A standardized psychiatric assessment scale for rating chronic psychotic patients

Cognitive Conceptualization of the Negative Symptoms of Schizophrenia

Cognitive therapy for the treatment of the negative symptoms of schizophrenia is in its infancy. Presented here is an outline of the conceptualization, assessment, and treatment of these disabling features of schizophrenia. Examination of possible secondary causes of the negative symptoms, including causes involving dysfunctional attitudes, is followed by a framing of primary negative symptoms in terms of the cognitive model of the influence of thoughts on emotion and behavior. Physiological models of the negative syndrome are incorporated into this cognitive framework. Unique features in the cognitive assessment and treatment of the negative symptoms are outlined. Clinical examples of clients with negative symptoms are provided.

Relationship between family attitudes and social functioning in schizophrenia: a nine-month follow-up prospective study in Spain

The objective was to study the relationship between family attitudes and social functioning in schizophrenia. A cohort of 80 patients was followed-up for 9 months after their hospitalization. The relatives' critical attitude and poor empathic attitude were measured by means of the Semantic Differential and the Questionnaire of Empathy, respectively. Time of useful work and social relations of the patients were measured before admission and at the end of follow-up. Symptoms, premorbid adjustment, and other course and demographic factors were also measured. Significant relationships were found between the relatives' poor empathic attitude and the patients' occupational functioning and social relations. These associations were maintained after controlling for the effects of other prognostic factors. These results suggest that empathy in the relative is an independent predictor of social functioning in people with schizophrenia. Different attitudinal dimensions of family attitudes might show different relationships with the social and clinical outcomes in this disorder.

The trauma of first episode psychosis: the role of cognitive mediation

OBJECTIVE

First episode psychosis can be a distressing and traumatic event which has been linked to comorbid symptomatology, including anxiety, depression and PTSD symptoms (intrusions, avoidance, etc.). However, the link between events surrounding a first episode psychosis (i.e. police involvement, admission, use of Mental Health Act, etc.) and PTSD symptoms remains unproven. In the PTSD literature, attention has now turned to the patient's appraisal of the traumatic event as a key mediator. In this study we aim to evaluate the diagnostic status of first episode psychosis as a PTSD-triggering event and to determine the extent to which cognitive factors such as appraisals and coping mechanisms can mediate the expression of PTSD (traumatic) symptomatology.

METHOD

Approximately 1.5 years after their first episode of psychosis, patients were assessed for traumatic symptoms, conformity to DSM-IV criteria for posttraumatic stress disorder (PTSD), and their appraisals of the traumatic events and coping strategies. Psychotic symptomatology was also measured.

RESULTS

31% of the sample of 35 patients who agreed to participate reported symptoms consistent with a diagnosis of PTSD. Although no relationship was found between PTSD (traumatic) symptoms and potentially traumatic aspects of the first episode (including place of treatment, detention under the MHA etc.), intrusions and avoidance were positively related to retrospective appraisals of stressfulness of the ward (i.e. the more stressful they rated it the greater the number of PTSD symptoms) and the patient's coping style (sealers were less likely to report intrusive re-experiencing but more likely to report avoidance).

CONCLUSIONS

The results call into question whether it is possible to make claims for a simple causal link between psychosis and PTSD. Instead patients' appraisals of potentially traumatic events and their coping styles may mediate the traumatic impact of a first episode of psychosis.

Ethnicity, Expressed Emotion, Attributions, and Course of Schizophrenia: Family Warmth Matters

The authors examined the role of family factors and the course of schizophrenia by carrying out additional assessments and analyses in 2 previously published studies of Mexican American and Anglo American patients and families. The authors found partial support for an attributional model of relapse for families who are low in emotional overinvolvement. Attributions of control, criticism, and warmth together marginally predicted relapse. The data also indicated that for Mexican Americans, family warmth is a significant protective factor, whereas for Anglo Americans, family criticism is a significant risk factor. These findings suggest that the sociocultural context shapes the pathways by which family processes are related to the course of illness. Moreover, the warmth findings suggest that families may contribute to preventing relapse.

Assessing the needs of people with learning disabilities and mental illness: development of the Learning Disability version of the Cardinal Needs Schedule

BACKGROUND

People with learning disability (LD) experience a range of mental health problems. They are a complex population, whose needs are not well understood. This study focuses on the development of a systematic process of needs assessment for this population.

METHODS

The Cardinal Needs Schedule used in general psychiatry was adapted for people with learning disabilities (LD). The Learning Disability version of the Cardinal Needs Schedule (LDCNS) was tested on a sample of 35 people with LD and mental illness for its inter-rater reliability.

RESULTS

The inter-rater reliability (Kappa) was calculated for 22 areas of functioning assessed by the LDCNS. Overall, there was very good agreement in seven areas, moderate agreement in six areas, fair agreement in three areas and poor agreement in one area. In four areas of functioning, Kappa could not be calculated. More needs were found in the social domain than in the clinical domain.

CONCLUSION

A systematic needs assessment schedule (LDCNS) was developed for people with LD and mental illness. The inter-rater reliability is generally acceptable, but requires further examination.

Management of the negative symptoms of schizophrenia: new treatment options

This article presents a systematic review of pharmacological treatment for negative symptoms of schizophrenia, based on MEDLINE searches from 1995 to September 2002 to identify pertinent clinical trials. The pharmacotherapy of negative symptoms in schizophrenia includes novel/atypical antipsychotics and classical antipsychotics, as well as antidepressants, glutamatergic compounds, antiepileptic drugs and estrogens. In the assessment of therapy for negative symptoms of schizophrenia, it is imperative that better studies of sound methodology are performed. In such studies, some important aspects to be considered include an accurate definition and assessment of negative symptoms (including well designed, valid and reliable rating scales), the differentiation between primary and secondary negative symptoms, an appropriate selection of standard comparators, adequate dosages of comparators (e.g. haloperidol dosages) and an overall optimal study design. Most of the available studies on treating negative symptoms in schizophrenia have focused on the atypical antipsychotics, while other potential candidates, mostly in the context of add-on therapy, have not been so intensively investigated. Atypical antipsychotics have been proven in placebo-controlled trials to be effective in treating negative symptoms of acute schizophrenic episodes. In many of the comparator studies, they showed efficacy in treating negative symptoms that was superior to that of typical antipsychotics. Data on stable, predominant negative symptoms in subchronic or chronic cases of schizophrenia, although limited, have demonstrated the efficacy of atypical antipsychotics. If the beneficial tolerability profile with respect to extrapyramidal symptoms is also taken into account during clinical decision making, the atypical antipsychotics should be preferred for the treatment of negative symptoms. It is also worth noting that the traditional antipsychotics have the risk of inducing negative symptoms in the context of akinesia. The benefits of add-on therapy with SSRIs or a glutamatergic compound are well documented. Estrogen add-on therapy seems promising. Other traditionally suggested approaches, such as comedication with an antiepileptic drug, lithium or beta-adrenoceptor antagonist, cannot generally be recommended on the basis of the available data.

