Measurement of therapeutic response in schizophrenia. A critical survey

Multiple-outcome criteria in schizophrenia: an overview of outcome with clozapine

The outcome of treatment in schizophrenia is best considered as a multidimensional construct. This report lists thirteen categories of outcome measures that have been studied in schizophrenia research, among the most important of which are psychopathology, cognitive function, interpersonal social function, quality of life, extrapyramidal function, the suicide tendeccy and the need for hospitalisation. Clozapine is effective in achieving improved outcome in all these measures in a high percentage of neuroleptic-resistant patients. Ninety-two of 180 (51.1%) clozapine-treated neuroleptic-resistant patients achieved a decrease of 20% in Brief Psychiatric Rating Scale total scores at six weeks using the 0–6 scaling system. Cognitive function contributes importantly to overall function for schizophrenia. Clozapine has been shown to improve some types of cognition in schizophrenia, especially semantic memory and some tests of executive function. Clozapine has also been shown to decrease the incidence of suicide and hospitalisation. The task of deciding which therapies to use in schizophrenia should encompass the spectrum of benefits of each therapy, their risks and costs, in relation to all alternatives.

Paranoid Thinking and Wellbeing. The Role of Doubt in Pharmacological and Metacognitive Therapies

INTRODUCTION

Pathological confidence in one's thoughts is a key mechanism of chronic paranoid thinking. For this reason, many of the current therapies focus on trying to reduce it. In fact, the way some antipsychotics (e.g., haloperidol) work seems to be through the induction of doubt. Because of the impact of these pathological thoughts on positive health, studying the well-being of people who experience paranoid thoughts is fundamental. The first objective of this research is to apply the Complete State Model of Health (CSMH) to a sample of patients characterized by the presence of paranoid thinking. Our second objective is to evaluate the impact of therapies based on reducing pathological confidence on patients' well-being.

METHODS

Sixty participants with SCID-5 confirmed DSM-5 diagnosis related with paranoid thinking and without mood symptoms were recruited. In order to test the existence of a two continua model of mental health (CSMH), we conducted a parallel analysis and an exploratory factor analysis. To test our hypothesis regarding the partially mediating role of doubt between paranoid thinking and patients' well-being, we conducted a biased corrected bootstrapping procedure.

RESULTS

As expected, two different unipolar dimensions emerged from the measures used to assess paranoid thinking and positive health (two continua model of mental health). When patients received metacognitive and pharmacological treatment, more paranoid thinking led to more doubt in all thoughts, which in turn affected well-being. The analyses carried out confirmed the partial mediating role of doubt.

CONCLUSION

Despite the efficacy shown by both metacognitive therapies and antipsychotics, it seems that they not only reduce pathological confidence, but can also affect other thoughts not linked to delirium. This effect of generalization of doubt in all thoughts negatively affected patients' well-being and quality of life.

Correlations between self-rating and observer-rating of psychopathology in at-risk mental state and first-episode psychosis patients: influence of disease stage and gender

AIM

Research findings on the correlations between self-rating and observer-rating of schizophrenic psychopathology are inconsistent and have rarely considered first-episode psychosis (FEP) and at-risk mental state (ARMS) for psychosis patients. This study investigates these correlations in ARMS and FEP patients and how they are moderated by disease stage and gender.

METHODS

In the Basel Früherkennung von Psychosen (FePsy) study, positive and negative psychotic and affective symptoms were rated in 126 ARMS and 94 FEP patients using two observer- and three self-rating scales. The agreement between self-rating and observer-rating and the moderating influence of disease stage and gender was quantified using Pearson correlation and multiple regression models.

RESULTS

Correlations between self- and observer-rated subscales covering the same symptom dimension were low and mostly non-significant except for one correlation of positive and one of negative symptoms. There was no moderating influence of disease stage and gender on the correlations between self-rating and observer-rating except for one higher association in positive symptoms in FEP compared to ARMS and in women compared to men. However, these significant interaction effects did not withstand correction for multiple testing.

CONCLUSIONS

This study suggests that the agreement between self-rating and observer-rating in FEP and ARMS patients is rather low, similar across symptom dimensions, and only partially dependent on disease stage and gender. However, low correlations between self-rating and observer-rating do not necessarily indicate that these patients have difficulties reporting their symptoms. They could also have occurred because the scales did not exactly cover the same symptom dimensions.

Engaging People with Enduring Psychotic Conditions in Primary Mental Health Care and Occupational Therapy

For people who have enduring psychotic conditions, interventions need to improve social functioning as well as reducing clinical problems. There is also a need to engage and keep in touch with general practitioner (GP) patients who have fallen out of contact with specialist psychiatric care.

A new model of service was designed to engage this patient group: an expanded primary care team in an inner-city area. The team extended the GP role, provided occupational therapy and care management and used liaison psychiatry. A case study design with mixed methods was used to investigate the new service. This article reports the quantitative investigation of engagement, clinical and social outcomes and cost consequences.

