Detecting improvement in quality of life and symptomatology in schizophrenia

Relapse in clinically stable adult patients with schizophrenia or schizoaffective disorder: evidence-based criteria derived by equipercentile linking and diagnostic test accuracy meta-analysis

BACKGROUND

There is no consensus on defining relapse in schizophrenia, and scale-derived criteria with unclear clinical relevance are widely used. We aimed to develop an evidence-based scale-derived set of criteria to define relapse in patients with schizophrenia or schizoaffective disorder.

METHODS

We searched the Yale University Open Data Access (YODA) for randomised controlled trials (RCTs) in clinically stable adults with schizophrenia or schizoaffective disorder, and obtained individual participant data on Positive and Negative Syndrome Scale (PANSS), Clinical Global Impression Severity (CGI-S), Personal and Social Performance (PSP), and Social and Occupational Functioning Assessment Scale (SOFAS). Our main outcomes were PANSS-derived criteria based on worsening in PANSS total score. We examined their relevance using equipercentile linking with CGI-S and functioning scales, and their test-performance in defining relapse with diagnostic test accuracy meta-analysis against CGI-S worsening (≥1-point increase together with a score ≥4 points) and psychiatric hospitalisation.

FINDINGS

Based on data from seven RCTs (2354 participants; 1348 men [57·3%] and 1006 women [42·7%], mean age of 39·5 years [SD 12·0, range 17-89]; 303 Asian [12.9%], 255 Black [10.8%], 1665 White [70.7%], and other or unspecified 131 [5.6%]), an increase of 12 points or more in PANSS total (range 30-210 points) corresponded to clinically important deterioration in global severity of illness (≥1 point increase in CGI-S, range 1-7) and functioning (≥10 points decline in PSP or SOFAS, range 1-100). The interpretation of percentage changes varied importantly across different baseline scores. An increase of 12 points or more in PANSS total had good sensitivity and specificity using CGI-S as reference standard (sensitivity 82·1% [95% CI 77·1-86·4], specificity 86·9% [82·9-90·3]), as well as good sensitivity but lower specificity compared to hospitalisation (sensitivity 81·7% [74·1-87·7], specificity 69·2% [60·5-76·9]). Requiring either an increase in PANSS total or in specific items for positive and disorganization symptoms further improved test-performance. Cutoffs for situations where high sensitivity or specificity is needed are presented.

INTERPRETATION

An increase of either 12 points or more in the PANSS total score, or worsening of specific positive and disorganisation symptom items could be a reasonable evidence-based definition of relapse in schizophrenia, potentially linking symptoms used to define remission and relapse. Percentage changes should not be used to define relapse because their interpretation depends on baseline scores.

FUNDING

German Research Foundation (grant number: 428509362).

Long-Term Outcome of Clozapine in Treatment-Resistant Schizophrenia

PURPOSE/BACKGROUND

The favorable effect of clozapine on psychotic symptoms in patients with treatment-resistant (TR) schizophrenia (SCZ) in short-term studies is well established. However, prospective studies of the long-term outcome of clozapine treatment on psychopathology, cognition, quality of life, and functional outcome in TR-SCZ are limited.

METHODS/PROCEDURES

Here, we have examined the long-term (mean duration of follow-up 14 years) effects of clozapine on those outcomes in a prospective, open label study in 54 TR-SCZ patients. Assessments were performed at baseline, 6 weeks, 6 months, and at the last follow-up.

FINDINGS/RESULTS

Brief Psychiatric Rating Scale (BPRS) total, positive symptoms, and anxiety/depression at the last follow-up improved significantly from baseline, as well as from the 6-month evaluation ( P < 0.0001), with a 70.5% responder rate (≥20% improvement at the last follow-up from baseline). Quality of Life Scale (QLS) total improved by 72% at the last follow-up, with 24% of patients rated as having "good" functioning compared with 0% at baseline. Suicidal thoughts/behavior was significantly reduced at the last follow-up from the baseline. No significant change in negative symptoms was found at the last follow-up in the total sample. Short-term memory function declined at the last follow-up from baseline, but there was no significant change in processing speed. The QLS total showed a significant negative correlation with BPRS positive symptoms but not with cognitive measures, or negative symptoms, at the last follow-up.

IMPLICATIONS/CONCLUSIONS

For patients with TR-SCZ, improving psychotic symptoms with clozapine seems to have a more significant impact than negative symptoms or cognition on improving psychosocial function.

Predictors of response to pharmacological treatments in treatment-resistant schizophrenia - A systematic review and meta-analysis

BACKGROUND

As the burden of treatment-resistant schizophrenia (TRS) on patients and society is high it is important to identify predictors of response to medications in TRS. The aim was to analyse whether baseline patient and study characteristics predict treatment response in TRS in drug trials.

METHODS

A comprehensive search strategy completed in PubMed, Cochrane and Web of Science helped identify relevant studies. The studies had to meet the following criteria: English language clinical trial of pharmacological treatment of TRS, clear definition of TRS and response, percentage of response reported, at least one baseline characteristic presented, and total sample size of at least 15. Meta-regression techniques served to explore whether baseline characteristics predict response to medication in TRS.