Prevalence and Characteristics of Subjective Akathisia, Objective Akathisia, and Mixed Akathisia in Chronic Schizophrenic Subjects

Akathisia is a complex syndrome that is characterized by subjective inner restlessness and objective motor manifestations, and it can be classified into several subtypes. The purpose of this study was to examine the prevalence of subjective akathisia, objective akathisia, and mixed akathisia, and to evaluate their relationships with other drug-induced movement disorders, in chronic schizophrenic subjects treated with antipsychotics. One hundred and forty-two in-patients were assessed for akathisia, drug-induced parkinsonism, and tardive dyskinesia. The subtypes of akathisia were specified according to the Barnes Akathisia Rating Scale. Drug-induced parkinsonism and tardive dyskinesia were assessed using the Simpson-Angus Scale and the Abnormal Involuntary Movement Scale, respectively. The prevalence of subjective, objective, and mixed akathisia was 11.3%, 6.3%, and 16.9%, respectively. Regarding concurrence rates of akathisia subtypes and other extrapyramidal syndromes, the comorbidity rates of mixed akathisia with parkinsonism and tardive dyskinesia were higher. In conclusion, the present study presented the prevalence of subjective, objective, and mixed akathisia among hospitalized schizophrenic subjects. Mixed akathisia showed an association with parkinsonism and tardive dyskinesia, suggesting a common vulnerability involved in these drug-induced movement disorders. Further studies are required to elucidate more detailed clinical characteristics of each subtype of akathisia.

Institutionalisation and schizophrenia in Japan: social environments and negative symptoms: Nationwide survey of in-patients

BACKGROUND

The number of psychiatric beds per capita in Japan is the highest in the world, and a replication of earlier British research is needed to identify possible means of improving the mental health system. Aims To describe the current situation of psychiatric hospitals in Japan and to examine the relationship between negative symptoms of schizophrenia and social environments.

METHOD

In-patients with schizophrenia were randomly selected from 139 hospitals. Data were obtained for 2758 participants using several scales, including the Manchester Scale and social environment scales.

RESULTS

Negative symptom scales showed a significant correlation with understimulating social environments in hospitals.

CONCLUSIONS

This study confirms the results from the UK and provides evidence for the importance of community-based care and for providing more-stimulating rehabilitation environments.

Dopamine D2 receptor gene Ser311Cys variant and schizophrenia: association study and meta-analysis

An association has been reported between a dopamine D(2) receptor gene (DRD2) Ser311Cys variant and schizophrenia. In a replication attempt, Swedish patients with schizophrenia (n = 173) and control subjects (n = 236) were assessed for the DRD2 Ser311Cys variant. Schizophrenic patients displayed higher Cys311 allele frequencies than control subjects (4.0 vs. 0.8%, chi(2) = 9.49, df = 1, P = 0.002; odds ratio (OR) 4.93, 95% confidence interval (95% CI) 1.61-15.12). The association was detected only in men. The results were supported by a meta-analysis of all published case-control studies comprising a total of 9,152 subjects (chi(2) = 11.37, df = 1, P < 0.001; OR 1.43, 95% CI 1.16-1.78). The present results support the involvement of the DRD2 gene in the pathogenesis of schizophrenia.

Glasgow's community care programme: 10 year follow up of discharged patients with schizophrenia

In 1986, the rehabilitation of every long stay psychiatric patient in Glasgow was assessed with a view to reducing bed numbers and developing comprehensive community services. Ten years on, we have attempted to trace 91 patients with a diagnosis of schizophrenia assessed at Gartnavel Hospital, in order to repeat assessments of their psychopathology and levels of functioning. We believe this population represents a unique group in terms of their age, length of hospital stay and chronicity of symptoms. Only two patients were untraced but 36% of the original 91 patients were decreased. Discharge to the community and variations in standards of care appeared to have little impact on the symptomatic presentation of the survivors over ten years. The results provide useful information on the success or otherwise of a large scale discharge and community care programme which is continuing in Scotland.

Managing side-effects to the optimum: valuing a client's experience

Despite the recent emergence of psychosocial interventions and other forms of practical treatments, antipsychotic medication remains the cornerstone of treatment for schizophrenia, as it is recognized to be effective in reducing relapse rates. Nevertheless, the side-effects of psychotropic medication make adherence to treatment regimens difficult for many clients and, until recently, little has been done by mental health nurses to consistently monitor or manage these symptoms. This report describes how the integration of knowledge and clinical skills in psychopharmacology optimized one client's concordance with medication. It reports on 'John's' treatment experience with medication and addresses the role that mental health nurses can play in appraising pharmaceutical effects, and assessing and working with side-effects, using a medication-management multidisciplinary team approach.

Care needs of elderly people with schizophrenia. Assessment of an epidemiologically defined cohort in Scotland

BACKGROUND

Little is known of the needs of elderly patients with psychotic illnesses.

AIMS

To measure the care needs of an epidemiologically based group of patients over the age of 65 years suffering from psychotic illness, using a standardised assessment.

METHOD

All patients aged 65 years and over with a diagnosis of schizophrenia and related disorders from a defined catchment area were identified. Their health and social care needs were investigated using the Cardinal Needs Schedule.

RESULTS

The 1-year prevalence of schizophrenia and related disorders was 4.44 per 1000 of the population at risk. There were high levels of unmet need for many patients, including those in National Health Service (NHS) continuing-care beds.

CONCLUSIONS

Many needs were identified, all of which could be addressed using the existing skills of local health and social care professionals. The investigation raises serious concerns about standards of hospital and community care for elderly patients with schizophrenia. The findings may be unique, reflecting long-standing problems within a particularly hard-pressed part of the NHS. However, it is not known whether a similar situation exists in other parts of the UK.

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

The reviewers searched the Cochrane Schizophrenia Group's register (March 2002). 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

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

Citations and, where possible, abstracts were independently inspected by reviewers, papers ordered, re-inspected and quality assessed. Data were extracted independently by at least two reviewers. Dichotomous data were analysed using relative risks (RR) and the 95% confidence interval (CI) estimated. Where possible the number needed to treat (NNT) or number needed to harm statistics were calculated. Continuous data were analysed using weighted mean differences (WMD).

MAIN RESULTS

The review currently 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.

REVIEWER'S 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 it justifies 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 Kraepelinian dichotomy: preliminary results of a 15-year follow-up study on functional psychoses: focus on negative symptoms

In a 15-year follow-up study, we used a comparative approach to assess course and outcome for all functional psychoses. The presented results focus on negative symptoms and refer to a sample of 76 patients with schizophrenia, 38 patients with a schizoaffective disorder and 32 patients with an affective disorder according to ICD-9. These patients were assessed at their first psychiatric hospitalization and 15 years later. In summary, the findings indicate that the course and outcome of schizophrenia is less favorable than that of affective and schizoaffective disorders. Negative symptoms occurred in all functional psychoses, but were more frequent and prominent in the schizophrenic group than in the other two diagnostic groups at any time of assessment. Narrower concepts of negative symptoms, conceptualized as the deficit syndrome, seem to be specific for schizophrenia and appear quite rarely in patients with affective psychoses. Overall, our study supports Kraepelin's original hypothesis that bifurcated the psychoses into the affective psychoses and schizophrenia, whereby the latter have a more deleterious long-term course and outcome.

Reduced frontotemporal functional connectivity in schizophrenia associated with auditory hallucinations

BACKGROUND

We used functional magnetic resonance imaging (fMRI) to investigate the frontotemporal disconnection hypothesis of schizophrenia.

METHODS

Eight DSM-IV schizophrenia patients and 10 control subjects were studied with fMRI while they thought of the missing last word in 128 visually presented sentences. The fMRI data were analyzed comparing the effect of sentence completion (vs. rest) using a random effects analysis.

RESULTS

There were no significant group differences in regional brain responses. Correlation coefficients between left temporal cortex (x = -54, y = -42, z = 3) and left dorsolateral prefrontal cortex (x = -39, y = 12, z = 24) were significantly lower in the schizophrenic group and were negatively correlated with the severity of auditory hallucinations.