The results showed that, at the start of the study, 37 people with psychotic conditions were in the sole care of their GPs; of these, 34 (92%) engaged with the new service. The sample of 28 receiving 12 months' interventions started with low levels of social functioning, which required intervention. Following interventions, they showed significant improvements in social functioning, clinical symptoms and Health of the Nation Outcome Scales (HoNOS). The costs were favourable when compared with similar services. The study suggests that expanded primary care, with occupational therapy and care management, can be a feasible service to improve people's engagement and functioning.

Quality of life in stabilized patients with schizophrenia is mainly associated with resilience and self-esteem

OBJECTIVE

Improving quality of life (QoL) is an important objective in the treatment of schizophrenia. The aim of the current study was to examine to what extent resilience, self-esteem, hopelessness, and psychopathology are correlated with QoL.

METHOD

We recruited 52 out-patients diagnosed with schizophrenia according to DSM-IV criteria and 77 healthy control subjects from the general community. In patients, psychopathology was quantified by the Positive and Negative Syndrome Scale. The following scales were used in both patients and control subjects: the Berliner Lebensqualitätsprofil, the Resilience Scale, the Rosenberg Self-Esteem Scale, and the Beck Hopelessness Scale to assess QoL, resilience, self-esteem, and hopelessness respectively.

RESULTS

Patients with schizophrenia presented with significantly less QoL, resilience, self-esteem, and hope compared to healthy control subjects. In patients, QoL correlated moderately with resilience, self-esteem, and hopelessness and weakly with symptoms. With respect to the latter, particularly depression and positive symptoms were negatively correlated with QoL.

CONCLUSION

Our results highlight the complex nature of QoL in patients suffering from schizophrenia. They underscore that significant efforts are necessary to enhance resilience and self-esteem and to diminish hopelessness as well as affective and positive symptoms in patients with schizophrenia.

Targets, attitudes, and goals of psychiatrists treating patients with schizophrenia: key outcome drivers, role of quality of life, and place of long-acting antipsychotics

PURPOSE

This survey of Italian psychiatrists was conducted to better define drivers of schizophrenia treatment choice in real-life practice, particularly for use of long-acting injectable (LAI) antipsychotics.

METHODS

Between October 15 and December 15, 2014, 1,000 surveys were sent to psychiatrists who treat schizophrenic patients; 709 completed questionnaires were analyzed (71% response rate).

RESULTS

The two most important factors determining therapy success were efficacy (75% of responses) and tolerability (45%) followed by global functioning (24%) and quality of life (17%). LAI antipsychotics were most often used to facilitate regular treatment monitoring (49%), and 41% of psychiatrists thought that patients with low adherence who had failed oral therapy were well-suited for LAI antipsychotics. Only 4% of respondents saw LAI antipsychotics as appropriate for patients without other therapeutic options.

CONCLUSION

Although efficacy and tolerability were the most common factors used to evaluate treatment success in schizophrenia, psychiatrists also consider QoL and global functioning to be important.

Outcome studies in schizophrenia

Objectives:To outline the limitations of traditional studies of outcome in schizophrenia and to review the findings arising from ‘first episode’ psychosis studies.

Method:An extensive literature search was performed and relevant papers were examined and analysed.

Results:Current knowledge regarding outcome predictors in schizophrenia has primarily been derived from a series of ‘consecutive admission’ and ‘long-term follow-back’ studies. However, methodological considerations may limit the generalisability of these studies' findings. The prospective evaluation of first episode cohorts has advanced our knowledge regarding the relative importance of premorbid and intercurrent factors in determining outcome in schizophrenia.

Conclusions:To date, the ‘first episode’ strategy has highlighted some potentially clinically modifiable outcome predictors. These findings may open the way for targeted introduction of measures aimed at preventing poor outcomes in schizophrenia.

Patient-reported outcome measures: are they patient-generated, patient-centred or patient-valued?

BACKGROUND

In the past two decades, there has been a growing interest in the development of a more patient-centred approach to assessing treatment outcomes. This interest has resulted in the increasing use of patient-reported outcome measures (PROMs) in both clinical trials and usual clinical practice.

AIMS

To briefly discuss the paucity of efficacy and effectiveness studies in the field of mental health (exemplified by schizophrenia, depression and opioid dependence) that significantly incorporate the patient's perspective. The limited concordance between the perspectives of patients and clinicians in outcome assessment is also addressed. Finally, we propose a new PROM classification system based on the degree to which these instruments incorporate the patient's perspective.

CONCLUSIONS

PROMs may differ little from traditional instruments unless they truly incorporate the patient's perspective and not just the perspectives of clinicians and researchers. Efforts to develop new PROMs that provide a more patient-centred outcome assessment should use qualitative and participatory methods to capture and incorporate patient perspectives and values.