RESULTS

77 articles were included in the systematic review. The overall sample included 7546 patients, of which 41% achieved response. Higher positive symptom score at baseline predicted higher response percentage. None of the other baseline patient or study characteristics achieved statistical significance at predicting response. When analysed in groups divided by antipsychotic drugs, studies of clozapine and other atypical antipsychotics produced the highest response rate.

CONCLUSIONS

This meta-analytic review identified surprisingly few baseline characteristics that predicted treatment response. However, higher positive symptoms and the use of atypical antipsychotics - particularly clozapine -was associated with the greatest likelihood of response. The difficulty involved in the prediction of medication response in TRS necessitates careful monitoring and personalised medication management. There is a need for more investigations of the predictors of treatment response in TRS.

Assessment of the Minimum Clinically Important Difference in Symptoms and Functions of Patients With Acute Schizophrenia: A Post hoc Analysis of an Open-Label, Single-Arm Multicenter Study

The purpose of this study was to evaluate the application of the minimum clinically important difference (MCID) concept to clinical results in Chinese patients with acutely exacerbated schizophrenia. The original study was an 8-week, open-label, single-arm, multicenter study of flexible doses of paliperidone-extended release (pali-ER) in Chinese patients with acutely exacerbated schizophrenia. This is a post hoc analysis to determine the MCID value of PANSS, PSP and evaluate the responsiveness of each outcome measurements in the acute phase of schizophrenia. The responsiveness of the four measurements (PANSS, PANSS reduction rate, PSP, CGI-S) was analyzed. Four hundred ninety nine patients completed the 8-week follow-up and were finally used for this post hoc analysis. The MCID calculated by different approaches varied from 14.02 to 31.50 for PANSS, 15.14 to 42.79% for PANSS reduction rate, and 7.62 to 13.13% for PSP. In addition, the improvement of the CGI-S owned the highest responsiveness of the four outcome measurements. The threshold value of MCID for schizophrenia patients was determined by choice of the assessment method to an extent. In addition, the CGI-S score appeared to be the most valid and responsive measure of effectiveness for the acute phase of schizophrenia when take the treatment satisfaction of patients as anchor.

Moving forward: distinct sensorimotor abnormalities predict clinical outcome after 6 months in patients with schizophrenia

Despite substantial efforts in the last decades, objective measures that can predict clinical outcome in patients with schizophrenia (SZ) after an acute psychotic episode are still lacking. Here, we introduced a comprehensive assessment of sensorimotor function to predict mid-term clinical outcome following an acute psychotic episode. This naturalistic follow-up of 43 patients with DSM-IV-TR diagnosis of SZ examined sensorimotor abnormalities (i.e. Neurological Soft Signs (NSS), parkinsonism, akathisia, catatonia and acute dyskinesia), psychopathology, cognition and psychosocial functioning using well-established instruments. A collection of statistical methods was used to examine the relationship between sensorimotor domain, psychopathology, cognition and psychosocial functioning. We also tested the clinical feasibility of this relationship when predicting clinical outcome after an acute psychotic episode. Longitudinal data were collected on 43 individuals after a follow-up period of >6 months. At follow-up, patients showed significantly reduced general symptom severity, as well as decreased levels of NSS, parkinsonism and catatonia. Further, NSS scores at baseline predicted PANSS negative scores and cognitive functioning at baseline. Finally, NSS scores at baseline predicted symptom change (reduction of PANSS positive and negative scores) at follow-up. In conclusion, our results suggest that NSS are significant predictors of poor clinical outcome in SZ at baseline and >6 months after an acute psychotic episode. These findings propose sensorimotor domain as state biomarker of SZ and support its predictive power with respect to treatment outcome.

Relevance of a subjective quality of life questionnaire for long-term homeless persons with schizophrenia

BACKGROUND

Increasing numbers of programs are addressing the specific needs of homeless people with schizophrenia in terms of access to housing, healthcare, basic human rights and other domains. Although quality of life scales are being used to evaluate such programs, few instruments have been validated for people with schizophrenia and none for people with schizophrenia who experience major social problems such as homelessness. The aim of the present study was to validate the French version of the S-QoL a self-administered, subjective quality of life questionnaire specific to schizophrenia for people with schizophrenia who are homeless.

METHODS

In a two-step process, the S-QoL was first administered to two independent convenience samples of long-term homeless people with schizophrenia in Marseille, France. The objective of the first step was to analyse the psychometric properties of the S-QoL. The objective of the second step was to examine, through qualitative interviews with members of the population in question, the relevance and acceptability of the principle quality of life indicators used in the S-QoL instrument.

RESULTS

Although the psychometric characteristics of the S-QoL were found to be globally satisfactory, from the point of view of the people being interviewed, acceptability was poor. Respondents frequently interrupted participation complaining that questionnaire items did not take into account the specific context of life on the streets.

CONCLUSIONS

Less intrusive questions, more readily understandable vocabulary and greater relevance to subjects' living conditions are needed to improve the S-QoL questionnaire for this population. A modular questionnaire with context specific sections or specific quality of life instruments for socially excluded populations may well be the way forward.