CONCLUSIONS

Previous demonstrations of hypofrontality in schizophrenia may reflect particular task requirements. Frontotemporal functional connectivity is reduced in schizophrenia and may be associated with auditory hallucinations.

Perceptual organization deficits in psychotic patients

It has been proposed that a characteristic of schizophrenic processing is an abnormality of top-down processing. The relationship between impaired top-down processing and symptoms of reality distortion was investigated using a 'degraded interference' task. In this task, fragmented stimuli (Stroop words, control words and crosses) are presented on a computer screen, and the extent to which they are visually integrated is inferred by their interfering properties. It was predicted that psychotic individuals would fail to show an interference effect with degraded Stroop stimuli. This predicts the absence of a delay in reaction time in the experimental condition, which therefore cannot be attributed to a generalized deficit. A sample of inpatients experiencing positive symptoms was compared to a healthy control group. The results provided support for a deficiency in top-down processing, with the psychotic group failing to show the significant degraded interference effect found in the healthy controls. Degraded interference was associated with low verbal IQ, but with no other symptomatic or demographic variables.

Community rehabilitation service for patients with severe psychotic disorders: the Slovene experience

BACKGROUND

Rehabilitation can be carried out at various sites.

METHOD

Two groups of patients with severe mental disorders were compared: those included in community rehabilitation service and those only attending an outpatient clinic regarding their clinical status, social functioning, standard of living and quality of life.

RESULTS

We found no significant global differences in group characteristics, social functioning and clinical status, but we did prove the lower social status of the group included in the rehabilitation service and their satisfaction with the services they use.

CONCLUSIONS

The community rehabilitation services in Slovenia are coping with existential social needs of their users but this study failed to demonstrate their success in improving health or social functioning.

Effects of the 5HT antagonist cyproheptadine on neuropsychological function in chronic schizophrenia

This study tests the hypothesis that the ability of atypical neuroleptics to improve negative symptoms is due to 5HT-receptor antagonism and enhanced frontal lobe function. We investigated the effects of cyproheptadine (a 5HT2 antagonist) on neuropsychological tests of frontal lobe functions in chronic schizophrenic patients. Eighteen stable schizophrenic patients on depot neuroleptic medication participated in a 4-week double blind crossover study. Outcome measures were clinical symptoms rating scales, neuropsychological tests (verbal fluency, Stroop colour word task, trail making) and antisaccade eye movements. During the cyproheptadine phase statistically significant improvement was seen on Stroop colour word task, verbal fluency and Trail B tests. The ability to suppress reflexive eye movement to a target light in an anti saccade task was also significantly enhanced. The patients had low clinical ratings of negative symptoms and they were unaffected by cyproheptadine. The results indicate that 5HT2C receptors selectively modulate speed and motor control mechanisms related to frontal lobe functions but this was not associated with changes in symptoms.

Cognitive behaviour therapy for schizophrenia

BACKGROUND

Medication is the mainstay of treatment for schizophrenia. Many people with schizophrenia, however, continue to experience symptoms in spite of medication and may experience side effects that are unwanted and unpleasant. In addition to medication additional forms of treatment include talking therapies such as cognitive behavioural therapy. This approach helps to link the person's feelings and patterns of thinking which underpin distress.

OBJECTIVES

To review the effectiveness of cognitive behavioural therapy for people with schizophrenia, when compared to standard care, specific medication, other therapies and non-intervention.

SEARCH STRATEGY

Electronic searches of Biological Abstracts (1980-1998), CINAHL (1982-1998), The Cochrane Library (Issue 2, 1998), The Cochrane Schizophrenia Groups' Register of Trials, which encompasses up to date searches of all listed databases (January 2001), EMBASE (1980-1998), MEDLINE (1966-1998), PsychLIT (1887-1997), SIGLE (1990-1998), Sociofile (1980-1998) were undertaken. All references of the articles selected were searched for further relevant trials.

SELECTION CRITERIA

This review includes relevant randomised trials of cognitive behaviour therapy for people with a diagnosis of schizophrenia-like illnesses. Outcomes such as death, mental state, relapse, psychological well-being and acceptability of treatment were sought.

DATA COLLECTION AND ANALYSIS

Studies were reliably selected and assessed for methodological quality. Data were extracted by two reviewers working independently. Dichotomous data were analysed on an intention-to-treat basis and continuous data with 65% completion rate are presented. Where possible, for dichotomous outcomes, a relative risk (RR) with the 95% confidence interval (CI) was estimated along with the number needed to treat statistic (NNT).

MAIN RESULTS

Twenty-two relevant papers describing thirteen trials were identified. Cognitive behavioural therapy in addition to standard care did not significantly reduce the rate of relapse and readmission to hospital when compared with standard care alone (medium term 1 RCT, N=61, RR 0.1 CI 0.01 to 1.7; long term 2 RCTs, N=123, RR 1.1 CI 0.8 to 1.5). A significant difference was observed, however, favouring cognitive behavioural therapy over standard care alone, in terms of being able to be discharged from hospital (1 RCT, N=62, RR 0.5 CI 0.3 to 0.9, NNT 3 CI 2 to 12). For 'no important improvement in mental state' data showed a significant difference favouring the cognitive behavioural therapy group over standard care alone when measured at 13 to 26 weeks (2 RCTs, N=123, RR 0.7 CI 0.6 to 0.9, NNT 4 CI 2 to 8). After one year the difference was no longer significant (3 RCTs, N=211, RR 0.95 CI 0.6 to 1.5). On continuous measures (BPRS, CPRS, Psychiatric Assessment Scale) data are not convincing of an effect. A cognitive behavioural therapy approach focusing on compliance may have some effects on insight and attitudes to medication, but the clinical meaning of these data is unclear. When compared with supportive psychotherapy, cognitive behavioural therapy had no effects on relapse rate and clinically meaningful improvements in mental state. Cognitive behavioural therapy combined with other psycho-social/educational interventions may decrease the numbers of people able to tolerate the intervention, at least under study conditions.

REVIEWER'S CONCLUSIONS

Cognitive behavioural therapy is a promising but under evaluated intervention. Currently, trial-based data supporting the wide use of cognitive behavioural therapy for people with schizophrenia or other psychotic illnesses are far from conclusive. More trials are justified, especially in comparison with a lower grade supportive approach. These trials should be designed to be both clinically meaningful and widely applicable.

Amisulpride for schizophrenia

BACKGROUND

The treatment of schizophrenia with old, 'typical' antipsychotic drugs such as haloperidol can be problematic, because many people treated with these drugs will suffer from movement disorders. Amisulpride is said to be an "atypical" antipsychotic which induces less movement disorder and which is effective for the negative symptoms of schizophrenia.

OBJECTIVES

To evaluate the effects of amisulpride as compared with placebo, typical and atypical antipsychotic drugs for schizophrenia.

SEARCH STRATEGY

The authors carried out electronic searches of Biological Abstracts (1982-1999), CINAHL (1982-1999), Cochrane Library (Issue 4, 1999), Cochrane Schizophrenia Group's Register (November 2000), EMBASE (1980-1999), LILACS(1982-1999), MEDLINE (1966-1999) and PsycLIT (1974-1999). They checked all identified studies for further trial citations, and sought these studies in the Science Citation Index. They also contacted authors of trials and the manufacturer of amisulpride.

SELECTION CRITERIA

All randomised controlled trials comparing amisulpride to placebo, typical or atypical antipsychotic drugs for schizophrenia or other non-affective serious mental illnesses.