Quality of life in parents of children with attention-deficit-hyperactivity disorder in Hong Kong

OBJECTIVE

There is no study on the quality of life (QOL) of parents of children with attention-deficit-hyperactivity disorder (ADHD), although QOL is increasingly gaining more attention and the interactions between children and their parents are bi-directional. The aim of the present study was therefore to survey the QOL of parents of children with ADHD in Hong Kong, and explore the relationships of sociodemographic and clinical variables with QOL.

METHOD

Seventy-seven parents of children with ADHD were consecutively selected and the sociodemographic and clinical characteristics of the parents and their children were assessed.

RESULTS

Compared with the general population in Hong Kong, significantly lower scores in physical, psychological, social and environmental QOL domains were found in the parents of children with ADHD. On multivariate analysis, for the children with ADHD, the severity of emotional and hyperactivity/inattention symptoms, and having a comorbid pervasive developmental disorder were significantly correlated with one or more domains of QOL; while for the parents, educational level, household monthly income and having major medical conditions were significantly correlated with one or more domains of QOL.

CONCLUSIONS

Parents of children with ADHD have low QOL and research is needed to understand the underlying problems.

Socio-demographic and clinical correlates of lifetime suicide attempts and their impact on quality of life in Chinese schizophrenia patients

This study determines the socio-demographic and clinical correlates of suicide attempts in Chinese schizophrenia outpatients and their impact on patients' quality of life (QOL). Two hundred and fifty-five clinically stable schizophrenia outpatients were randomly selected in Hong Kong (HK) and their counterparts matched according to sex, age, age at onset and length of illness were recruited in Beijing (BJ). All subjects at both sites were interviewed by the same investigator using standardized assessment instruments. Basic socio-demographic and clinical data and history of suicide attempts were collected. The lifetime prevalence of suicide attempts was 26.7% in the whole sample and 20% and 33.6% in the HK and BJ samples, respectively. Patients with a history of suicide attempts were less likely to receive depot antipsychotic (AP) medication, more likely to receive clozapine, benzodiazepines (BZD) and higher doses of APs; were younger at onset, had more hospitalizations; had more severe positive, depressive, anxiety and extrapyramidal (EPS) symptoms; were poorer QOL in the physical, psychological, social and environmental domains; and were more likely to be BJ residents. In multiple logistic regression analysis, early age at onset, poor physical QOL, use of clozapine and BZDs, and study site (HK vs BJ) were significant contributors to lifetime suicide attempts. Significant difference was found between matched samples in HK and BJ with respect to suicide attempts. HK is a cosmopolitan city with a Western social structure and mental health system, whereas in BJ more traditional Chinese cultural values predominate, with a mental health policy radically different from that of HK. These differences suggest that socio-cultural factors play a significant role in determining suicide attempts in schizophrenia.

Understanding the results of CATIE in the context of the field

The Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study was undertaken to provide a valid assessment of the differences between conventional and atypical antipsychotics and among the atypicals themselves in patients with schizophrenia. The CATIE investigators reported that while none of the study medications were ideal, olanzapine was the most effective in terms of treatment discontinuation, and there were no significant differences in effectiveness between the conventional antipsychotic perphenazine and the atypicals quetiapine, risperidone, and ziprasidone. Each drug differed slightly in rates of side effects, with more patients discontinuing perphenazine due to extrapyramidal side effects and more patients discontinuing olanzapine due to weight gain and metabolic effects. In order for data from phase 1 of the CATIE study to be interpreted within the appropriate context, physicians must understand how aspects of study design and statistical methods affect interpretation, and how this trial weighs against other data in the literature. This article enumerates the factors that complicate our understanding of the CATIE results and compares these findings with those from previously published meta-analyses. It is clear that therapeutic and side effects of antipsychotics vary from person to person. The goal of schizophrenia management is to maintain pharmacotherapeutic efficacy and tolerability over the long-term in order to maximize treatment adherence and benefits. What should emerge from CATIE is a renewed commitment to tailor schizophrenia treatment to the individual patient for long-term management.

Outcome on quality of life in a Canadian national sample of patients with schizophrenia and related psychotic disorders

OBJECTIVE

To examine changes in subjective and objective dimensions of quality of life (QoL) in a large Canadian sample of patients with diagnosis of schizophrenia or schizoaffective disorder treated in academic and non-academic settings over a 2-year period.

METHOD

Patients recruited in the study across the country were assessed for QoL and functioning using the Client and Provider versions of the Wisconsin Quality of Life Questionnaire (WQoL) and the Short Form-36 (SF-36) at baseline (n = 448), 1 year (n = 308-353) and 2 years (188-297). Data were analyzed to examine change across time using multivariate analyses controlling for potential influence of variables such as age, regional variation, gender, duration of illness, type of treatment taken and baseline measures of symptoms and QoL.

RESULTS

The weighted quality of life index (W-QoL-I) showed a significant change on both the client and the provider versions of the WQoL while the physical and mental composites of the SF-36 showed change only at 2 years. These changes were influenced significantly by baseline scores on W-QoL-I and in the case of provider version of the WQoL by baseline Brief Psychiatric Rating Scale (BPRS) scores. Regional variation or type of medication had no impact on improvement in QoL.