Defining the minimal clinically important difference (MCID) of the Heinrichs-carpenter quality of life scale (QLS)

To determine the Minimal Clinically Important Difference (MCID) of the Heinrichs-Carpenter Quality of Life Scale (QLS). Data from the "Schizophrenia Trial of Aripiprazole" (STAR) study were used in this analysis. The MCID value of the QLS total score was estimated using the anchor-based method. These findings were substantiated/validated by comparing the MCID estimate to other measurements collected in the study. Half of the patients (49%) showed improvement in Clinical Global Impressions of Severity (CGI-S) during the trial. The estimated MCID of the QLS total score was 5.30 (standard error: 2.60; 95% confidence interval: [0.16; 10.43]; p < 0.05). Patients were divided into two groups: "QLS improvers" (QLS total score increased ≥ six points) and "non-improvers". The QLS improvers had significantly better effectiveness and reported significantly higher levels of preference for their current medications. There was a statistically significant difference between the two groups in the change in two of the four domains of QLS; "Interpersonal relations" and "Intrapsychic foundations" domains during the study. These findings support the value of the estimated MCID for the QLS and may be a useful tool in evaluating antipsychotic treatment effects and improving long-term patient outcomes in schizophrenia. Copyright © 2015 John Wiley & Sons, Ltd.

Obtaining employment as an anchor for estimating the minimum clinically important difference on the Positive and Negative Syndrome Scale (PANSS) in schizophrenia

Statistical differences on clinical scales are often used to compare the effectiveness of treatments. However, statistical significance does not necessarily indicate clinical significance. The minimum clinically important difference (MCID) refers to clinically meaningful treatment differences. This study estimates the MCID of the Positive and Negative Syndrome Scale (PANSS) by anchoring the change in scores to an objective clinical outcome: employment. This secondary analysis compared PANSS score change from baseline among 1049 non-working individuals with schizophrenia, who were followed and categorized as either having not worked, worked 1-10 days, or worked >10 days at 15 or 18 months. The difference in change in average PANSS Total scores between participants who did not work and those who worked 1-10 days (4.25 points) and >10 days (8.30) were statistically significant. This study estimates the MCID for the PANSS to be between 4.25 and 8.30 Total points. This study revealed significant differences in PANSS score changes between participants who did and did not work. Using employment, an objective and clinically meaningful change in health status, to determine the MCID of PANSS resulted in estimates lower than previously reported. MCID estimates vary across methods but using objective anchors increases face validity.

A cluster-analytical approach toward real-world outcome in outpatients with stable schizophrenia

BACKGROUND

This study aims to empirically identify profiles of functioning, and the correlates of those profiles in a sample of patients with stable schizophrenia in a real-world setting. The second aim was to assess factors associated with best profile membership.

METHODS

Three hundred and twenty-three outpatients were enrolled in a cross-sectional study. A two-step cluster analysis was used to define groups of patients by using baseline values for the Heinrichs-Carpenter Quality of Life Scale (QLS) total score. Logistic regression was used to construct models of class membership.

RESULTS

Our study identified three distinct clusters: 50.4% of patients were classified in the "moderate" cluster, 27.9% in the "poor" cluster, 21.7% in the "good" cluster. Membership in the "good" cluster versus the "poor" cluster was characterized by less severe negative (OR=.832) and depressive symptoms (OR=.848), being employed (OR=2.414), having a long-term relationship (OR=.256), and treatment with second-generation antipsychotics (SGAs) (OR=3.831). Nagelkerke R(2) for this model was .777.

CONCLUSIONS

Understanding which factors are associated with better outcomes may direct specific and additional therapeutic interventions, such as treatment with SGAs and supported employment, in order to enhance benefits for patients, as well as to improve the delivery of care in the community.

Cross diagnostic comparisons of quality of life deficits in remitted and unremitted patients with schizophrenia and bipolar disorder

BACKGROUND

Patients with schizophrenia (SCZ) and bipolar disorder (BD) have been found to report lower quality of life (QOL) compared to healthy controls separately. However, data are wanting on cross diagnostic comparisons of QOL within psychotic spectrum conditions. This study examined QOL differences and clinical predictors between schizophrenia (SCZ) and bipolar disorder (BD). Based on extant data, we hypothesized that patients with remitted SCZ and BD had comparable QOL levels, and that more severe symptoms and poorer psychosocial functioning predicted poorer QOL in our patients.

METHODS

Two hundred and twenty-two sex and age-matched subjects (44 BD, 122 SCZ, 56 healthy controls) were assessed on their QOL, psychosocial functioning, symptomatology, and state of remission.

RESULTS

Overall, SCZ patients had worse QOL in the environment domain (p=0.008) and overall QOL (p=0.007) compared with BD patients. Both patient groups in remission had similar QOL, while unremitted SCZ patients reported poorer QOL in all domains compared to unremitted BD patients (p<0.01). Within patients, greater severity of negative symptoms and poorer psychosocial functioning were associated with poorer QOL (p<0.05).

DISCUSSION

Remission status affected QOL in both patient groups. The association of worse QOL with greater negative psychotic psychopathology and poorer psychosocial functioning highlighted potential clinical markers of QOL, which can aid in the management of psychotic spectrum disorders.

