Embase) was carried out according to the guidelines for systematic reviews. Based on the findings of this review, the updated conclusion is that CBT has emerged as an effective adjuvant to antipsychotic medication in the treatment of persistent symptoms of schizophrenia. Studies of the use of CBT in the prodromal phase of psychosis and in combination with family therapy are currently underway.

Schizotypal cognitions as a predictor of psychopathology in adolescents with mild intellectual impairment

BACKGROUND

There is evidence to suggest that among young people with mild intellectual disability there are those whose cognitive difficulties may predict the subsequent manifestation of a schizophrenic phenotype. It is suggested that they may be detectable by simple means.

AIMS

To gain adequate cooperation from educational services, parents and students so as to recruit a sufficiently large sample to test the above hypothesis, and to examine the hypothesis in the light of the findings.

METHOD

The sample was screened with appropriate instruments, and groups hypothesised as being likely or not likely to have the phenotype were compared in terms of psychopathology and neuropsychology.

RESULTS

Simple screening methods detect a sample whose psychopathological and neuropsychological profile is consistent with an extended phenotype of schizophrenia.

CONCLUSIONS

Difficulties experienced by some young people with mild and borderline intellectual disability are associated with enhanced liability to schizophrenia. Clinical methods can both identify those with this extended phenotype and predict those in whom psychosis will occur.

Managing Psychotic Illness in Young People: A Practical Overview

  The management of early onset psychosis poses a significant challenge to professionals working in Child and Adolescent Mental Health Services. Young people with psychotic illness often present with a mixed clinical picture and a wide variety of attendant issues. Over the last decade there has been accumulating research, mainly based on work with adults, regarding the efficacy and effectiveness of medical and psychosocial interventions for patients with schizoaffective spectrum disorders. This article takes a symptoms-based approach, collating and summarising recent evidence, where it exists, regarding best practice when managing young people affected by schizophrenia, schizoaffective or bipolar affective disorder.

Physical activity, dietary habits and Coronary Heart Disease risk factor knowledge amongst people with severe mental illness: a cross sectional comparative study in primary care

BACKGROUND

Evidence regarding Coronary Heart Disease (CHD) related lifestyle in people with severe mental illnesses (SMI) such as schizophrenia is sparse. We aimed to quantify adverse CHD knowledge, diet and exercise in a representative primary care sample, and to determine whether socio-economic deprivation explained any findings.

METHOD

We compared CHD lifestyle and CHD knowledge in 74 people with SMI and 148 without from seven general practices. We measured CHD knowledge, dietary fibre, fats and exercise using validated instruments and adjusted for socio-economic status.

RESULTS

Fewer people with SMI had higher CHD knowledge: OR 0.49 (95% CI: 0.27-0.88), higher total exercise scores 0.49 (0.27-0.86), higher fibre 0.46 (0.26-0.82) or lower saturated fat diets 0.53 (0.30-0.94). These results were stable irrespective of antipsychotic medication, socio-economic status or type of statistical analysis.

CONCLUSION

High fat, low fibre diets, lack of exercise and smoking are the likely causes of the majority of CHD in this high-risk group, irrespective of medication and socio-economic deprivation. This lifestyle and particularly the lower CHD knowledge provides a theoretical focus for more comprehensive preventative CHD interventions in SMI.

Association between CCK-AR gene and schizophrenia with auditory hallucinations

OBJECTIVE

Previous studies on a possible association between CCK-AR polymorphisms and schizophrenia have been controversial. The aim of the present study was to assess a potential association between schizophrenic patients with auditory hallucinations and polymorphisms of the CCK-AR gene.

METHODS

A set of single nucleotide polymorphisms mainly located in the regulatory region of the CCK-AR gene was analysed in a sample of 163 Diagnostic and statistical manual of mental disorders-IV-diagnosed schizophrenic patients and 162 healthy controls.

RESULTS

Significant differences in the genotype (P=0.011) and allele (P=0.0009) frequencies of the +121C/G SNP (located in the 5' regulatory region) were found between patients and controls. The excess of the C allele in the patient group remained significant after Bonferroni correction (P=0.03). However, functional in vitro assays, did not reveal significant differences on gene expression between +121G and +121C alleles of this SNP. Further investigations revealed two risk haplotypes: +121C/+978A/+984T (P=0.01) and +121C/+978T/+984C (P=0.0091) as well as a protective haplotype: +121G/+978T/+984T (P=0.0001).

CONCLUSION

Our data support a possible role of the CCK-AR gene in the vulnerability to schizophrenia in patients with auditory hallucinations, and suggest remarkable allele heterogeneity.

Association of subjective cognitive dysfunction with akathisia in patients receiving stable doses of risperidone or haloperidol

BACKGROUND AND OBJECTIVE

Antipsychotic-induced akathisia leads to poor compliance with medication and is still a source of concern in the treatment with antipsychotic drugs. Regarding clinical characteristics, the distinguishing features of akathisia in comparison with other extrapyramidal syndromes are prominent subjective symptoms. The purpose of the present study was to examine the subjective cognitive dysfunction associated with antipsychotic-induced akathisia.

METHODS

Sixty-seven outpatients with schizophrenia receiving stable doses of risperidone or haloperidol were evaluated for akathisia and other extrapyramidal side effects. Subjective cognitive dysfunction was comprehensively assessed using the Frankfurt Complaint Questionnaire (FCQ). The severity of subjective cognitive deficits was compared between the groups with and without akathisia using analysis of covariance with relevant variables as covariates.