CONCLUSION

Within a naturalistic sample of schizophrenia patients treated and followed in routine care the overall QoL showed an improvement over time but this improvement was not influenced by the type of medication prescribed.

How antipsychotics work: the patients' perspective

BACKGROUND

While much is known about the neuropharmacology and objective efficacy of antipsychotics, little is known about how these drugs act on psychosis from the patients' perspective. Most previous studies of the patient's perspective have focused on drug tolerability and acceptability-rather than their effects on psychosis per se.

METHODS

The authors examined how antipsychotics work from a patient's perspective by analyzing their responses to a subjective questionnaire. Ninety-one patients with schizophrenia (cross-sectional component) and eight neuroleptic naïve patients (before and after treatment, longitudinal component) participated. The patients' responses to the questionnaire were analyzed using Principal Component Analysis (PCA) and general linear models.

RESULTS

Analysis of the patients' responses showed that from their perspective the drugs were substantially more effective in: "help deal, help stop thinking, and make the symptoms not bother" rather than "take away" or "change my mind". This differentiation was clear in the raw data and was supported by a formal PCA. Two underlying factors-the first termed detachment and second eradication-explained 71% of the variance in the patients' perspective on how antipsychotics work for them. Neuroleptic naïve patients, who had no prior exposure, expected drugs to help with both detachment and eradication, but, changed their mind with just 6 weeks of experience with the medications.

CONCLUSIONS

From the patients' perspective the action of antipsychotics is best characterized by a detachment from symptoms-rather than an eradication or elimination of symptoms. They have more wide-ranging expectations prior to antipsychotic exposure, but, even 6 weeks of exposure is sufficient to change their mind in favor of detachment. This finding is consistent with some of the very earliest ideas that antipsychotics produced a state of "indifference" and is also consistent with the more recent, neurobiologically informed notions that antipsychotics work by dampening the salience of psychotic symptoms.

Impact of present and past antipsychotic side effects on attitude toward typical antipsychotic treatment and adherence

OBJECTIVE

(1) determine which antipsychotic side effects (SE) schizophrenic patients consider the most distressing during treatment with typical antipsychotics, (2) measure the impact of actual and past SE on patients' attitude toward antipsychotics and (3) assess the influence of both on adherence.

METHODS

The 213 schizophrenics, treated with conventional antipsychotics, were recruited in two psychiatric hospitals in Hamburg. Subjects were assessed about type and severity of present and past side effects and their attitude and adherence to antipsychotic treatment.

RESULTS

The 82 (39%) patients presented present SE while 131 (61%) did not. Sexual dysfunctions (P < 0.001), extrapyramidal (P < 0.05) and psychic side effects (P < 0.05) were rated as significantly subjectively more distressing than sedation or vegetative side effects. Patients presenting with present SE compared with patients without present SE had a significantly more negative general attitude toward antipsychotics (P < 0.05), were more doubtful about their efficacy (P < 0.01) and were less likely to encourage a relative to take such a medication in case of need (P < 0.001). A regression analysis indicated that nonadherence was mainly influenced by negative general and efficacy attitudes toward antipsychotics and the experience of past or present antipsychotic side effects.

CONCLUSIONS

All antipsychotic side effects, present or past, can have a durable negative impact on patient's attitude toward antipsychotic treatment and adherence. Non-adherence is mainly determined, among other factors, by these negative attitudes, which are partly influenced by the experience of past or present antipsychotic-induced side effects.

Subjective outcome measures of drug efficacy

The use of subjective outcome measures for assessing drug efficacy varies according to the disease in question. Subjective outcome measures used to complement an objective outcome measure can clearly claim the status of a main outcome measure. The validation of an instrument follows an appropriate methodology that focuses on two points: the methods used for its construction are set out and its performance is evaluated in a study. In drug evaluation, the importance of the subjective outcome measure should be discussed, depending on the aim and the disease. The methodology of the study obeys the same rules as when an objective outcome measure is used. The issue of the clinical significance of the results should be broached and discussed. Subjective outcome measures deserve to be considered in the evaluation of the drug because they provide a different and complementary perspective on the disease and the patient, both at the time of obtaining the marketing authorization or when reassessing a drug.

The brief symptom inventory and the positive and negative syndrome scale: discriminate validity between a self-reported and observational measure of psychopathology

Concern within the literature has emerged from time to time arguing the poor validity of self-reported measures in psychopathology, namely, the reporting of psychotic experience. Although it is commonly believed that patients who have had a psychotic episode cannot accurately self-report their experience, very few studies have been conducted to measure the concordance between self-reported and observational measures of psychopathology using multivariate statistical techniques. Sixty-nine patients presenting their first psychotic episode were interviewed and assessed on the Positive and Negative Syndrome Scale (PANSS) and were asked to complete the Brief Symptom Inventory (BSI). By clustering symptom dimensions from the BSI into discriminate functions, the research demonstrated that these symptom dimensions could adequately classify high versus low scores on the PANSS subscales and total score. When the same clusters were entered into multivariate analysis of variance (MANOVA) models, they also demonstrated significant differences between high versus low observed symptomatology on the PANSS Positive and General Subscale Groups and Total Score Groups. The current findings shed some doubt on the supposition that those who experience psychosis are unable to report symptom dimensions that concord with those who observe the psychosis. It appears that models, operational definitions, and the language used in measuring psychopathology may differ significantly from those who experience the psychotic experience and those who observe it. Techniques such as multitrait multimethod are discussed as ways of overcoming these concerns.