Noninferiority of perphenazine vs. three second-generation antipsychotics in chronic schizophrenia

Noninferiority analysis is a statistical method of growing importance in comparative effectiveness research that has rarely been used in psychopharmacology. This method is used here to evaluate whether first-generation antipsychotics are clinically not inferior to second-generation antipsychotics (SGAs) using data from the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE). A conservative noninferiority margin (NIM) on the Positive and Negative Syndrome Scale (PANSS) was derived from the smallest published value for the minimal clinically important difference, further reduced by 25%. This NIM was used to assess whether perphenazine is noninferior to olanzapine, risperidone, and quetiapine on the basis of the 95% confidence intervals of differences in mean PANSS outcomes (N = 1049). Perphenazine was noninferior to all three SGAs during 18 months of intention-to-treat analysis and in several subanalyses. Noninferiority can be evaluated from studies designed as superiority trials. Power was available in the CATIE to conduct noninferiority analysis.

Assessment of the minimum clinically important difference in quality of life in schizophrenia measured by the Quality of Well-Being Scale and disease-specific measures

This study examines the psychometric properties of the Quality of Well Being Scale (QWB), the Positive and Negative Syndrome Scale (PANSS), the Heinrich-Carpenter Quality of Life Scale (QOLS), and the Lenert PANSS-based utility measure in a cohort of patients with schizophrenia and identifies threshold values of clinically meaningful change using the Clinical Global Impressions scale (CGI), as the anchor. The correlation of these measures at baseline and change at 6 and 12 months post enrollment in a comparative effectiveness trial was evaluated in 350 veterans with schizophrenia or schizoaffective disorder. An equipercentile method was used to estimate the minimum clinically important difference (MCID) for each measure. Effect size of 0.30-0.50 for baseline quality of life associated with inpatient status supported concurrent validity. The QWB was moderately correlated with disease-specific measures. The MCID as detected by the CGI at 6 months was 0.17 for QWB, 0.15 for the Lenert utility score, 1.13 for the QOLS, and 20.2 for the PANSS. These differences were stable at 12 months. The QWB is significantly correlated with disease specific measures of health related quality of life in schizophrenia.

Improved quality of life over one year is associated with improved adherence in patients with schizophrenia

AIM

Quality of life (QoL) is increasingly considered an important outcome in health research. We wished to explore the determinants of change in QoL in patients with schizophrenia over the course of a one-year RCT.

METHODS

Predictors of change in observer-rated QoL (Quality of Life Scale: QLS) were assessed in 363 patients with schizophrenia during the CUtLASS clinical trial.

RESULTS

Change in QLS score over the course of a year correlated with change in psychotic and depressive symptoms and treatment adherence. Linear regression showed that improvement in QoL was predicted by reduction in negative and depressive symptoms and improvement in adherence rating. These three change scores together explained 38% of the variance in QLS change. Exploration of the direction of any possible causal effect, using TETRAD, indicated that improved adherence leads to improved QoL, and that change in depression also leads to QoL change. The relationship between QoL and negative symptoms suggests that greater social activity (reflected as better QoL scores) improves negative symptoms. Such a direct relationship between treatment adherence and QoL has not been reported before.

CONCLUSION

Improving adherence to medication would appear to be a key approach to improving measured quality of life in people with schizophrenia.

Empirically driven definitions of "good," "moderate," and "poor" levels of functioning in the treatment of schizophrenia

Purpose

This study used an empirical approach to identify and validate the classification of patients with schizophrenia in “good,” “moderate,” or “poor” functioning groups based on the assessment of functional measures.

Methods

Using data from a study of schizophrenia outpatients, patients were classified into functional groups using cluster analysis based on the Heinrich–Carpenter Quality of Life Scale (QLS), the 36-item Short-Form Health Survey (SF-36) Mental Component Summary Score, and a productivity measure. A three-cluster solution was chosen. Concurrent, convergent, and discriminant validity were assessed. Criteria for classifying patient functioning as “good,” “moderate,” or “poor” were established using classification and regression tree analysis.

Results

The three clusters consistently differentiated patients on the QLS, SF-36 Mental Component Summary Score, and productivity measure. The clusters also differed on other functional measures and were concordant with previous functional classifications. Concurrent, convergent, and discriminant validity were good. “Good” functioning was identified as a QLS total score ≥84.5; “moderate” and “poor” functioning were separated by a cutoff score of 15.5 on the QLS intrapsychic foundation domain. Sensitivity ranged from 86 to 93 % and specificity from 89 to 99 %.

Conclusions

The heterogeneity in functioning of schizophrenia patients can be classified reliably in an empirical manner using specific cutoff scores on commonly used functional measures.