RESULTS

The akathisia group (n = 25) scored significantly higher on the total FCQ score than the non-akathisia group (n = 42) (P < 0.05). In phenomenological subscale scores, the akathisia group had significantly higher scores on various subscales, i.e. 'anxiety', 'disorder of selective attention', 'deterioration of discrimination', 'perceptual disorder' and 'disorder of coping responses' than the non-akathisia group (P < 0.05).

CONCLUSIONS

These results suggest that akathisia is significantly associated with a variety of subjective cognitive-perceptual deficits. Early therapeutic interventions for akathisia should be performed considering its significant association with the subjective cognitive dysfunction and the impairment of coping responses.

Subjective cognitive dysfunction associated with drug-induced parkinsonism in schizophrenia

The authors investigated the subjective cognitive dysfunction associated with drug-induced parkinsonism (DIP) among 58 stabilized schizophrenic outpatients. Subjective cognitive dysfunction was comprehensively assessed using the Frankfurt Complaint Questionnaire (FCQ). Multivariate analysis revealed that the DIP group scored significantly higher on the total FCQ score than the non-DIP group. In phenomenological subscale scores, the DIP group had significantly higher scores on "deterioration of discrimination", "psychomotor disorder", and "perceptual disorder" than the non-DIP group. These results suggest that DIP is significantly associated with subjective cognitive-perceptual dysfunction, reflecting the complex nature of DIP that includes motor and cognitive aspects.

Identifying unmet therapeutic domains in schizophrenia patients: the early contributions of Wayne Fenton from Chestnut Lodge

Wayne Fenton, MD, died on September 3, 2006, while giving emergency clinical care. His leadership at National Institute of Mental Health provided a framework for therapeutic discovery. He crafted a new approach to psychosis based on poor functional outcomes and the psychopathology domains underlying long-term morbidity. His research and clinical observations during his career at the Chestnut Lodge clarified the unmet therapeutic needs in schizophrenia and provided the foundation for his vision. The results have radically changed the paradigm for discovery with emphasis on impaired cognition and negative symptom psychopathology.

Language and crossed finger localization in patients with schizophrenia

Language deficits are frequently reported in studies of patients with schizophrenia. The present study sought to test the hypothesis that such deficits are related to callosal function in this group. The FAS test of verbal fluency and Perin's Spoonerisms test of phonological processing were the tests of language. Callosal function was assessed using a Crossed Finger Localisation Test (CFLT), which is a measure of the interhemispheric transfer of somatosensory information. Patients with schizophrenia performed less well than controls on measures of language function, as well as on the CFLT. Significant positive correlations between CFLT performance and language function were present in the patient group, but not the control group. These findings extend on previous studies that report functional abnormalities of the corpus callosum in schizophrenia and are consistent with the hypothesis that language deficits in schizophrenia are related to impaired callosal functioning in this group. However, other explanations cannot be ruled out.

Lithium for schizophrenia

BACKGROUND

Many people with schizophrenia do not achieve a satisfactory treatment response with ordinary antipsychotic drug treatment. In these cases, various add-on medications are used, among them lithium.

OBJECTIVES

To review the effects of lithium for the treatment of schizophrenia and schizophrenia-like psychoses.

SEARCH STRATEGY

We searched the Cochrane Schizophrenia Group's register (November 2006). This register is compiled by methodical searches of BIOSIS, CINAHL, Dissertation abstracts, EMBASE, LILACS, MEDLINE, PSYNDEX, PsycINFO, RUSSMED, Sociofile, supplemented with hand searching of relevant journals and numerous conference proceedings. We also contacted pharmaceutical companies and authors of relevant studies to identify further trials and to obtain original patient data.

SELECTION CRITERIA

We included all randomised controlled trials comparing lithium to antipsychotics or to placebo (or no intervention), whether as sole treatment or as an adjunct to antipsychotic medication for the treatment of schizophrenia and/or schizophrenia-like psychoses.

DATA COLLECTION AND ANALYSIS

We extracted data independently. For homogenous dichotomous data we calculated random effects, relative risk (RR), 95% confidence intervals (CI) and, where appropriate, numbers needed to treat (NNT) on an intention-to-treat basis. For continuous data, we calculated weighted mean differences (WMD).

MAIN RESULTS

The update search in 2006 did not detect further studies that met our inclusion criteria. The review thus still includes 20 studies with a total of 611 participants. Most studies were small, of short duration and incompletely reported, but a number of authors were willing to share their data with us. Three studies comparing lithium with placebo as the sole treatment showed no difference in any of the outcomes we analysed. In eight studies comparing lithium with antipsychotic drugs as the sole treatment, more participants in the lithium group left the studies early (n=270, RR 1.8, CI 1.2 to 2.9, NNT 9, CI 5 to 33). Several of the outcomes relating to these studies suggested that lithium is less effective than antipsychotic drugs, but it was difficult to summarise the data because a variety of rating scales were used in the studies. Eleven studies examined whether the augmentation of antipsychotic drugs with lithium salts is more effective than antipsychotic drugs alone. More participants who received lithium augmentation had a clinically significant response (n=244, RR 0.8, CI 0.7 to 0.96, NNT 8, CI 4 to 33). However, statistical significance became borderline when participants with schizoaffective disorders were excluded in a sensitivity analysis (n=120, RR 0.8, CI 0.6 to 1.0, p=0.07). Furthermore, more participants in the lithium augmentation groups left the studies early (n=320, RR 2.0 CI 1.3 to 3.1, NNT 7, CI 4 to 14), suggesting a lower acceptability of lithium augmentation compared to those on antipsychotics alone. No superior efficacy of lithium augmentation in any specific aspect of the mental state was found. While based on very little data, there were no differences between groups for adverse events.