Patients' subjective experiences of antipsychotics: clinical relevance

The subjective experience of patients with schizophrenia who are receiving antipsychotic medication has been a neglected research area, as has the satisfaction of patients with their drug treatments. This is unfortunate, as satisfaction with treatment appears to be related strongly to the readiness of patients to take their medication as prescribed, and thereby to outcome. Patients' perceptions of their treatment do not appear to be related strongly to severity of illness or symptom ratings, although there are associations between perceptions of treatment and adverse effects. Surveys of patient experience with typical antipsychotics have tended to indicate high levels of dissatisfaction and perceived adverse effects. There have been a number of surveys of patients' perceptions of treatment with the atypical antipsychotics. These tend to accord with the expectation that a relative freedom from adverse effects with the atypical antipsychotics will be reflected in enhanced levels of satisfaction and perceived well-being. In general, these studies share a number of weaknesses, including small sample sizes, bias in selection of respondents, open treatment and lack of suitable comparator groups. In addition, many have adopted a cross-sectional, rather than longitudinal, approach and have relied on nonvalidated and perhaps idiosyncratic rating measures. Recently, there have been studies of better methodological quality. These, too, have indicated that patients regard the newer treatments more positively than the older regimens. In addition, there is now evidence that the various new-generation antipsychotics may be evaluated differently by patients.

Personal evaluation of transitions in treatment (PETiT):a scale to measure subjective aspects of antipsychotic drug therapy in schizophrenia

The paper describes the development and preliminary testing of a scale designed to capture aspects of subjective responses to, and tolerability of antipsychotic drugs, treatment adherence, and impact of antipsychotic drug therapy on the quality of life of individuals treated for schizophrenia. Using empirical study approaches and qualitative methods of data analysis, twelve themes were initially identified as relevant to the quality of life of individuals during antipsychotic drug therapy. Based on these dimensions, in the second phase, a 30 item self report questionnaire was constructed and field tested in a community based, heterogeneous sample of schizophrenic patients (n=335). The scale was easy to self-administer (in 2-5 min) and perceived as user-friendly by patients. Correlational analysis revealed a high internal consistency (Cronbach's alpha=0.92) and split half reliability (Spearman-Brown coefficient of 0.85). The scale scores were able to distinguish subjects with lower and higher rates of treatment adherence, and factor analysis confirmed the robustness of the original construct. Repeated administration of the scale in a sub-sample of clinically stable schizophrenic population (n=71) revealed a test-retest reliability coefficient of 0.97 (P<0.001); and repeat administration at quarterly intervals in a sample of patients receiving active treatment (n=54) indicated a significant increases in mean scores (t=6.2, df=53, P<0.005), suggesting that the scale was sensitive to changes in patients' clinical status. Based on these preliminary data, PETiT could be considered as a potentially useful tool for measuring client-centred outcomes in clinical practice, drug trials, quality assurance programs and interventional research involving schizophrenic patients.

Randomized controlled trials in schizophrenia: a critical perspective on the literature

OBJECTIVE

The randomized trial provides an opportunity to minimize the inclusion of biases in the evaluation of interventions in psychiatry. Difficulties arise, however, when applying their results to 'real world' clinical practice and decision-making. We, therefore, examined the real world applicability of schizophrenia trials.

METHOD

A narrative overview of the content and quality of the randomized trials relevant to the care of those with schizophrenia is provided.

RESULTS

Complex, explanatory, under-powered randomized drug trials dominate evaluative research in schizophrenia.

CONCLUSION

Explanatory designs are a necessary but insufficient step in establishing the true worth of interventions in schizophrenia. Research from other spheres of mental health and wider health care suggest that pragmatic trials are feasible. This design allows large scale trials to be conducted which include patients which we would recognize from routine practice and which record outcomes which are of genuine interest to decision-makers.

Quality of life in treated and never-treated schizophrenic patients

OBJECTIVE

To evaluate quality of life (QOL) among treated and never-treated schizophrenic patients.

METHOD

QOL ratings were obtained for (a) 112 Moroccan participants with schizophrenia who had never received neuroleptic medications, (b) matched samples of chronically-medicated schizophrenic patients in Morocco and the United States and (c) matched community controls in both countries.