Rater evaluations for psychiatric instruments and cultural differences: the positive and negative syndrome scale in China and the United States

This article compares Positive and Negative Syndrome Scale (PANSS) data from Chinese and American inpatients with chronic schizophrenia to show how differences in item ratings may reflect cultural attitudes of raters. The Chinese sample (N = 504) came from Beijing Huilongguan Hospital. The American sample came from 268 PANSS assessments of Clinical Antipsychotic Trials of Intervention Effectiveness subjects hospitalized for 15 days or more to optimize equivalence of the samples. When controlling for age and sex, the Chinese sample scored significantly lower for total score by 25% (p < 0.0001), for the positive subscale by 35% (p < 0.0001), and on the general subscale by 32% (p < 0.0001) but not significantly different on the negative subscale score (+0.26%; p = 0.76). However, the Chinese sample scored 26% higher on the item on poor rapport (p < 0.0001), 10.2% higher on passive social withdrawal (p = 0.003), and most notably 46% higher on the item on lack of judgment and insight (p < 0.0001). These results remain broadly consistent across sex subgroup analyses. Differences seem to be best explained by both cultural differences in patient clinical presentations and varying American and Chinese cultural values affecting rater judgment.

Reliability and validity of the Personal and Social Performance scale in patients with schizophrenia

OBJECTIVE

The construct validity and test-retest reliability of the Personal and Social Performance (PSP) scale were used to assess social functioning in a cohort of ethnically diverse UK patients with schizophrenia.

METHODS

A total of 73 patients with schizophrenia took part in the study. At baseline, the PSP, two symptomatology scales and two other functioning scales were administered. A subset of the sample (N=40) took part in a retest where the Clinical Global Impression-Severity (CGI-S) and PSP scales were administered 8-10 days later.

RESULTS

PSP significantly correlated with all other measures, Positive and Negative Syndrome Scale (PANSS), Global Assessment of Functioning (GAF) and Quality of Life Scale (QLS) at baseline (p<0.02) and with CGI-S at follow-up (p<0.01). In addition, the PSP scale was moderately sensitive to the severity of illness. Test-retest reliability for the PSP score was 0.45 and the scale was able to discriminate between known groups (mild and severe patients).

CONCLUSION

The PSP was easy to administer in this predominantly inpatient cohort and was moderately correlated with all other functioning measures tested. Due to patient homogeneity, the test-retest reliability statistic of the PSP was lower than that observed in other studies.

Treatment response after relapse in a placebo-controlled maintenance trial in schizophrenia

While placebo-controlled studies continue to be required by regulatory authorities for the licensing of new drugs for schizophrenia to demonstrate maintenance of effect, the long-term risks to participants are largely unknown. We compared the response to treatment with paliperidone palmitate before and after relapse in such a study. This was a post-hoc analysis of 97 patients with schizophrenia who relapsed while receiving placebo in a multinational relapse prevention clinical trial. Patients underwent an initial open-label treatment phase of 33 weeks (comprising a 9-week transition phase to switch patients to paliperidone palmitate, a 12-week flexible-dose phase and a 12-week fixed-dose phase); a double-blind phase of variable duration during which stabilized patients were randomized 1:1 to either continue paliperidone palmitate or receive placebo; and an optional 52-week open-label flexible-dose extension phase. There was a small but significant increase in PANSS total scores after eight months of treatment following relapse (56.7[12.68]) compared with prerelapse endpoint (54.5[11.74]) (p=0.026). Fourteen of 97 (14.4%) patients who had initially responded favorably to treatment met predefined nonresponse criteria in the postrelapse treatment phase, suggesting that treatment refractoriness may evolve in a subset of patients after relapse. However, relapses occurred in 18% of patients randomized to ongoing treatment in the double-blind phase, raising the possibility that treatment failure may also evolve in patients receiving continuous treatment. These findings may help inform decisions regarding the future of placebo-controlled trials in schizophrenia.

Minimum clinically important difference in the Positive and Negative Syndrome Scale with data from the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE)

CONTEXT

Establishing the minimum clinically important difference in the Positive and Negative Syndrome Scale (PANSS) is important to the interpretation of the research and clinical work conducted with this scale.

METHOD

This study employed both anchor-based and distributive methods to estimate the minimum clinically important difference for the PANSS by using data from the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) schizophrenia trial, a large, multicenter trial for patients with schizophrenia. By using an equipercentile method, data from 1,442 individuals linked PANSS scores with both clinician and patient ratings on the Clinical Global Impressions scale (CGI). Data were also used to investigate the magnitude of the standard error of measurement (SEM), offering another estimate of the minimum clinically important difference.

RESULTS

Cross-sectional, clinician-rated CGI-Severity of illness scores of 1 through 7 linked to PANSS scores of 32.4, 42.2, 57.5, 74.5, 93.0, 110.9, and 131.0, respectively. The minimum clinically important difference for PANSS scores using this scale equaled a 15.3-point (34.0%) change from baseline. A 1.96 SEM on the PANSS corresponded to a 16.5-point (36.2%) change from baseline. The minimum clinically important difference for a subsample with above-median baseline PANSS scores was 38% higher than a sample with lower baseline scores. With the patient-rated CGI as the anchor, PANSS scores were higher for CGI scores of 1 through 4, and the minimum clinically important difference was lower, 11.2 points (24.6%).

CONCLUSION

Minimum clinically important difference estimates from a longer-term effectiveness trial were consistent with previous efforts from shorter-term efficacy trials. Minimum clinically important difference estimates can help clinicians and researchers design future studies and interpret treatment change in future research and clinical work.