AUTHORS' CONCLUSIONS

There is no randomised trial-based evidence that lithium on its own is an effective treatment for people with schizophrenia. The evidence available on augmentation of antipsychotics with lithium is inconclusive, but does justify further, large, simple and well-designed trials. These should concentrate on two target groups: 1) people with no affective symptoms, so that trialists can determine whether lithium has an effect on the core symptoms of schizophrenia, 2) people with schizoaffective disorders for whom lithium is widely used in clinical practice, although there is no evidence to support this use.

The Camden Schizophrenia Surveys. III: Five-year outcome of a sample of individuals from a prevalence survey and the importance of social relationships

BACKGROUND

Most studies of outcome in schizophrenia have focused on incidence cohorts or samples identified through specialist mental health services; population-based samples provide a more complete picture of the effectiveness of community services.

AIMS

To examine whether outcome predictors, derived from studies of selected patients with prolonged schizophrenia, would emerge in a largely community-dwelling population sample.

METHODS

A follow-up sample of 114 adults with schizophrenia was identified via two censuses of key informants conducted for two prevalence surveys in North London, five years apart. Symptomatic, clinical and functional outcomes were assessed after five years. A composite score was derived for each individual. Multiple Linear Regression analyses were conducted in two phases to derive a best subset of predictors for global outcome.

RESULTS

After five years, 33% were worse and 62% were better overall. The four best predictors (social isolation, living apart from relatives, longer illness and being an inpatient at first census) accounted for 32% of the variance in outcome of those with schizophrenia and related diagnoses.

CONCLUSIONS

Social relationships during the course of illness are an important predictor of overall outcome and relationships with friends and family each seem to make a positive contribution. Policy and service developments should focus on improving participation in community life for people with schizophrenia, particularly their social connectedness.

Persistent negative symptoms in schizophrenia: an overview

Persistent negative symptoms represent an alternative approach for assessing negative symptoms in the context of clinical trials. Persistent negative symptoms are designed to capture those symptoms that lead to functional impairment but are currently understudied and for which there are no currently available effective treatments. Persistent negative symptoms differ from the 2 most commonly used approaches: primary, enduring negative symptoms or deficit symptoms and negative symptoms broadly defined to include negative symptoms, regardless of their etiology or duration. In contrast to deficit symptoms, persistent negative symptoms may include secondary negative symptoms. However, in contrast to negative symptoms broadly defined, the secondary negative symptoms included in the assessment of persistent negative symptoms only include those that have failed to respond to usual treatments for secondary negative symptoms. In consequence, the presence of persistent negative symptoms identifies a patient population with clinically relevant symptomatology, which is larger than the one with the deficit syndrome but less heterogeneous than that captured through the use of a nonrestrictive definition of negative symptoms. This may facilitate the selection of subjects for inclusion into research and efforts to develop new pharmacological treatments and enhance our understanding of a relevant clinical problem. Ultimately, the investigation of the different entities characterized by negative symptoms, such as persistent negative symptoms, and the enhanced understanding of their biological and clinical characteristics may help to unravel the psychopathological and biological heterogeneity of schizophrenia.

Familial association of schizophrenia symptoms retrospectively measured on a lifetime basis

OBJECTIVE

The objective of this study was to characterize the familial associations of symptoms or symptom dimensions of schizophrenia, as a component of the effort to delineate suitable phenotypic markers under the homogenous genetic control.

METHODS

Clinical symptoms of the patients were evaluated on a lifetime basis, with the Korean version of the Diagnostic Interview for Genetic Studies and the Krawieka scale. Our sample consisted of 54 sibling pairs who were concordant for Diagnostic and statistical manual of mental disorder-IV schizophrenia or schizoaffective disorder.

RESULTS

At the individual symptom level measured by the Diagnostic Interview for Genetic Studies, we observed a statistically significant degree of concordance within the sibling pairs for auditory hallucination (kappa=0.600, chi(2)=15.193, P=0.000). The within-sibling resemblance of this symptom was also indicated by the results of correlation analyses of individual items of the Krawiecka scale (partial correlation coefficient=0.423, P=0.005). Among the individual symptoms or symptom dimensions of the Krawiecka scale, the 'anxious' (partial correlation coefficient=0.469, P=0.001) and the 'affective dimension' (including the items of 'anxious' and 'depressed') (partial correlation coefficient=0.436, P=0.003) were also determined to indicate significant intra-pair correlations after controlling for potential confounding variables, such as sex, duration of illness, and age of onset.

CONCLUSIONS

The results of this study suggest that familial factors, possibly genetic factors, contribute a liability to the development of auditory hallucinations. This symptom might then prove useful as a phenotype marker in future genetic studies.

Does structured clinical supervision during psychosocial intervention education enhance outcome for mental health nurses and the service users they work with?

This study aimed to assess whether clinical supervision provided by workplace-based supervisors can enhance outcomes for mental health nurses attending a psychosocial intervention education programme and the service users whom they work with. A quasi-experimental controlled design was used. The main outcome measure was student knowledge and attitudes towards individuals with psychosis and their caregivers. Secondary outcome measures for service users included the KGV (M) symptom scale and the Social Functioning Scale. Students in the experimental group demonstrated a significant increase in knowledge of psychological interventions compared with the control group. Service users seen by the students in the experimental group showed significantly greater reductions in positive psychotic symptoms and total symptoms compared with those seen by students in the control group. Workplace clinical supervision may offer additional benefit to nurses attending psychosocial intervention courses. Further research adopting more robust designs is required to support these tentative findings.