RESULTS

QOL ratings were generally higher for US groups, although Moroccan controls obtained higher ratings than US controls for some domains. QOL ratings were higher for controls compared to patients within each country, although US patients' scores were similar to controls on some dimensions. We found no differences between treated and untreated Moroccan patients for any QOL domain, although relationships among predictors were different.

CONCLUSION

Within the context of Moroccan culture, benefits of medications alone are not evident in QOL scores. QOL appears to be a complex construct influenced by different factors within each of the groups studied.

The importance of treatment acceptability to patients

Antipsychotic drug treatment plays a central role in the care of patients with schizophrenia. The chronic nature of the illness means that most patients are likely to require long-term antipsychotic medication to alleviate symptoms and to prevent recurrence of an acute psychotic episode. Unfortunately, a high proportion of patients with schizophrenia do not comply with medication and this has profound consequences in terms of the number and severity of relapse episodes, rehospitalization rates, worsening of residual symptoms and social costs, including substance misuse, homelessness and the burden on carers. Ensuring that antipsychotic treatment is acceptable to the patient is fundamental to managing adherence. Side-effects, particularly mental and extrapyramidal symptoms (EPS), are the cause of much distress to patients and dissatisfaction with treatment, so a treatment regimen with a low side effect profile will help to improve adherence to the treatment. Such regimens have unmasked many of the other side-effects of treatment that were previously viewed as subsidiary to EPS; but the physical and psychological consequences of side-effects such as antipsychotic-induced sexual dysfunction or weight gain are highly distressing to the patient, and as likely as EPS to trigger non-adherence to medication. Consequently, careful selection of antipsychotic agent and dose regimens is essential to maximize the efficacy of the antipsychotic and to minimize the overall burden of side-effects. Satisfaction also depends very much on the extent to which the patient understands the treatment and its side-effects. Therefore, a close therapeutic alliance between the patient and the psychiatrist must underpin all attempts to increase the acceptability of treatment. This will allow the clinician to determine how the illness and its treatment are affecting all aspects of the life of the patient, and then to tailor the treatment continuously to obtain the best possible outcome for the patient.

Olanzapine versus haloperidol in the treatment of schizophrenia and other psychotic disorders: quality of life and clinical outcomes of a randomized clinical trial

BACKGROUND

Little information is available on the impact of the atypical antipsychotic olanzapine on quality of life (QOL). A 6-week, double-blind randomized multicenter trial, with a long-term extension, was conducted to evaluate the clinical efficacy and QOL of olanzapine and haloperidol in treating schizophrenia and other psychotic disorders.

METHODS

A total of 828 outpatients provided QOL data. Study patients were aged greater than 18 years with a DSM-III-R diagnosis of schizophrenia, schizophreniform disorder, or schizoaffective disorder and baseline BPRS (items scored on 0-6 scale) total scores, > or = 18 were randomized to 6 weeks of treatment with olanzapine 5 to 20 mg/day or haloperidol 5 to 20 mg/day. Patients entered a 46-week double-blind extension if they demonstrated minimal clinical response and were tolerant to study medication. The Quality of Life Scale (QLS) and SF-36 Health Survey were used to evaluate QOL.

RESULTS

During the 6-week acute phase, olanzapine treatment significantly improved BPRS total (p = 0.004), PANSS total scores (p = 0.043), QLS total (p = 0.005), intrapsychic foundations (p < 0.001) and interpersonal relations scores (p = 0.036), and SF-36 mental component summary scores (p < 0.001) compared with haloperidol. During the extension phase, olanzapine treatment significantly improved PANSS negative scores (p = 0.035) and improved QLS total (p = 0.001), intrapsychic foundations (p < 0.001), and instrumental role category scores (p = 0.015) versus haloperidol treatment. Significantly more haloperidol patients discontinued treatment due to adverse events during the acute and extension phases (p = 0.041 and p = 0.014, respectively). Changes in QLS total and MCS scores were associated with changes in clinical symptoms, depression scores and extrapyramidal symptoms.

CONCLUSIONS

Olanzapine was more effective than haloperidol in reducing severity of psychopathology and in improving QOL in patients with schizophrenia and other psychotic disorders. The QOL benefits of olanzapine, although modest, may be important for long-term treatment.

Computerized self-assessment in psychiatric in-patients: acceptability, feasibility and influence of computer attitude

In recent years various approaches using computerized assessments and tests in psychiatry have been published. In our study, the acceptability and feasibility of computerized self-assessments and attitude to computers were examined in psychiatric in-patients, using an improved interactive schedule, the Interactive Self-Assessment Scale (ISAS), based on the Windows operating system. In general we found a good level of acceptability and feasibility of the computerized self-assessment. Our results confirm the influence of attitude to computers on acceptability, and indicate a lack of self-confidence in interacting with computers, accompanied by a less positive attitude to computers than reported by healthy subjects and psychiatric out-patients. Computerized self-assessment is suitable for psychiatric in-patients. Nevertheless, further research is necessary in order to improve attitude to computers and the patient-computer interaction.