Comparing the PANSS in Chinese and American inpatients: cross-cultural psychiatric analyses of instrument translation and implementation

This article compares data from the Positive and Negative Syndrome Scale (PANSS) collected from Chinese and American inpatients diagnosed with schizophrenia to show how patterned differences in item ratings may reflect cultural attitudes of the raters. The Chinese sample (N=553) was based on consecutive admissions to four academic hospitals in Changsha, China. Only patients ill for 3 or more years were included in the analysis to match the chronically ill sample represented in the US CATIE sample. A total of 261 PANSS assessments were completed during a month when CATIE subjects had been hospitalized for 15 days or more to optimize equivalence of the US and Chinese samples. Controlling for age and gender, the total PANSS and the three sub-scores were all significantly lower in the Chinese than in the US CATIE sample by 5-8% (all p<.05). However, on 9 items, the Chinese sample scored 10-30% higher than the US sample (all p<.05) and on 5 items they scored over 20% higher (all p<.0001). These items rated increased hostility, poorer attention, lack of judgment and insight, disturbance of volition, and poorer impulse control. We ascribe these differences to cultural variations in the ways individuals relate to others in their social environment within Chinese and American societies.

The association between weight change and symptom reduction in the CATIE schizophrenia trial

BACKGROUND

Weight gain and changes in metabolic indicators associated with some antipsychotics may be related to symptom improvement and thus an unavoidable correlate of clinical benefit.

METHODS

Data from the CATIE schizophrenia trial comparing the effectiveness of perphenazine, olanzapine, risperidone, quetiapine and ziprasidone in a randomized, double-blind, trial over 18 months were used to evaluate the relationship between percent change in body mass index (BMI) and change in total serum cholesterol and triglycerides with the Positive and Negative Syndrome Scale (PANSS) score. Analysis of covariance for observations at 3 months and a mixed effects model for all observations up to 18 months adjusted for potentially confounding variables were used to examine these associations.

RESULTS

In both models, there was a significant association (p = 0.001) between change in PANSS total score and percent change in BMI, equating to a 0.28 and 0.21 point decrease in PANSS total score (range 30-210) per 1% increase in BMI respectively. Change in BMI accounted for 3% or less of variance for change in PANSS scores. There was no evidence that the association of symptoms and weight gain differed across medications in spite of substantial differences in weight gain and other metabolic measures. Neither total serum cholesterol nor triglyceride levels displayed a significant association with change in PANSS.

CONCLUSION

The magnitude of the relationship between change in BMI and PANSS was too small to be clinically important, indicating that switching medications to one with less metabolic risk is unlikely to result in meaningful loss of clinical benefit.

Second generation antipsychotics improve sexual dysfunction in schizophrenia: a randomised controlled trial

The impact of antipsychotic drug treatment on sexual function was investigated during a randomised trial comparing first generation antipsychotics (FGAs) to (nonclozapine) second generation antipsychotics (SGAs). Sexual function and quality of life were (rater-blind) assessed in 42 patients with DSM-IV schizophrenia (aged 18-65) using the self-report version of the Derogatis Interview for Sexual Function (DISF-SR) and the Heinrichs Quality of Life Scale (QLS), prior to, and 12 weeks following, a change in medication from an FGA drug to either an FGA or SGA drug. SGAs significantly improved sexual function compared to FGAs. Change in sexual function was associated with change in quality of life. Where impaired sexual functioning is a distressing adverse effect of treatment with an FGA agent, consideration should be given to switching to an SGA.

Neuroplasticity-based cognitive training in schizophrenia: an interim report on the effects 6 months later

BACKGROUND

New cognitive treatments for schizophrenia are needed that drive persistent gains in cognition and functioning. Using an innovative neuroplasticity-based cognitive training approach, we report our interim findings on the effects on cognition and functional outcome at 6 months after treatment.

METHODS

Thirty-two clinically stable schizophrenia subjects were randomly assigned to either targeted cognitive training (TCT, N = 22) or a computer games (CGs) control condition (N = 10). Twelve TCT subjects completed 50 hours of auditory based training; 10 TCT subjects completed an additional 50 hours of training targeting visual and cognitive control processes. Subjects were assessed on neurocognition and functional outcome after training and at 6-month follow-up.

RESULTS

Both TCT subject groups showed significant durable gains at 6 months on measures of verbal learning/memory and cognitive control. Only TCT subjects who completed 100 hours of training showed durable gains on processing speed and global cognition, with nonsignificant improvement in functional outcome. Improved cognition was significantly associated with improved functional outcome at 6 months for TCT subjects.

CONCLUSIONS

A total of 50 hours of neuroplasticity-based computerized cognitive training appears sufficient to drive improvements in verbal learning/memory and cognitive control that endure 6 months beyond the intervention, but a higher "dose" and more "broad-spectrum" training may be necessary to drive enduring gains in processing speed and global cognition. Training-induced cognitive improvement is related to enhanced functioning at 6 months. These data suggest that (1) higher and "broader" doses of cognitive training may confer the most benefits for schizophrenia patients; (2) the posttraining period opens a critical window for aggressive adjunctive psychosocial rehabilitation.