DATA COLLECTION AND ANALYSIS

Data were independently extracted and analysed on an intention-to-treat basis. The relative risk (RR) and 95% confidence intervals (CI) of dichotomous data were calculated using a random effects model, and, where possible, the number needed to treat was calculated. Weighted mean differences (WMD) were calculated for continuous data.

MAIN RESULTS

This review currently includes 19 randomised studies with a total of 2443 participants. Most trials were of short duration. Data from 4 trials with 514 participants with predominantly negative symptoms suggest that low-dose (up to 300mg/day) amisulpride was a more acceptable treatment than placebo (n=514, RR 0.6 CI 0.5 to 0.8, NNT 3 CI 3 to 7), the improvement of the participants' global state (n=242, RR 0.6 CI 0.5 to 0.8, NNT 3 CI 2 to 6) and the treatment of negative symptoms (n=177, WMD -10.1 CI -16.6 to -3.5). Amisulpride was shown to be more likely to cause extrapyramidal symptoms than placebo in two studies (n=269, RR 2.2 CI 1.2 to 4.2), but this result did not hold calculating the risk reduction so that an NNT-statistic could not be indicated. Compared to typical antipsychotics, the pooled results of a total of fourteen trials suggest that amisulpride was more effective in improving global state (n=651, RR 0.7 CI 0.5 to 0.9, NNT 6 CI 4 to 11), the general mental state (n=695, WMD -4.2 CI -6.5 to -1.9) and the negative symptoms of schizophrenia (n=506, WMD -2.8 CI -4.3 to -1.3). Regarding positive symptoms, amisulpride was as effective as typical antipsychotics. Amisulpride was less prone to cause at least one general adverse event (n=751, RR 0.9 CI 0.8 to 0.97, NNH 9 CI 6 to 18), one extrapyramidal symptom (n=771, RR 0.7 CI 0.6 to 0.9, NNH 5 CI 4 to 9) or to require the use of antiparkinson medication (n=851, RR 0.6 CI 0.5 to 0.8, NNH 4 CI 3 to 6). No clear differences in other adverse events compared to typical drugs were found. Amisulpride also seemed to be more acceptable than conventional drugs as measured by the outcome 'leaving the studies early' (n=1512, RR 0.8 CI 0.7 to 0.9, NNT 16 CI 9 to 69) than conventional drugs, but this result might have been overestimated due to a publication bias which could not be excluded with certainty. A single trial compared amisulpride to another 'atypical' antipsychotic, risperidone. With the exception of agitation, which was more frequent in the amisulpride group (n=228, RR 3.4 CI 1.2 to 10.1, NNH 11 CI 6 to 50) no significant differences were recorded on efficacy or acceptability.

REVIEWER'S CONCLUSIONS

This systematic review confirms that amisulpride is an effective 'atypical' antipsychotic drug for those with schizophrenia. Amisulpride may offer a good general profile, at least compared to high-potency 'typical' antipsychotics. It may also yield better results in some specific outcomes related to efficacy, such as improvement of global state and general negative symptoms. It might be more acceptable and more tolerable than high-potency conventional antipsychotics, especially regarding extrapyramidal side-effects. Longer term randomised trials are needed to evaluate the comparative value of amisulpride, particularly compared to other expensive atypical antipsychotics. These should focus on important outcomes which have not been sufficiently monitored such as service use, family burden and quality of life.

Comorbid non-alcohol substance misuse among people with schizophrenia: epidemiological study in central London

BACKGROUND

Few epidemiological studies have assessed the extent and nature of comorbid non-alcohol substance misuse in people with schizophrenia in the community in the UK.

AIMS

To study the extent and nature of comorbid non-alcohol substance misuse in people with schizophrenia in central London.

METHOD

Subjects were identified in an epidemiological census survey of South Westminster. Standardised assessment of each subject included demographic data, ratings of mental state and movement disorder and questioning about drug and alcohol misuse.

RESULTS

Individuals with schizophrenia or related psychoses were identified (n=352) and 57 (16%) reported a lifetime history of non-alcohol substance misuse. Age and gender were the main variables relevant to the extent and pattern of misuse. Self-reported non-alcohol substance misuse showed no significant relationship with a range of outcome measures.

CONCLUSIONS

The high proportion of subjects reporting non-alcohol substance misuse is comparable with figures from the USA. The reports of lifetime misuse most commonly referred to cannabis, psychostimulants, LSD, opiates and anticholinergics. Misuse was concentrated in those younger than 36 years and was reported more often by males.

Quality of life and treatment costs in schizophrenic outpatients, treated with depot neuroleptics

Study aim was 1) to find out the influences on quality of life (QoL) of chronic outpatients with schizophrenia; 2) to calculate Quality Adjusted Life Years (QALY); and 3) to estimate direct 1-year treatment costs. In a 20% sample (100 males, 100 females) of schizophrenic outpatients from the Outpatients Clinic in Ljubljana, Slovenia receiving depot neuroleptics demographic, clinical, and treatment data were collected for the year 1996. The Krawiecka Scale, Global Assessment Scale (GAS), Abnormal Involuntary Movement Scale, Rating Scale for Drug-Induced Akathisia, Rating Scale for Extrapyramidal Side Effects, Quality of Life Scale (QLS), EQ-5D and QALY were used. Multivariate linear regression was used with the QLS score as dependent variable. The patients were on average 44 years old and had been treated for 14 years. The average GAS score was 70. GAS was positively related to the QLS score while the parkinsonism score was inversely correlated with QLS. The patients can expect to live for 10. 20 more QALY on average. The QoL on the EQ-5D scale was 0.73. The annual direct treatment costs amounted to $216,216 in 1996 prices. In well-adjusted chronic patients with schizophrenia the QoL seems to depend mostly on their psychosocial performance and side effects. Although rare, re-hospitalisations accounted for one-half of all treatment expenses.

Summer birth and deficit schizophrenia in Nithsdale, Scotland

Patients with deficit schizophrenia differ from other people with schizophrenia relative to course of illness, treatment response, and neurobiological correlates. An association between deficit schizophrenia and summer birth, in contrast to the winter birth risk factor associated with schizophrenia as a whole, has also been reported. We attempted to replicate the association between summer birth and deficit schizophrenia by using data from a prevalence survey in Nithsdale in southwest Scotland, in which all patients with schizophrenia in Nithsdale were identified and 87% were interviewed directly. Deficit schizophrenia was associated with summer birth, defined as birth in June/July/August (p < .02), June/July (p < .02), or July/August (p < .03). The association with summer birth is consistent with other evidence that patients with deficit schizophrenia have a pathophysiology that differs in some ways from that of other patients with schizophrenia.

The use of outcome measures to evaluate the efficacy and tolerability of antipsychotic medication: a comparison of Thorn graduate and CPN practice

Assessing the tolerability and efficacy of treatment with antipsychotic medication is a vital part of mental health care. Research has suggested that many side-effects go undetected by clinicians and there is a need to use standardized assessment tools to ensure that treatments are comprehensively evaluated. The training of Community Psychiatric Nurses (CPNs), who provide much of patients' care, should focus on enhancing skills in using such assessments. This study aimed to examine differences in the use of standardized assessments of antipsychotic side-effects and psychopathology by CPNs and Thorn graduates who had received additional training in delivering psychosocial interventions. A questionnaire was sent to 240 Thorn graduates and CPNs practising in England, with an overall adjusted response rate of 54%. Thorn graduates reported using significantly more standardized assessments of side-effects and psychopathology than CPNs. A trend in both groups towards the use of measures that relied on patient self-report of side-effects was observed. This study identified important deficiencies in current CPN practice. A programme of targeted training may be a more realistic and efficient method of enhancing medication management practices in large numbers of CPNs compared to the more expensive and time-consuming Thorn programme.