Guidelines for depot antipsychotic treatment in schizophrenia. European Neuropsychopharmacology Consensus Conference in Siena, Italy

These guidelines for depot antipsychotic treatment in schizophrenia were developed during a two-day consensus conference held on July 29 and 30, 1995 in Siena, Italy. Depot antipsychotic medications were developed in the 1960s as an attempt to improve the long-term treatment of schizophrenia (and potentially other disorders benefiting from long-term antipsychotic medication). Depot drugs as distinguishable from shorter acting intramuscularly administered agents can provide a therapeutic concentration of at least a seven day duration in one parenteral dose. The prevention of relapse in schizophrenia remains an enormous public health challenge worldwide and improvements in this area can have tremendous impact on morbidity, mortality and quality of life, as well as direct and indirect health care costs. Though there has been debate as to what extent depot (long-acting injectable) antipsychotics are associated with significantly fewer relapses and rehospitalizations, in our view when all of the data from individual trials and metaanalyses are taken together, the findings are extremely compelling in favor of depot drugs. However in many countries throughout the world fewer than 20% of individuals with schizophrenia receive these medications. The major advantage of depot antipsychotics over oral medication is facilitation of compliance in medication taking. Non-compliance is very common among patients with schizophrenia and is a frequent cause of relapse. In terms of adverse effects, there are not convincing data that depot drugs are associated with a significantly higher incidence of adverse effects than oral drugs. Therefore in our opinion any patient for whom long-term antipsychotic treatment is indicated should be considered for depot drugs. In choosing which drug the clinician should consider previous experience, personal patient preference, patients history of response (both therapeutic and adverse effects) and pharmacokinetic properties. In conclusion the use of depot antipsychotics has important advantages in facilitating relapse prevention. Certainly pharmacotherapy must be combined with other treatment modalities as needed, but the consistent administration of the former is often what enables the latter.

Quality of life and self-esteem in working and nonworking persons with mental illness

The purposes of this research were to examine first the relationship between work status and quality of life and self-esteem in persons with severe, persistent mental illness and secondly, the relationship between (a) demographic characteristics, attitudes toward psychotropic medications, and perceptions of the meaning of work and (b) quality of life and self-esteem in working and nonworking persons with severe mental illness. The sample included 92 persons (51 workers and 41 nonworkers). Instruments included the quality of Life (QOL) Interview (Lehman, 1983), Rosenberg's (1965) Self-Esteem Inventory, the Drug Attitude Inventory (DAI) (Hogan, 1983), and a Perception of Work instrument, developed by the researcher. Workers reported significantly higher self-esteem than did nonworkers (t = 2.17, df = 90, p = .033). A significant difference in overall QOL was not found, but workers scored higher on all but one QOL subscale. There were no significant differences in self-esteem, QOL, or valuing of work based on demographic factors. No significant differences in drug attitudes were found based on work status. Workers rated the importance of work higher than did nonworkers (t = 6.46, df = 90, p = .000). Analysis of qualitative data revealed that contrary to the nonworkers' fears, workers reported that work provided a distraction from symptoms and contributed to better mental health.

CCPP-Copenhagen Community Psychiatric Project. Implementation of community mental health centres in Copenhagen: effects of service utilization, social integration, quality of life and positive and negative symptoms

Deinstitutionalization of psychiatry in Denmark has been extensive and the number of psychiatric beds per 1,000 inhabitants is among the lowest in Europe. The effect of supplementing hospital treatment with treatment in community mental health centres was evaluated in a quasi-experimental design. The patient group examined consisted of patients with long-term contact with psychiatric services. When development in intervention and control districts was compared, the only significant difference was that the total patient group in the intervention district had an increased number of day attendances per year. Comparison of patients from intervention districts who attended day-centres regularly with patients from control districts before and after implementation of community mental health centres indicated that patients from intervention districts had a reduction in the use of inpatient services, a significant increase in quality of life and a significant decrease in the presence of the negative symptom, alogia. We concluded that implementation of community mental health centres can increase the quality of life for the patients and decrease the frequency of the negative symptom, alogia.

Subjective experience of treatment, side-effects, mental state and quality of life in chronic schizophrenic out-patients treated with depot neuroleptics

Attitude towards treatment, side-effects, mental state and quality of life was assessed in 53 chronic schizophrenic out-patients on maintenance treatment with depot neuroleptics. It was found that 60% of the patients viewed depot medication positively, while only 8% viewed it negatively. Only 70% of patients complained about side-effects, even though 94% had scored as having them. Hypokinesia and hyperkinesis were the side-effects least noticed by the patients, but most noticed by the treating physician, while the opposite was the case with psychic side-effects. Only 49% of patients thought they had a psychotic illness, and there was no correlation between the patients' own evaluation of the severity of their illness and their score on the Positive and Negative Symptom Scale (PANSS) or the treating physician's evaluation. Quality of life did not correlate with either side-effect score or PANSS score. The schizophrenic patients' assessment of their condition was therefore in general different both from that of the treating physician and from that determined using rating scales.