Olfactory sensitivity through the course of psychosis: Relationships to olfactory identification, symptomatology and the schizophrenia odour

There is some evidence for an unusual body odour in schizophrenia that has been linked to a hexenoic acid derivative (trans-3-methyl-2-hexenoic acid; MHA). Poor body odour has been linked to increased negative symptoms and reduced olfactory identification ability. However, the relationship between these findings and MHA, including olfactory sensitivity for MHA, has not been examined. Olfactory sensitivity thresholds were assessed for MHA and n-butyl-alcohol (NBA), in normal controls (CTL; n=24), patients with chronic schizophrenia (CHR; n=32) and a first-episode psychosis cohort (FE; n=31). In addition, forced choice detection of the pheromonal steroids 5-alpha-androst-16-en-3-one, androsterone-sulphate and estrone-3-sulphate was performed along with a measure of olfactory identification. CHR patients had significantly reduced sensitivity to MHA, but not NBA, compared to FE and CTL subjects. While sensitivity to pheromones was not different between the groups, CHR patients who could not detect them also showed poorer sensitivity to MHA. Further, the CHR group showed a significant association between reduced MHA sensitivity and greater levels of disorganised and negative symptoms. No relationships between identification and sensitivity for any substance were found. Our findings are the first to report reduced sensitivity for MHA in chronic schizophrenia patients, in the absence of similar impairment for more traditionally used substances. This may be linked to olfactory habituation effects, abnormal chemical processing or a genetic predisposition.

Toward specifying the nature of the relationship between expressed emotion and schizophrenic relapse: the utility of curvilinear models

Although expressed emotion (EE) has been demonstrated to be associated with the course of schizophrenia, the nature of this relationship is unclear. This study proposes that testing for curvilinear relationships can identify the specific nature of the relationships between EE indices and relapse. The utility of curvilinear models was explored through a reanalysis of data from a prior study of EE among Mexican-Americans (Karno et al., 1987). The results suggest that the relationship between the EE index of emotional overinvolvement (EOI) and relapse is curvilinear and that high levels of EOI may exert a toxic effect on course of illness whereas medium levels of EOI may be protective. The relationship between the EE index of warmth and relapse is also curvilinear and high levels of warmth appear to exert a protective effect on the course of illness. The role of culture is explored in explaining the specific manner in which EE relates to relapse among Mexican-Americans.

Adolescent-onset psychosis: prevalence, needs and service provision

BACKGROUND

Little is known of the epidemiology and care needs of people with adolescent-onset psychosis.

AIMS

To examine prevalence and the cross-sectional disability, needs and service provision for adolescent-onset psychosis in areas of central Scotland with a total population of 1.75 million.

METHOD

We identified and contacted 103 young people using an opt-out research design. Fifty-three participants and their carers and keyworkers were interviewed using a modified version of the Cardinal Needs Schedule.

RESULTS

The 3-year prevalence was 5.9 per 100,000 general population. Twenty-one (20%) adolescents were not in contact with mental health services; 80% of first admissions were to adult acute psychiatric wards. Those interviewed had high levels of morbidity: 29 (55%) had serious to pervasive impairment of functioning; there were relatively high levels of side-effects, negative symptoms, anxiety, occupational, friendship and family difficulties. Care provision was better for'clinical'than for'social'domains; 20% had five or more unmet needs; 17% had at least one intractable problem.

CONCLUSIONS

This low-prevalence disorder requires an assertive multi-agency approach in the context of a national planning framework.

Classifying episodes in schizophrenia and bipolar disorder: criteria for relapse and remission applied to recent-onset samples

Research on predicting and preventing episodes of schizophrenia and mood disorder lacks consistent, specific definitions of episodes. We present an operational system for identifying relapse, exacerbation, and remission of schizophrenia and bipolar disorder within longitudinal studies that involve repeated symptom assessments. Three major classes of episodic outcome are defined: relapse or significant exacerbation, nonrelapse, and stable, severe persisting symptoms. These major classes are further subdivided to distinguish nine categories of episodic outcome. To examine ease of use, interrater reliability, and validity, the classification system was applied to recent-onset samples of schizophrenia patients (N=77) and bipolar mood disorder patients (N=23) followed on medication for 9- to 12-month periods. A range of episodic outcomes were distinguished with high interrater reliability. Despite being prescribed continuous medication, 21% of the recent-onset schizophrenia patients and 61% of bipolar patients met criteria for relapse or significant exacerbation during this follow-up period. Predictive relationships support the validity of this system for classifying episodes. A computer program is available to facilitate its use. Use of these explicit definitions of episodes may help to clarify the relationship between episodic outcome and other fundamental domains of illness outcome, particularly other symptom dimensions, work functioning, and social functioning.

Differentiating the effects of pharmacological and psychosocial interventions in an intensive rehabilitation programme

BACKGROUND

It is of clinical importance to identify the contribution of the individual components in a composite intervention, but this is difficult in practice. The aim of this study was to differentiate the effects of pharmacological and psychosocial interventions in improving the symptoms of patients with schizophrenia undergoing an intensive rehabilitation programme.

METHOD

The Krawiecka Goldberg Vaughn scale was used to record the symptoms of 19 long-stay inpatients in the rehabilitation programme. Ratings were made every 2 weeks for periods of between 1 year and 20 months.

RESULTS

Analysis of the time course of symptoms showed that substitution of a single novel antipsychotic for conventional antipsychotic regimes was followed by a significant reduction in delusions but no improvement in hallucinations or negative symptoms. However, hallucinations and negative symptoms reduced significantly over the whole period of the observations, indicating an effect of the composite psychosocial interventions in the programme.