Cognitive therapy for psychosis in schizophrenia: an effect size analysis

We conducted a meta-analysis using all available controlled treatment outcome studies of cognitive therapy (CT) for psychotic symptoms in schizophrenia. Effect sizes were calculated for seven studies involving 340 subjects. The mean effect size for reduction of psychotic symptoms was 0.65. The findings suggest that cognitive therapy is an effective treatment for patients with schizophrenia who have persistent psychotic symptoms. Follow-up analyses in four studies indicated that patients receiving CT continued to make gains over time (ES=0.93). Further research is needed to determine the replicability of standardized cognitive interventions, to evaluate the clinical significance of cognitive therapy for schizophrenia, and to determine which patients are most likely to benefit from this intervention.

A survey of female patients in high security psychiatric care in Scotland

BACKGROUND: The State Hospital, Carstairs, is the sole high security psychiatric facility for Scotland and Northern Ireland. METHOD: This study compares the female (n = 28) and male (n = 213) patients resident there between 1992 and 1993 using data derived from case-note reviews and interviews with patients and staff. RESULTS: Nearly three-quarters of both the male and female populations had a primary diagnosis of schizophrenia, and secondary diagnoses of substance abuse and antisocial personality disorder were common. Female patients were more frequently admitted from other psychiatric hospitals, had less serious index offences and more minor previous convictions, and were less likely to be subject to a restriction order. They had more often experienced depressive symptoms and had significantly greater histories of self-harm, physical and sexual abuse. At interview, nearly three-quarters had active delusions and over half had recently behaved in an aggressive manner. Almost 90% were said not to require the security of the State Hospital. CONCLUSIONS: It was concluded that mental illness and adverse social circumstances had combined to create a very disadvantaged group of women in high security psychiatric care in Scotland. As a group these women were inappropriately placed and their requirement was for intensive, rather than high security psychiatric care.

Costs and characteristics of heavy inpatient service users in outer London

"Heavy users" is a new term often used to describe those who occupy a disproportionate number of psychiatric beds. In this study we identified the heaviest 10% (193) inpatient service users in one London borough over a 6 year period and compared these with a control group of 400 ordinary inpatient users. A weighting index was used to combine frequency of admission with duration. Heavy users were diagnostically and demographically similar to ordinary inpatient service users and only differed by their extensive use of services, about 3 times more than ordinary users in terms of health care costs, during the measured year. Their heavy use mainly depended on occupying hospital beds, and their use of outpatient, day patient and community services was relatively light.

Use of quantitative rating scales to assess outcome in schizophrenia prevention studies

OBJECTIVE

To present a summary of quantitative scales relevant to schizophrenia prevention studies.

METHOD

Fifteen scales were reviewed and summarised in terms of structure, domains assessed, previous use and psychometric properties. Instruments of symptom measurement, role functioning and global functioning were considered, along with multidimensional instruments and other scales of potential interest to research in schizophrenia prevention.

RESULTS AND CONCLUSIONS

No scales of potential value in measuring premorbid risk for schizophrenia have been sufficiently tested for reliability and validity in the context of primary prevention of schizophrenia. The absence of a sufficiently sensitive and specific means for identifying those at high risk of schizophrenia before the onset of psychosis is a major barrier to valid measurement of the outcome of attempts at primary prevention. However, there have been advances in the development of instruments relevant to the goals of secondary and tertiary prevention. Most studies use instruments developed for patients with established psychoses and have applied them to early psychosis groups with some success, although possible 'floor' effects may confound measurement in the 'prodromal' period.

Changes in regional cerebral blood flow due to cognitive activation among patients with schizophrenia

BACKGROUND

The regional cerebral blood flow (rCBF) response to the Wisconsin Card Sort Test (WCST) has been used to assess the functional integrity of the prefrontal cortex in patients with schizophrenia.

AIMS

In this study, patients were divided into two groups according to whether they had made few or many perseverative errors on a modified version of the WCST. A control group consisted of normal volunteers. The groups were then compared with respect to rCBF response to WCST activation.

METHOD

rCBF was measured during administration of a modified version of the WCST and during a card sorting control task, using single photon emission computerised tomography (SPECT).

RESULTS

Performance of the modified WCST was associated with a widespread and substantial increase in rCBF, particularly in the frontal region. The poorly performing group of patients with schizophrenia showed only a modest increase in rCBF in the left anterior cingulate region.

CONCLUSION

Subjects with schizophrenia are able to respond to specific neuropsychological challenge with activation of the frontal regions.

The relationship between cognitive inhibition and psychotic symptoms

Cognitive models of schizophrenia have highlighted deficits of inhibitory attentional processes as central to the disorder. This has been investigated using "negative priming" (S. P. Tipper, 1985), with schizophrenia patients showing a reduction of negative priming in a number of studies. This study attempted to replicate these findings, but studied psychotic symptoms rather than the broad diagnostic category of schizophrenia. Psychotic individuals exhibiting positive symptoms were compared with asymptomatic psychiatric patients and with a normal control group. As predicted, the symptomatic group failed to show the usual negative priming effect, which was present in the asymptomatic and normal groups. A modest but significant correlation was found between negative priming and delusions. Neither diagnosis, nor affective or negative symptoms, nor chronicity, nor medication, was related to negative priming. These data replicate previous findings that positive symptoms are related to a reduction in cognitive inhibition, although considerable variability was observed among the psychotic patients.

Cognitive therapy and recovery from acute psychosis: a controlled trial. 3. Five-year follow-up

BACKGROUND

This paper describes the 5-year outcome of a cohort of patients who had received a cognitive therapy intervention during an acute episode of non-affective psychosis.

METHOD

Thirty-four out of the original 40 patients who had taken part in a randomised controlled trial of a cognitive intervention were assessed, using standardised instruments completed at entry into the study. In the original trial, half the patients received a cognitive therapy programme (CT group) and the other half received recreational activities and support (ATY group).

RESULTS

At follow-up no significant differences in relapse rate, positive symptoms or insight between the groups were found, although the CT group did show significantly greater perceived 'Control over illness' than the ATY group. For individuals who had experienced a maximum of one relapse in the follow-up period, self-reported residual delusional beliefs and observer-rated hallucinations and delusions were significantly less in the CT than in the ATY group.

CONCLUSION

Cognitive therapy applied in the acute phase of a psychotic disorder can produce enduring and significant clinical benefits if experience of relapse can be minimised.

[Therapeutic needs in psychiatric patients: a systematic review of the literature. I. General concepts and assessment measures. Needs for services]

OBJECTIVE

In Italy, mental health care is in phase of reorganisation. In this frame the measurement of users' needs may be a useful tool in planning individualised mental health service interventions and in their evaluation. Aims of the present study are (I) to highlight the basic concepts of 'needs for care' and give a brief description of the main needs assessment tools specifically developed for psychiatric patients; (II) to review studies assessing needs for mental health services in the general population; (III) to discuss the role played by the assessment of needs in planning mental health care.

METHODS

Studies published in the international literature from January 1980 to June 1999 were reviewed. The studies were located through a computerised search of the databases MEDLINE and PsycLit; in addition, the reference lists of the studies located through the computerised search and the content of main international psychiatric journals were manually scanned in order to avoid possible omissions. Studies assessing needs for services and studies assessing needs on individual level were separately reviewed. Both groups of studies, in turn, were divided in studies assessing needs for mental health care in the general population and in psychiatric patients.