Personal and social functioning in schizophrenia: defining a clinically meaningful measure of maintenance in relapse prevention

BACKGROUND

Relapse prevention and maintenance of social functioning are important treatment objectives in the long-term management of schizophrenia. However, relatively little is known about measuring maintenance of social functioning to assess treatment benefit in relapse prevention clinical trials or as a tool to predict relapse in clinical practice. This study aims (1) to define a clinically meaningful decrease in the Personal and Social Performance scale (PSP) to assess antipsychotic treatment benefit in terms of maintenance of functioning and (2) to explore the threshold value of PSP decline as a useful tool to predict relapse in clinical practice.

METHODS

This post hoc analysis of two similar placebo-controlled relapse prevention clinical trials consisted of an exploration of change in PSP that would represent a clinically important decrement to measure treatment benefit in terms of time to PSP decrement (ITT analysis set; Study 1: n = 205) and an assessment of predictive value of PSP decrement and relapse status (ITT analysis set; Study 2: n = 408).

RESULTS

A 10-point decrement in PSP score was the threshold value for a clinically meaningful decline in personal and social functioning in a relapse prevention trial (Study 1). A strong association was found with relapse status: 61% of subjects with at least a 10-point decrease in PSP experienced the decrement prior to (between start of double-blind phase and before day of relapse) or on the day of relapse (Study 2). Kaplan-Meier survival analysis of time to at least a 10-point decrement in PSP showed that the proportion of subjects who did not experience at least a 10-point PSP decrease was statistically significantly greater in the paliperidone palmitate group than in the placebo group (p = 0.0014) (Study 2).

CONCLUSIONS

Findings suggest a 10-point PSP decrement is a clinically relevant measure of maintenance of functioning in patients stabilized with antipsychotic therapy. Paliperidone palmitate demonstrated a statistically significant treatment benefit in terms of maintenance of functioning versus placebo. Furthermore, measuring a clinically relevant PSP decrement may be useful as an early functional indicator of relapse in clinical practice.

LIMITATIONS

The exploration and validation of the threshold value of change in the PSP was designed and conducted post hoc. Predictive value is limited by the frequency in which PSP assessments were carried out in these trials, underscoring the importance of regular assessment.

Progress in defining optimal treatment outcome in schizophrenia

Historically, schizophrenia has been associated with early-onset, persistent symptoms, and progressive decline accompanied by poor functional recovery. The advent of effective drugs in the 1950s improved symptom control, at least from the standpoint of positive features (e.g. hallucinations, delusions). However, even here the response was limited and efficacy in other symptom domains (cognitive, deficit/negative) was minimal. With clozapine as the prototype, the second-generation antipsychotics arrived in the 1990s with claims of improved tolerability, as well as greater and broader clinical efficacy, all of which was to translate to gains in functional outcome and quality of life. The capacity of these drugs to effect such changes has since been tempered, but it remains that the research and hope generated served as an impetus to redefine outcomes. A medical-based model, centred on pharmacotherapy and symptom resolution, has given way to a re-conceptualization of schizophrenia and treatment goals. There is a clearer distinction between clinical and functional outcomes, and, with this, greater attention has been given to these other symptom domains that curtail improvement in the latter. At the same time, a concerted shift to shared decision making has underscored quality-of-life issues that benefit from, but cannot be guaranteed by, either clinical or functional improvement. To this end, the field has now embraced a recovery model that is seen as a process, multidimensional and individualized, rather than dichotomous and symptom driven.

Reliability, validity and ability to detect change of the clinician-rated Personal and Social Performance scale in patients with acute symptoms of schizophrenia

OBJECTIVE

To describe the measurement properties of the Personal and Social Performance scale (PSP), a clinician-reported measure of severity of personal and social dysfunction, in subjects with acute symptoms of schizophrenia.

METHODS

Pooled data from three paliperidone extended-release clinical studies (n = 1665) and data from a separate noninterventional, cross-sectional, validation study (n = 299) were analyzed.

RESULTS

The PSP showed good interrater (intraclass correlation coefficient [ICC] = 0.87) and test-retest (ICCs > 0.90) reliability. Pearson correlation coefficient for association between baseline PSP and Positive and Negative Syndrome Scale (PANSS) total scores was -0.32 for subjects assessed by the same rater and -0.29 for subjects assessed by different raters, suggesting low overlap in measurement constructs between the PANSS and PSP. Spearman Rank correlation coefficient for association between baseline PSP and Clinical Global Impression-Severity (CGI-S) scores was -0.51 with the same rater and -0.15 with different raters. Hypothesized relationships between the PSP and the PANSS or CGI-S based on levels of disease severity were prospectively defined. These hypotheses were confirmed by analyses showing statistically significant differences between baseline mean PSP scores in subjects grouped by severity rating on the CGI-S (mild or less vs. at least moderate) (p < 0.001) and the PANSS ('low symptom severity' vs. 'high symptom severity') (p = 0.005). The PSP was sensitive to change based on statistically significant correlations between change in the PSP and change in the CGI-S (p < 0.001) and the PANSS (p < 0.001). Limitations of analyses include pooling data across studies, interrater reliability assessment in the validation study only, post hoc assessment of test-retest reliability in the paliperidone ER studies, different raters for the PSP and PANSS not specified in the paliperidone ER studies, PSP validity assessment based on the PANSS and the CGI-S as comparators rather than another social function instrument.