CONCLUSIONS

For patients with persistent psychotic symptoms, changing from conventional to novel antipsychotic medication is likely to reduce delusions, whereas hallucinations and negative symptoms may be more responsive to a combination of psychosocial interventions.

Family support predicts psychiatric medication usage among Mexican American individuals with schizophrenia

BACKGROUND

Support provided by family caregivers to persons with schizophrenia is a viable intervention focus to improve psychiatric medication usage. However, little is known about the relation between medication usage and family support as well as other key caregiving factors.

METHOD

Family support and Expressed Emotion (EE) dimensions were tested as predictors of medication usage during a 9-month period following psychiatric hospital discharge in a sample of 30 individuals of Mexican descent with schizophrenia.

RESULTS

Family instrumental support predicted higher medication usage (Odds Ratio = 4.8) in multivariate analyses that statistically adjusted for the impact of emotional support, family EE, and psychiatric status (e.g., positive symptoms) on medication usage.

CONCLUSIONS

Findings suggest that efforts to improve medication usage among Mexican American individuals with schizophrenia should take into account social supportive factors such as instrumental or directive, hands-on assistance from family caregivers.

Association between FOXP2 polymorphisms and schizophrenia with auditory hallucinations

OBJECTIVE

A mutation in the FOXP2 gene has been the first genetic association with a language disorder. Language disorder is considered as a core symptom of schizophrenia. Therefore, the FOXP2 gene could be considered a good candidate gene for the vulnerability to schizophrenia.

METHODS

A set of single nucleotide polymorphisms mainly located in the 5' regulatory region of the FOXP2 gene was analysed in a sample of 186 DSM-IV schizophrenic patients with auditory hallucinations and in 160 healthy controls.

RESULTS

Statistically significant differences in the genotype (P=0.007) and allele frequencies (P=0.0027) between schizophrenic patients with auditory hallucinations and controls were found in the single nucleotide polymorphism rs2396753. These P values changed to 0.07 and 0.0273, respectively, after Bonferroni sequential correction. The haplotype rs7803667T/rs10447760C/rs923875A/rs1358278A/rs2396753A (TCAAA) also showed a significant difference confirmed with a permutation test (P=0.009).

CONCLUSIONS

These results suggested that the FOXP2 gene may confer vulnerability to schizophrenic patients with auditory hallucinations.

Cognitive functioning in delusions: A longitudinal analysis

BACKGROUND

This study explored the longitudinal course of the relationship between delusions and different aspects of cognitive functioning.

METHODS

Deluded patients were compared to psychiatric and non-clinical controls on three tasks: negative priming, a probabilistic judgement task (the 'beads' task), and the pragmatic inference task (PIT). All groups were tested at two time points, once when actively symptomatic, and once when in remission.

RESULTS

Deluded individuals exhibited a 'jump-to-conclusions' (JTC) reasoning bias: i.e., they made decisions on the basis of limited evidence and were more likely to revise their estimates when faced with disconfirmatory evidence. This JTC bias remained stable over time, although probability judgments seemed to normalise in remission. No deficits in cognitive inhibition were found on negative priming. The deluded group displayed an excessive self-focus on the PIT at both time points, but did not show a depressive attributional style. Only a small sub-sample, characterised by the "bad-me" type of paranoia [Trower & Chadwick, 1995 Clinical Psychology: Science and Practice, 2, 263-278.], demonstrated depressive schemas when symptomatic, but no longer did so when remitted. Few relationships were found between tasks, suggesting that different areas of functioning are relatively independent. The only measures associated with delusion symptom scores were from the 'beads' task.

CONCLUSIONS

Overall these findings suggest that the JTC bias is a stable factor associated with delusional thinking, while the depressive attributional style characteristic of a small sub-sample of paranoid patients fluctuates with delusional course.

Pharmacological management of akathisia in combination with psychological interventions by a mental health nurse consultant

The article describes the management of akathisia by a mental health nurse (MHN) prescriber, working in partnership with the patient. A single-case design was used to evaluate this. It highlights three features: first, MHN can safely prescribe psychiatric medication in combination with concordance therapy. Second, the value base underpinning prescribing practice is partnership, honesty and choice for the patient. Finally, the pharmacological mechanism of antipsychotic medication, which contributes towards akathisia, requires further analysis.

Symptomatology and social inference: a theory of mind study of schizophrenia and psychotic affective disorder

INTRODUCTION

There is evidence that certain patients with schizophrenia have deficits in theory of mind (ToM) capabilities. It is, however, unclear whether these are symptom or diagnosis-specific.

METHODS

A ToM hinting task was given to 15 patients with a DSM-IV diagnosis of schizophrenia, 15 patients with affective disorder and 15 healthy controls. Severity of the current psychopathology was measured using the Krawiecka standardised scale of psychotic symptoms (Krawiecka, Goldberg, & Vaughan, 1977); IQ was estimated via the Ammons and Ammons Quick Test (Ammons & Ammons, 1962).

RESULTS

The group with schizophrenia performed significantly worse than the affective and control groups. Poor performance on the hinting task was found to be significantly related to the presence of positive symptoms (instead of negative ones) and specifically related to delusions and hallucinations. These findings remained when covariance for potentially confounding variables was applied.

CONCLUSIONS

Individuals with high levels of delusions and hallucinations performed significantly worse on this ToM task, regardless of diagnosis, implying ToM impairment is not exclusive to schizophrenia but is evident in other forms of psychosis. Between-group analyses showed the schizophrenia group had a significantly poorer performance on this task than the others.