RESULTS

Although most studies on needs for services used indirect methodologies and employed quite heterogeneous experimental design, they provide at large overlapping results. In the general population, about 60%-70% of patients with anxiety, depression and other neurotic disorders and 30%-40% of psychotic patients do not receive any specialist mental health care, suggesting that the majority of subjects suffering from a psychiatric disorder do not receive the mental health care they need.

CONCLUSIONS

Unmet needs for services show a higher frequency in patients with neurotic and depressive disorders, indicating a shortage in services delivery that should be taken into account both by psychiatrists and mental health planners. Moreover, the finding that a large number of patients suffering from psychotic disorders do not receive any kind of mental health care is of particular relevance for planning mental health services, since these subjects are usually the most problematic and difficult to treat.

The expression of sexuality in people with psychosis: breaking the taboos

While mental health professionals should recognize that people suffering from schizophrenia have sexual and relationship requirements, there appears to be a failure to address adequately the subject of human sexuality, particularly in the area of psychosocial rehabilitation. The broad aim of this small study was to identify the sexual and relationship needs of people being cared for in hospital and preparing for a return to community living. The objectives of the study were to discover the clients' sexual expressions in the past and present, and to try to elicit hopes and aspirations for the future. An attempt was made to uncover some of the obstacles to the expression of sexuality and explore some of the clients' subjective experiences of the issues. The number of respondents was 11 from a possible 15. Data were collected through: a questionnaire on demographic characteristics; an adapted version of a questionnaire investigating the determinant factors of sexual behaviour through life; and a semi-structured interview devised to elicit subjective experiences regarding sexual expression. The findings show that people with psychotic illness are prepared to discuss issues relating to sex and relationship matters. No interviews had to be prematurely terminated. No exacerbations of symptoms were noted. All of the respondents showed an openness to discuss a range of intimate feelings. Most respondents seemed hopeful about the opportunity to form intimate and fulfilling relationships in the future. A drive towards more rigorous holistic nursing assessments and appropriate psychosocial responses is proposed.

Prospective controlled study of psychiatric out-patient non-attendance. Characteristics and outcome

BACKGROUND

Psychiatric clinics have high non-attendance rates and failure to attend may be a sign of deteriorating mental health.

AIMS

To investigate why psychiatric out-patients fail to attend, and the outcome of attenders and non-attenders.

METHOD

Prospective cohort study of randomly selected attenders and non-attenders at general adult psychiatric out-patient clinics. Subjects were interviewed at recruitment and severity of mental disorder and degree of social adjustment were measured. Six and 12 months later their engagement with the clinic and any psychiatric admissions were ascertained.

RESULTS

Of the 365 patients included in the study, 30 were untraceable and 224 consented to participate. Follow-up patients were more psychiatrically unwell than new patients. For follow-up patients, non-attenders had lower social functioning and more severe mental disorder than those who attended. At 12-month follow-up patients who missed their appointment were more likely to have been admitted than those who attended.

CONCLUSIONS

Those who miss psychiatric follow-up out-patient appointments are more unwell and more poorly socially functioning than those who attend. They have a greater chance of drop-out from clinic contact and subsequent admission.

Depot haloperidol decanoate for schizophrenia

BACKGROUND

The mainstay of treatment for schizophrenia is the antipsychotic group of drugs. These are usually given orally but compliance with medication given by this route may be difficult to quantify. Problems with treatment adherence are common. The development of depot injections in the 1960s gave rise to their extensive use as a means of long-term maintenance treatment. Haloperidol decanoate is one depot drug available in clinical practice.

OBJECTIVES

To assess the effects of haloperidol decanoate versus oral anti-psychotics and other depot antipsychotic preparations for people with schizophrenia in terms of clinical, social and economic outcomes.

SEARCH STRATEGY

Relevant trials were identified by searching Biological Abstracts (1982-1998), Cochrane Library (Issue 2, 1998), Cochrane Schizophrenia Group's Register (June 1998), EMBASE (1980-1998), MEDLINE (1966-1998) and PsycLIT (1974-1998). References of all identified trials were also inspected for more studies.

SELECTION CRITERIA

All relevant randomised trials focusing on people with schizophrenia where haloperidol decanoate, oral anti-psychotics or other depot preparations were compared. Outcomes such as death, clinically significant change in global function, mental state, relapse, hospital admission, adverse effects and acceptability of treatment were sought.

DATA COLLECTION AND ANALYSIS

Studies were reliably selected, quality rated and data extracted. For dichotomous data Mantel-Haenszel odds ratios (OR) with the 95% confidence intervals (CI) were estimated. Where possible, the number needed to treat statistic (NNT) was calculated. Analysis was by intention-to-treat. Normal continuous data were summated using the weighted mean difference (WMD). Scale data were presented only for those tools that had attained pre-specified levels of quality.

MAIN RESULTS

In a haloperidol decanoate versus placebo comparison, two small studies reported that significantly fewer people on depot left early (OR 0.09 CI 0.03-0.21, NNT 2 CI 1-3) or experienced no important improvement in mental state (OR 0. 04 CI 0.01-0.15). Zississ (1982) suggested that those taking haloperidol decanoate would need less additional antipsychotic medication (OR 0.14 Cl 0.04-0.55, NNT 2 CI 1-5). Haloperidol decanoate was compared to oral haloperidol in a single trial that showed no differences in global impression, mental state or side effects ( approximately approximately Zuardi 1983 approximately approximately , n=22). Compliance with medication was not reported in this study. Eight trials compared haloperidol decanoate to other depot neuroleptics and again no differences were found for the outcomes of death, global impression, mental state, behaviour, or side effects.

REVIEWER'S CONCLUSIONS

Haloperidol decanoate may have a substantial effect in improving the symptoms and behaviour associated with schizophrenia in comparison to placebo, but data are remarkably sparse. There are no discernible differences between the depot form of haloperidol and its oral equivalent. For those needing and willing to take the drug, the means of administration is then a matter of individual choice and clinical judgement. As there are no clear differences between haloperidol decanoate and other depots, the choice of depot medication could also be individually tailored and patient preference exercised. Well-conducted and reported randomised trials are needed comparing haloperidol decanoate with other depots but the comparison of haloperidol decanoate to oral antipsychotics is a priority.

Zuclopenthixol decanoate for schizophrenia and other serious mental illnesses

BACKGROUND

There is a clear link between stopping antipsychotic medications and a relapse of psychotic symptoms. A series of long-acting intra-muscular preparations has been developed since the 1960s in the hope of reducing the frequency of relapse and, hence, overall disability. These depot preparations, active for weeks at a time, are frequently used for those who find taking oral medication on a regular basis difficult or unacceptable. It has, however, been a consistent concern that any reduction in relapse rate afforded by depot preparations may be offset by an increase in adverse effects such as drug-induced movement disorders.

OBJECTIVES

To compare zuclopenthixol decanoate to oral zuclopenthixol and other antipsychotic preparations for the treatment of schizophrenia and similar serious mental illness.

SEARCH STRATEGY

Electronic searches of Biological Abstracts (1982-1998), CINAHL (1982-1998), The Cochrane Library (Issue 2, 1998), The Cochrane Schizophrenia Group's Register (April 1998), EMBASE (1980-1998), MEDLINE (1966-1998), and PsycLIT (1974-1998) were searched. References of all eligible studies were searched for further trials. The manufacturer of zuclopenthixol was contacted.

SELECTION CRITERIA

Inclusion criteria were that the clinical study should be randomised, focus on people with schizophrenia or other serious mental illness with psychotic symptoms, and compare the use of zuclopenthixol decanoate to oral zuclopenthixol or other antipsychotic preparations.