Validity of self-administered symptom scales in clients with schizophrenia and schizoaffective disorders

Few studies have used self-administered symptom scales as outcome measures with individuals who have schizophrenia. However, with the increase in community-based treatment for the serious and persistently mentally ill and the emphasis on client empowerment, their ability to monitor and report symptoms needs to be assessed. Two forms of self-administered items, symptom distress statements and symptom intensity statements, were formed from 10 BPRS symptoms and administered to 29 individuals with schizophrenia. Both forms of self-administered items were highly correlated with BPRS items, supporting concurrent validity. Self-administered responses for positive symptoms of schizophrenia and nonpsychotic symptoms may be more valid than self-administered responses for negative or deficit symptoms.

A clinical study of clozapine treatment and predictors of response in a Canadian sample

OBJECTIVE

To study the clinical response to clozapine in patients with refractory schizophrenia.

METHOD

Open trial of clozapine in 61 consecutively-treated patients.

RESULTS

Following clozapine, the level of function of patients was improved relative to admission (p = 0.0001) and to the highest level in the previous year (p = 0.0001). Severity of illness was decreased (p = 0.0001). Overall, 31% of the patients were classified as responders to clozapine and the responders were all identified by 32 weeks of treatment. Poor functioning in the previous year was associated with less favourable response. At a mean interval of 26 months following discharge, 72% of the patients were continuing clozapine treatment.

CONCLUSIONS

This open trial of patients who were treated consecutively indicates a comparable degree of response to clozapine as observed in controlled clinical trials, and that level of functioning in the previous year was the best predictor of response.

An overview of family interventions and relapse on schizophrenia: meta-analysis of research findings

The purpose of this overview is to appraise the studies on the efficacy and effectiveness of family interventions in decreasing relapse in schizophrenic patients. The studies were identified by means of a computerized MEDLINE search, and the scanning of review articles and the reference lists of the primary articles identified. More than 300 citations were reviewed, and the potentially relevant articles revealed six randomized controlled trials that were included in this meta-analysis. The criteria for selecting potential studies as well as for the meta-analysis were tested by means of an inter-rater reliability check that showed a good agreement between two independent raters (kappa = 0.83, and kappa = 0.82, respectively). There were independent assessments of the quality of the studies selected, and data extraction comprised a descriptive information of the study population, the types of interventions, and the relevant outcome measurements. The total number of patients included in the six trials was 350 (181 in the control group and 169 in the experimental group). Regarding the decrease of relapse in the experimental group, the pooled odds ratios and their 95% confidence intervals were: 0.30 (0.06, 0.71) for six months; 0.22 (0.09, 0.37) for nine months; and 0.17 (0.10, 0.35) for the 2-year follow-up. Two to five patients needed to be treated to avert one episode of relapse in a nine-month follow-up. The changes in Expressed Emotion status between experimental and control group combining nine months and one year follow-ups were shown to be marginally significant (P < 0.06), in favour of the experimental group. Emotional over-involvement was also marginally significant (P < 0.07), and there was no statistical difference in the distribution of criticism and hostility. In addition, the experimental group showed a significant increase with drug compliance and a reduction in hospitalization over time. These findings are discussed in light of the potential ingredients in the efficacy of family interventions by focusing on the limitations of using relapse as primary outcome in the assessment of efficacy trials with schizophrenic patients.

New perspectives on the clinical neurobiology of treatment response in schizophrenia

A structured approach is used to review the rapid progress in neurobiology related to treatment response in schizophrenia. Findings are presented and discussed according to the molecular, cellular and regional levels of brain organization. The genotype-phenotype structure is used to consider potential interactions between genes, clinical manifestations of the illness and treatment response. The integration of neurobiological research into the future development of new treatment strategies for schizophrenia holds significant promise.

Schizophrenic syndromes associated with treatment response

1. The influence of clinical syndromes (determined by factor analysis) on treatment response was explored in a sample of schizophrenics treated by clinician choice. Patients were obtained from 115 consecutive admissions to an acute inpatient unit and were diagnosed by DSM-III-R criteria. Patients were thoroughly assessed during the first five days of hospitalization using SANS-SAPS, TLC and SEB. Factor analyses of these scales were carried out to explore the existence of syndromes made up of groups of symptoms. All patients were treated with neuroleptics and 70% with biperiden (to exclude akinesia). The response to treatment was measured by the CGI efficacy index. 2. Inappropriate affect, asociality, negative formal thought disturbances and bizarre behavior syndromes showed significant correlation with poor response to treatment. Affective flattening did not display consistent significant correlations with the response to treatment. Visual hallucinations (an infrequent syndrome) and manic thought disorder (a non-specific syndrome) showed significant correlations with better response to neuroleptics. 3. In a stepwise multiple regression model to predict treatment response, asociality and inappropriate affect were the most important predictors. In a discriminant analysis dividing patients between responders and non-responders, the syndromes predicting poor response were more important that those predicting good response.