Modified Sainsbury tool: an initial risk assessment tool for primary care mental health and learning disability services

Risk assessments by health and social care professionals must encompass risk of suicide, of harm to others, and of neglect. The UK's National Confidential Inquiry into Homicide and Suicide paints a picture of failure to predict suicides and homicides, failure to identify opportunities for prevention and a failure to manage these opportunities. Assessing risk at 'first contact' with the mental health service assumes a special place in this regard. The initial opportunity to be alerted to, and thus to influence, risk, usually falls to the general psychiatric service (as opposed to forensic specialists) or to a joint health and local authority community mental health team. The Mental Health and Learning Disabilities Directorate of Renfrewshire & Inverclyde Primary Care NHS Trust, Scotland, determined to standardize their approach to risk assessment and selected a modified version of the Sainsbury Risk Assessment Tool. A year-long pilot revealed general support for its service-wide introduction but also some misgivings to address, including: (i) rejection of the tool by some medical staff; (ii) concerns about limited training; and (iii) a perceived failure on the part of the management to properly resource its use. The tool has the potential to fit well with the computer-networked needs assessment system used in joint-working with partner local authorities to allocate care resources.

Effects of environmental deprivation on negative symptoms of schizophrenia: a nationwide survey in Japan's psychiatric hospitals

Research into the effects of environmental deprivation on negative symptoms of schizophrenia is limited, and few attempts have been made to differentiate secondary symptoms caused by the social environment. Japan's mental health system allows us to examine the extent to which understimulating social environments in hospitals contribute to negative symptoms of institutionalized patients while controlling for other factors. A random sample of inpatients of diagnosed with schizophrenia and hospitalized for 1 year or longer was drawn from the universe of inpatients attending a convenience sample of 20 hospitals across Japan. Data were collected for 549 study participants (a response rate of 91.5%). Measures included the Scale for the Assessment of Negative Symptoms (SANS), other clinical condition scales such as the Manchester Scale, and social condition scales including the Nurses' Opinion Scale and the Ward Restrictiveness Scale. Hierarchical regression analyses were conducted to determine the contribution of social environment to negative symptoms. Results showed significant correlations between negative symptom scales and most of the social environment scales, where social environment scales accounted for 18% of the variance in SANS scores. The study confirms the influence of understimulating social environments in psychiatric hospitals on negative symptoms.

Neuroleptic‐induced acute and chronic akathisia: A clinical comparison

We compared the severity of subjective and objective symptomatology of akathisia between the acute and chronic subtypes of neuroleptic-induced akathisia. Sixty-one schizophrenic subjects were evaluated. Multivariate analysis revealed that motor manifestations and distress of akathisia were less severe in chronic akathisia than in acute akathisia. The severity of subjective restlessness was not significantly different between the two groups. In conclusion, there were differences in the severity of symptoms and signs between the acute and chronic subtypes of akathisia, suggesting that the severity of the subjective and objective components of akathisia may be differentially affected by the duration of akathisia.

Language, therapeutic relationships and individualized care: addressing these issues in mental health care pathways

Care pathways are used extensively in inpatient medical and surgical services to facilitate the delivery of evidence-based health care. There is a growing interest in their use in the mental health arena. However, questions remain about their acceptability to service users and staff. Most current literature is aimed at communicating the value of care pathways. Consequently, issues that are particularly pertinent to mental health, like language, therapeutic relationships and individualized care have not been fully addressed. This paper reports on the development of a care pathway in residential services in Nottingham. It will illustrate how by working in multidisciplinary groups with service users and carers these issues were incorporated into a comprehensive pathway that follows the service user's journey from admission to discharge. The paper concludes by highlighting some of the challenges of care pathway implementation and suggests ways they can be overcome.

Reasons for admission and their implications for the nature of acute inpatient psychiatric nursing

The purpose of acute inpatient psychiatric care, and nurses' role within that, are in need of clarification and restatement in order to provide a framework for practice, education, research and development. Inpatient psychiatry has suffered from a paucity of research in recent years. In addition, being a complex system, involving multiple professions with differing ideologies, means that widely accepted succinct descriptions of its purpose are hard to achieve. Yet such a framework is essential to support positive attitudes to patients and for good staff-management relationships. Using an oblique strategy, this paper defines the function of acute inpatient psychiatry, and the role of psychiatric nurses, via a structured examination of the literature on reasons for admission to acute inpatient psychiatric wards. Seven such reasons were discovered and are described: dangerousness, assessment, medical treatment, severe mental disorder, self-care deficits, respite for carers, and respite for the patient. Acute inpatient psychiatric nurses are therefore: providing safety for the patient and others; collecting and communicating information about patients, giving and monitoring treatment; tolerating and managing disturbed behaviour; providing personal care; and managing an environment where patients can comfortably stay. The implications for psychiatric nursing are discussed.

Exploration of the psychometric properties of an Inventory of Voice Experiences

The aim of the study was to identify psychometric properties of an inventory of voice-hearing experiences (IVE) [corrected] One hundred fifteen psychiatric nurses rated the language content represented on two forms of the IVE and the Brief Psychiatric Rating Scale (BPRS) [corrected] while viewing a videotaped assessment of an experienced voice hearer. Findings revealed modest to moderate support for internal consistency and concordance of the language represented on the measures as well as moderate support for convergent validity of IVE Forms A and B and modest support for their convergence with the BPRS. Nurse ratings of the IVE [corrected] explained 14 to 15 percent [corrected] of the variation in the same nurses' ratings of the hallucinated symptom item on the BPRS measure. Other [corrected] findings from the study [corrected]augment the position that not all hallucinated voices are indicative of clinical pathology, providing an additional basis on which to further refine and test the two measures [corrected]

FOXP2 polymorphisms in patients with schizophrenia

BACKGROUND

FOXP2 was described as the first gene involved in our ability to acquire spoken language. The main objective of this study was to compare the distribution of FOXP2 gene polymorphisms between patients with schizophrenia and healthy controls.