DATA COLLECTION AND ANALYSIS

Data was extracted independently by two reviewers (EC, MF). Authors of trials were contacted for additional and missing data. Odds ratios (ORs) and 95% confidence intervals (CIs) of homogenous dichotomous data were calculated with the Peto method. Where possible the number needed to treat (NNT) and its 95% confidence interval was also calculated.

MAIN RESULTS

Four studies relating to zuclopenthixol decanoate were included. All compared zuclopenthixol decanoate with other depot preparations. Zuclopenthixol decanoate prevented or postponed relapses when compared to other depots (NNT 8, CI 5-53). However, zuclopenthixol decanoate may induce more adverse effects (NNH 5, CI 3-31) although it decreases need for anticholinergic medication when compared to a group of other depot preparations (NNT 9, CI 5-38). For the risk of leaving the study early, there was also a trend for benefit to those allocated to zuclopenthixol decanoate. None of the studies reported outcomes on service utilisation, costs, or quality of life.

REVIEWER'S CONCLUSIONS

Choice of which depot to use must always take into account clinical judgement and the preferences of the recipients of care and their carers. Limited trial data suggests, however, that there are real differences between zuclopenthixol decanoate and other depots and these differences largely favour the former. This review highlights the need for good controlled clinical trials to fully address the effects of zuclopenthixol decanoate for those with schizophrenia. Future studies should report service utilisation data, as well as satisfaction with care and economic outcomes. Duration of such trials should be of a longer duration than the included studies (12 months or more).

Sulpiride for schizophrenia

BACKGROUND

The antipsychotic drug sulpiride was formulated over 20 years ago and was marked as having a 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 estimate the clinical efficacy and tolerability of sulpiride.

SEARCH STRATEGY

Electronic searches of Biological Abstracts (1982-1997), CINAHL (1982-1998), Cochrane Schizophrenia Group's Register (March 1998), Cochrane Library (Issue 1, 1998), EMBASE (1980-1998), MEDLINE (1966-1998), PsycLIT (1974-1997), SIGLE (1994-1998), and Sociofile (1974-1997) were supplemented by reference searching, contacting authors and the manufacturers of sulpiride.

SELECTION CRITERIA

All randomised or quasi-randomised clinical trials focusing on the use of different doses of sulpiride or comparing sulpiride to (i) placebo; (ii) typical antipsychotic drugs; or (iii) atypical antipsychotic drugs, for those with schizophrenia or serious mental illness were selected.

DATA COLLECTION AND ANALYSIS

Trials were reliably selected and quality rated. Data were independently extracted, by two reviewers (BGOS, MF), and analysed on an intention-to-treat basis. It was assumed that people who did not complete the follow up had no improvement. Authors of trials were contacted for additional and missing data. Relative risk (RR) and 95% confidence intervals (CI) of dichotomous data were calculated with the random effects model and weighted mean difference (WMD) was calculated for continuous data.

MAIN RESULTS

The review currently includes 18 studies (30 citations). Studies are generally small and of poor quality. Limited evidence suggests that there is little difference between sulpiride and other drugs although the incidence of side effects may be less for sulpiride. There are no clear findings relating to negative symptoms.

REVIEWER'S CONCLUSIONS

Sulpiride may be an effective antipsychotic drug but evidence is limited and data relating to claims for its value against negative symptoms is not trial-based.

Functional anatomy of verbal fluency in people with schizophrenia and those at genetic risk. Focal dysfunction and distributed disconnectivity reappraised

BACKGROUND

PET studies of verbal fluency in schizophrenia report a failure of 'deactivation' of left superior temporal gyrus (STG) in the presence of activation of left dorsolateral prefrontal cortex (DLPFC), which deficit has been attributed to underlying 'functional disconnectivity'.

AIM

To test whether these findings provide trait-markers for schizophrenia.

METHOD

We used H2(15)O PET to examine verbal fluency in 10 obligate carriers of the predisposition to schizophrenia, 10 stable patients and 10 normal controls.

RESULTS

We found no evidence of a failure of left STG deactivation in carriers or patients. Instead, patients failed to deactivate the precuneus relative to other groups. We found no differences in functional connectivity between left DLPFC and left STG but patients exhibited significant disconnectivity between left DLPFC and anterior cingulate cortex.

CONCLUSIONS

Failure of left STG 'deactivation' and left fronto-temporal disconnectivity are not consistent findings in schizophrenia; neither are they trait-markers for genetic risk. Prefrontal functional disconnectivity here may characterise the schizophrenic phenotype.

Gamma-aminobutyric acid agonists for neuroleptic-induced tardive dyskinesia

BACKGROUND

Chronic antipsychotic drug treatment may cause tardive dyskinesia (TD), a long-term movement disorder. The gamma-aminobutyric acid (GABA) agonist drugs have been trialed as a treatment for TD, but these drugs have intense sedative properties and can possibly exacerbate psychotic symptoms.

OBJECTIVES

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

SEARCH STRATEGY

Electronic searches of Biological Abstracts (1982-1998), The Cochrane Library CENTRAL (1998), Cochrane Schizophrenia Group's Register of Trials (1998), EMBASE (1980-1998), LILACS (1982-1996), MEDLINE (1966-1998), PsycLIT (1974-1998), and SCISEARCH were undertaken. References of all identified studies were searched for further trial citations. First authors of each included trial were contacted.

SELECTION CRITERIA

The inclusion criteria for all relevant randomised studies were that they should focus on people with schizophrenia or other chronic mental illnesses, with neuroleptic-induced TD and compare the use of GABA agonist drugs to placebo or no intervention.

DATA COLLECTION AND ANALYSIS

The reviewers extracted the data independently and the odds ratio (OR) and its 95% confidence interval (CI) or the weighted mean difference with 95% CI were estimated. The reviewers assumed that people who dropped out had no improvement.

MAIN RESULTS

Eight studies were able to be included. Results were equivocal, showing only a tendency for clinical improvement for those using GABA agonist drugs but, when analysis of any improvement (rather than clinical improvement) was performed, a significant reduction was noted in the GABA group (OR 0.36 CI 0.15-0.85). This suggests that for every 10 people treated with GABA drugs one person would benefit with a reduction in TD symptoms. People using the interventions had more confusion (OR 7.4 CI 1.3-40.9) and sedation (OR 3.0 CI 1.2-7.6). The numbers of people needed to treat to cause one extra person to experience these side effects were three and six, respectively. Tendency for more deterioration of the TD symptoms (OR 1.72 CI 0. 54-5.5), deterioration of the mental state (OR 3.07 CI 0.78-12.05), and to drop out before the end of the trial (OR 2.05 CI 0.8-5.21) were also observed in those using GABA agonists.

REVIEWER'S CONCLUSIONS

No clear statement about the efficacy of GABA agonist drugs could be provided. From the combined data, GABA agonist drugs tend to be associated with some degree of improvement in TD symptoms, but also with side effects such as confusion and sedation and a deterioration of the person's mental state.

Depot flupenthixol decanoate for schizophrenia or other similar psychotic disorders

BACKGROUND

Anti-psychotic drugs are the mainstay treatment for schizophrenia and similar psychotic disorders. Long-acting depot injections of drugs such as flupenthixol decanoate are extensively used as a means of long-term maintenance treatment.

OBJECTIVES

To evaluate the effects flupenthixol decanoate in comparison with placebo, oral antipsychotics and other depot neuroleptic preparations for people with schizophrenia and other severe mental illnesses, in terms of clinical, social and economic outcomes.