METHODS

Two FOXP2 polymorphisms, Intron3a and SNP 923875, and the G-->A transition in exon 14 were analysed in 149 patients with schizophrenia and schizoaffective disorders according to DSM-IV, as well as in 137 controls. All the patients showed a history of auditory hallucinations.

RESULTS

The transition G-->A at exon 14, detected in all the affected members in KE family, was not found in any of the analyzed samples from patients or controls. No significant differences were found between individual controls and patients for the two analysed polymorphisms.

CONCLUSIONS

This study would not support a possible role of the two FOXP2 analyzed polymorphisms in the vulnerability to schizophrenia.

Do all people with schizophrenia receive the same benefit from different family intervention programs?

The study evaluated baseline characteristics that could be used to predict the outcome of family intervention in schizophrenia and focussed on identifying the subgroups of patients who were more likely to respond to one therapeutic modality than another. We conducted a controlled trial in which participants were assigned at random to either a Behavioral Family Intervention Group or a Relatives' Group. Patients in one catchment area, having suffered one psychotic relapse within the previous year and living with their families, were assessed by an independent evaluator at baseline and 12 months later. Some clinical and family factors such as the duration of illness, number of hospital admissions and relatives' level of psychological distress can predict the differential outcome of either type of family intervention modality. The results suggested that the short-term illness group requires more intensive and personal intervention, while the long-term illness group needs more continuous support. Our results should be confirmed in a larger sample before clinical recommendations can be made.

A theory of mind investigation into the appreciation of visual jokes in schizophrenia

BACKGROUND

There is evidence that groups of people with schizophrenia have deficits in Theory of Mind (ToM) capabilities. Previous studies have found these to be linked to psychotic symptoms (or psychotic symptom severity) particularly the presence of delusions and hallucinations.

METHODS

A visual joke ToM paradigm was employed where subjects were asked to describe two types of cartoon images, those of a purely Physical nature and those requiring inferences of mental states for interpretation, and to grade them for humour and difficulty. Twenty individuals with a DSM-lV diagnosis of schizophrenia and 20 healthy matched controls were studied. Severity of current psychopathology was measured using the Krawiecka standardized scale of psychotic symptoms. IQ was estimated using the Ammons and Ammons quick test.

RESULTS

Individuals with schizophrenia performed significantly worse than controls in both conditions, this difference being most marked in the ToM condition. No relationship was found for poor ToM performance and psychotic positive symptomatology, specifically delusions and hallucinations.

CONCLUSION

There was evidence for a compromised ToM capability in the schizophrenia group on this visual joke task. In this instance this could not be linked to particular symptomatology.

Depot fluphenazine decanoate and enanthate for schizophrenia

BACKGROUND

Intramuscular injections (depot preparations) offer an advantage over oral medication for treating schizophrenia by reducing poor compliance. The benefits gained by long acting preparations, however, may be offset by a higher incidence of adverse effects.

OBJECTIVES

To investigate the clinical effects of fluphenazine decanoate and enanthate.

SEARCH STRATEGY

For this update we searched the Cochrane Schizophrenia Group's Register (May 2002).

SELECTION CRITERIA

We considered all relevant randomised clinical controlled trials focusing on people with schizophrenia comparing fluphenazine decanoate or enanthate with placebo or oral anti-psychotics or other depot preparations.

DATA COLLECTION AND ANALYSIS

We reliably selected, quality rated and data extracted studies. For dichotomous data we estimated relative risk (RR) with 95% confidence intervals (CI), and, where possible, the number needed to treat/harm (NNT/H). Analysis was by intention-to-treat. We used the weighted mean difference (WMD) for normal continuous data. Tests of heterogeneity and for publication bias were undertaken.

MAIN RESULTS

This review now includes 70 randomised studies. Compared with placebo, fluphenazine decanoate did not reduce relapse over 6 months to 1 year, but one longer term study found that relapse was significantly reduced in the fluphenazine arm (n=54, RR 0.35, CI 0.2 to 0.6, NNT 2 CI 2 to 4). Fluphenazine decanoate does not reduce relapse more than oral neuroleptics (n=419, 6 RCTs, RR relapse 26-52 weeks 1.46 CI 0.8 to 2.8) or other depot antipsychotics (n=581, 11 RCTs, RR relapse 26-52 weeks 0.82 CI 0.6 to 1.2). Relapse rates over 6 months to 1 year were not significantly different between standard dosage of fluphenazine decanoate over a low dose group (n=523, 4 RCTs, RR 2.09 CI 0.6 to 7.1). Movement disorders were significantly less for people receiving fluphenazine decanoate compared with oral neuroleptics (n=259, 3 RCTs, RR 0.47 CI 0.2 to 0.9, NNT 14 CI 10 to 82). For fluphenazine enanthate there were limited data but no clear difference in global change (0 to 5 weeks) when compared with oral neuroleptics (n=31, 1 RCTs, RR 0.67 CI 0.3 to 1.7), and in relapse rates over 6-26 weeks between fluphenazine enanthate and other depots. Compared with placebo, giving the enanthate caused no more people to need need anticholinergic drugs (n=25, 1 RCT, RR 9.69 CI 0.6 to 163.0) and movement disorders, tardive dyskinesia, tremor, blurred vision and dry mouth were equally prevalent when enanthate was compared with other depot neuroleptics.