SEARCH STRATEGY

Relevant trials were identified by searching Biological Abstracts (1982-1998), Cochrane Library (Issue 2, 1998), Cochrane Schizophrenia Group's Register (December 1998), EMBASE (1980-1998), MEDLINE (1966-1998) and PsycLIT (1974-1998). The references of all identified trials were inspected for more studies and the first author of each included trial and relevant pharmaceutical companies were contacted.

SELECTION CRITERIA

All randomised controlled trials that focused on people with schizophrenia or other similar psychotic disorders where flupenthixol decanoate had been compared to placebo or other antipsychotic drugs. All clinically relevant outcomes were sought.

DATA COLLECTION AND ANALYSIS

Studies were reliably selected, quality rated and data extracted. For dichotomous data Peto odds ratios (OR) with 95% confidence intervals (CI) were estimated. Where possible, the number needed to treat statistic (NNT) was also calculated. Analysis was by intention-to-treat. Normal continuous data were summated using the weighted mean difference (WMD). Scale data were presented only for those tools that had attained pre-specified levels of quality.

MAIN RESULTS

No trials compared flupenthixol decanoate to placebo. One small study compared flupenthixol decanoate with an oral antipsychotic (penfluridol). There were no clear differences between the two preparations. When flupenthixol decanoate was compared to other depot preparations, there were no differences between depots for outcomes such as death, global impression, relapse (OR 1.16 CI 0.7-1.9) or leaving the study early (OR 1.00 CI 0.6-1.7). Two small studies suggest that flupenthixol decanoate is responsible for less movement disorders than other depot antipsychotic drugs (OR 0.23 CI 0.08-0.7, NNT 5). This finding did not hold for specific side effects, such as tremor (OR 1.2 CI 0.3-4) and tardive dyskinesia (OR 1.60 CI 0.4-6). Two trials comparing high doses of flupenthixol decanoate to the standard approximately 40mg per injection reported no significant difference for the outcome of relapse (OR 0.32 CI 0.09-1.2). One small (n=59) trial comparing a very low dose of flupenthixol decanoate ( approximately 6 mg/IM) to a very low dose approximately 9 mg per injection also reported no difference in relapse rates (OR 0.3 CI 0.1-1.1).

REVIEWER'S CONCLUSIONS

From the data reported in clinical trials, it would be understandable if those suffering from schizophrenia, who are willing to take flupenthixol decanoate, would request the standard dose rather than the high dose. In the current state of evidence, there is nothing to choose between flupenthixol decanoate and other depot antipsychotics. The choice of which depot to use must therefore be based on clinical judgement and the preferences of people with schizophrenia and their carers. Managers and policy makers should expect better data than the research community has provided thus far. This review highlighted the need for large, well-designed and reported randomised clinical trials to address the effects of flupenthixol decanoate, in particular when compared to oral antipsychotics. Future studies should also consider hospital and service outcomes, satisfaction with care and record economic data.

Can a standardized needs assessment be used to improve the care of people with severe mental disorders? A pilot study of 'needs feedback'

The care programme approach (CPA) was introduced in the United Kingdom in 1991 to ensure that the needs of people with mental health problems are met appropriately. Many community psychiatric nurses (CPNs) act as 'key workers' under the CPA. Recent evidence suggests that the CPA is not particularly effective at meeting the needs of this vulnerable group, but it might be possible to enhance the CPA by introducing a more 'needs-led' approach to the planning of nursing care. 'Needs feedback' is a technique for enhancing the CPA. Needs feedback begins with a standardized assessment of patients' psychiatric and social needs by a nurse specialist. The patient's CPN is then provided with information on: (a) the needs identified; (b) why these needs have been identified; (c) the interventions required to meet the identified needs; and (d) how these interventions may be obtained. In the pilot study reported in this paper, 20 patients with severe mental disorder were evaluated before and after their CPN received needs feedback. All patients were living in the community and being managed by CPNs under the CPA. Outcome was assessed 6 months after the feedback in terms of: mental state, social behaviour and number of 'unmet' needs. Needs feedback was found to be compatible with the CPA in that it proved acceptable to CPNs and patients. Significant improvements were seen in the number of 'unmet' needs and the level of anxious/depressive symptoms. Improvements approaching significance were seen for social functioning and negative psychiatric symptoms, but not for positive psychiatric symptoms. This pilot study suggests that needs feedback may improve the quality of nursing assessment and care planning within the CPA. Further controlled investigations of needs feedback are justified.

Community care for long-stay psychiatric patients: need- or policy-driven?

This paper describes an economic analysis undertaken as part of an evaluation of mental health services in Clwyd. This project was conducted in response to the decision to close the North Wales Hospital, Denbigh; a long-stay psychiatric hospital. Cost data were collected in both the hospital setting and subsequent community care settings. These data are compared with effectiveness data developed in other parts of the overall project in order to place the discussion in a cost effectiveness framework. Little significant difference in care effectiveness between hospital and community settings is identified, although minor improvements in some aspects for some patients are noted. However, there are considerable changes in the care costs. The cost estimates show that old long-stay patients cost more to care for in the community than the new long-stay patients, whilst in hospital they had cost less. In addition, the results highlight the significant influence of pay scales and capital funding on cost of care. The paper concludes that the cost of care is substantially affected by non-needs-driven policy decisions as well as by direct patient needs.

Smoking habits, current symptoms, and premorbid characteristics of schizophrenic patients in Nithsdale, Scotland

OBJECTIVE

Previous studies of smoking habits of schizophrenic patients have found rates as high as 88%. The authors report the smoking habits of all known schizophrenic patients within a discrete geographical area and compare them with the smoking habits of a general population sample.

METHOD

All known schizophrenic patients in Nithsdale in South-West Scotland (N = 168) were invited to complete a questionnaire on smoking habits. Also assessed were mental state, drug-related side effects, and premorbid childhood personality and social adjustment.

RESULTS

One hundred thirty-five of the 168 patients returned the questionnaires. The rate of smoking among the patients was 58% (N = 78), compared with 28% in the general population. Sixty-eight percent of the patients who smoked (N = 53) had 25 or more cigarettes per day. The mean age at starting smoking was 17 years in both patients and normal subjects. Ninety percent of the patients who smoked (N = 70) started smoking before the onset of schizophrenia. Patients who smoked were younger than nonsmokers, and more of them were male. They had had more hospitalizations, and more were in contact with psychiatric services. More were receiving intramuscular antipsychotic medication. Smokers had poorer childhood social adjustment. Among the female patients, there was a positive correlation between age at starting smoking and age at onset of schizophrenia.

CONCLUSIONS

The rate of smoking and level of nicotine addiction are greater in schizophrenic patients than in the general population. Smoking may be a marker for the neurodevelopmental form of the illness and may be another environmental risk factor for schizophrenia in vulnerable individuals.

Does a four-week delay in the introduction of medication alter the course of functional psychosis?

This study is an analysis of findings of a follow-up study of 105 patients with functional psychotic illness who had participated in a random and blind 4-week trial of pimozide, lithium, both and placebo. The intention was to examine the question of whether a 4-week delay in initiating antipsychotic treatment has a detrimental effect 2.5 years later. Detailed follow-up measures included need for care over the 2.5 years, treatments required, occupational decline, police contact, substance misuse, psychopathology and cognitive function. There was no evidence at all that those initially randomized to placebo had a poorer outcome in terms of any of these variables. It is concluded that a 4-week delay in initiating active treatment in patients with functional psychosis has no long-term adverse effects.