AUTHORS' CONCLUSIONS

There are more data for fluphenazine decanoate than for the enanthate ester. Both are effective antipsychotic preparations. In the context of trials, there is little advantage of these depots over oral medications in terms of compliance but this is unlikely to be applicable to everyday clinical practice.

Toward convergence in the medication treatment of bipolar disorder and schizophrenia

Reaching a correct differential diagnosis among patients with psychotic symptoms was especially important during the era of first-generation antipsychotics, when treatments for the different disorders varied in terms of adverse events and likelihood of response. The historical "overdiagnosis" of schizophrenia and "underdiagnosis" of bipolar disorder in the United States was blamed for an increased exposure to neuroleptics among patients who might have benefited from lithium. With the recognition that second-generation antipsychotics are useful in the treatment of both schizophrenia and bipolar mania, and that combining them with classic mood stabilizers such as valproate may results in increased efficacy, the field is witnessing a convergence of pharmacological approaches to the treatment of schizophrenia and bipolar disorder. Substantially more data is available regarding combination treatments for bipolar disorder than for schizophrenia, and appropriate diagnosis remains important in predicting prognosis, but until the precise pathophysiology of psychotic disorders can be elucidated, and specific targeted treatments crafted, we will continue to see similar blended treatments for these two disease states.

Multidimensional sensory phenomena in antipsychotic-induced akathisia

The primary distinguishing features of akathisia in comparison with other extrapyramidal syndromes are the prominent subjective manifestations, which include various sensory symptoms. The sensory symptoms are multidimensional in nature and encompass various forms of bodily and mental sensations. The purpose of the present study was to elucidate the multidimensional aspects of the sensory phenomena associated with antipsychotic-induced akathisia. Seventy stable and chronic schizophrenic subjects receiving maintenance antipsychotic treatment were evaluated for akathisia and other extrapyramidal side effects. Subjective sensory phenomena were evaluated in 3 dimensions (ie, bodily sensations, mental sensations, and autonomic sensations). The frequency of each dimension of these sensory phenomena was compared between the groups with and without akathisia using chi test with Bonferroni correction. The akathisia group (n = 29) reported significantly more frequent focal or generalized bodily sensations than the non-akathisia group (n = 41) (P < 0.001). The akathisia group also showed significantly more frequent mental sensations such as mental urge and a feeling of inner tension/pressure (P < 0.001). In autonomic phenomena, there was a trend for the akathisia group to show more frequent autonomic sensations. The most common autonomic phenomena associated with akathisia were palpitation and difficulty breathing. The results of the present study suggest that the sensory phenomena of antipsychotic-induced akathisia are characterized by multidimensional features such as bodily sensations, mental sensations, and several autonomic sensations. The assessment of these multidimensional sensory phenomena would be useful in evaluating the important phenotypic features of akathisia.

Gamma-aminobutyric acid agonists for neuroleptic-induced tardive dyskinesia

BACKGROUND

Chronic antipsychotic drug treatment may cause tardive dyskinesia (TD), a long-term movement disorder. Gamma-aminobutyric acid (GABA) agonist drugs, which have intense sedative properties and may exacerbate psychotic symptoms, have been used to treat TD.

OBJECTIVES

To determine the effects of GABA agonist drugs (baclofen, gamma-vinyl-GABA, gamma-acetylenic-GABA, progabide, muscimol, sodium valproate and tetrahydroisoxazolopyridine (THIP)) for people with antipsychotic-induced tardive dyskinesia (TD) and schizophrenia or other chronic mental illnesses.

SEARCH STRATEGY

We updated the previous Cochrane review by searching the Cochrane Schizophrenia Group Register (September 2003). We searched references for further trial citations and, where possible, contacted authors.

SELECTION CRITERIA

Randomised controlled trials comparing use of non-benzodiazepine GABA agonist drugs with placebo or no intervention, involving people with schizophrenia or other chronic mental illnesses with signs of antipsychotic-induced TD.

DATA COLLECTION AND ANALYSIS

Working independently, we selected and critically appraised studies, extracted data and analysed on an intention-to-treat basis. Where possible and appropriate we calculated risk ratios (RR) and their 95% confidence intervals (CI) with the number needed to treat (NNT). For continuous data Weighted Mean Differences (WMD) were calculated.

MAIN RESULTS

We identified eight small poorly reported studies for inclusion. For the outcome of 'no clinically important improvement in tardive dyskinesia' GABA agonist drugs were not clearly better than placebo (n = 108, RR 0.83 CI 0.6 to 1.1). Deterioration in mental state was more likely to occur in people receiving GABA medication (n = 95, RR 2.47 CI 1.1 to 5.4), but this effect was influenced by the decision to assign a negative outcome to those who dropped out before the end of the study. A greater proportion of people allocated GABA medication may fail to complete the trial compared with those allocated placebo (20% versus 9%), but this difference was not statistically significant (n = 136, RR 1.99 CI 0.8 to 4.7). There is a suggestion of an increase in ataxia (loss of power of muscular coordination) for both baclofen and sodium valproate (n = 95, RR 3.26 CI 0.4 to 30.2), and in sedation (n = 113, RR 2.12 CI 0.8 to 5.4) compared with placebo, but this was not significant. Withdrawal of tetrahydroisoxazolopyridine (THIP) may cause seizures.

REVIEWERS' CONCLUSIONS

Evidence of the effects of baclofen, progabide, sodium valproate, or THIP for people with antipsychotic-induced TD is inconclusive and unconvincing. Any possible benefits are likely to be outweighed by the adverse effects associated with their use.