CONCLUSION

These initial reliability and validity assessments suggest the PSP has promise as a measure of social functioning in patients with acute symptoms of schizophrenia.

Clozapine versus typical neuroleptic medication for schizophrenia

BACKGROUND

Long-term drug treatment of schizophrenia with typical antipsychotics has limitations: 25 to 33% of patients have illnesses that are treatment-resistant. Clozapine is an antipsychotic drug, which is claimed to have superior efficacy and to cause fewer motor adverse effects than typical drugs for people with treatment-resistant illnesses. Clozapine carries a significant risk of serious blood disorders, which necessitates mandatory weekly blood monitoring at least during the first months of treatment.

OBJECTIVES

To evaluate the effects of clozapine compared with typical antipsychotic drugs in people with schizophrenia.

SEARCH STRATEGY

For the current update of this review (March 2006) we searched the Cochrane Schizophrenia Group Trials Register.

SELECTION CRITERIA

All relevant randomised clinical trials (RCTs).

DATA COLLECTION AND ANALYSIS

We extracted data independently. For dichotomous data we calculated relative risks (RR) and their 95% confidence intervals (CI) on an intention-to-treat basis, based on a fixed-effect model. We calculated numbers needed to treat/harm (NNT/NNH) where appropriate. For continuous data, we calculated weighted mean differences (WMD) again based on a fixed-effect model.

MAIN RESULTS

We have included 42 trials (3950 participants) in this review. Twenty-eight of the included studies are less than 13 weeks in duration, and, overall, trials were at significant risk of bias. We found no significant difference in the effects of clozapine and typical neuroleptic drugs for broad outcomes such as mortality, ability to work or suitability for discharge at the end of the study. Clinical improvements were seen more frequently in those taking clozapine (n=1119, 14 RCTs, RR 0.72 CI 0.7 to 0.8, NNT 6 CI 5 to 8). Also, participants given clozapine had fewer relapses than those on typical antipsychotic drugs (n=1303, RR 0.62 CI 0.5 to 0.8, NNT 21 CI 15 to 49). BPRS scores showed a greater reduction of symptoms in clozapine-treated patients, (n=1145, 16 RCTs, WMD -4.22 CI -5.4 to -3.1), although the data were heterogeneous (Chi(2) 0.0001, I(2) 66%). Short-term data from the SANS negative symptom scores favoured clozapine (n=196, 5 RCTs, WMD -5.92 CI -7.8 to -4.1). We found clozapine to be more acceptable in long-term treatment than conventional antipsychotic drugs (n=982, 16 RCTs, RR 0.60 CI 0.5 to 0.7, NNT 15 CI 12 to 20). Blood problems occurred more frequently in participants receiving clozapine (3.2%) compared with those given typical antipsychotics (0%) (n=1031, 13 RCTs, RR 7.09 CI 2.0 to 25.6). Clozapine participants experienced more drowsiness, hypersalivation, or temperature increase, than those given conventional neuroleptics. However, clozapine patients experienced fewer motor adverse effects (n=1433, 18 RCTs, RR 0.58 CI 0.5 to 0.7, NNT 5 CI 4 to 6).The clinical effects of clozapine were more pronounced in participants resistant to typical neuroleptics in terms of clinical improvement (n=370, 4 RCTs, RR 0.71 CI 0.6 to 0.8, NNT 4 CI 3 to 6) and symptom reduction. Thirty-four per cent of treatment-resistant participants had a clinical improvement with clozapine treatment.

AUTHORS' CONCLUSIONS

Clozapine may be more effective in reducing symptoms of schizophrenia, producing clinically meaningful improvements and postponing relapse, than typical antipsychotic drugs - but data are weak and prone to bias. Participants were more satisfied with clozapine treatment than with typical neuroleptic treatment. The clinical effect of clozapine, however, is, at least in the short term, not reflected in measures of global functioning such as ability to leave the hospital and maintain an occupation. The short-term benefits of clozapine have to be weighed against the risk of adverse effects. Within the context of trials, the potentially dangerous white blood cell decline seems to be more frequent in children and adolescents and in the elderly than in young adults or people of middle-age.The existing trials have largely neglected to assess the views of participants and their families on clozapine. More community-based long-term randomised trials are needed to evaluate the efficacy of clozapine on global and social functioning as trials in special groups such as people with learning disabilities.

Reliability, validity and ability to detect change of the Personal and Social Performance scale in patients with stable schizophrenia

This report describes the measurement properties of the Personal and Social Performance scale (PSP), a clinician-reported measure of severity of personal and social dysfunction, in an outpatient population with stabilized schizophrenia. Pooled data from two similar antipsychotic clinical studies were analyzed (n=411). The PSP showed good test-retest reliability (intraclass correlation coefficient=0.79). The PSP was more highly correlated with the Strauss-Carpenter Level of Function, an instrument measuring a similar construct, than the Positive and Negative Syndrome Scale, an instrument measuring a different construct. There was a statistically significant difference between mean PSP scores in subjects grouped by their severity rating on the Clinical Global Impression-Severity (CGI-S) (mild or less versus at least moderate), indicating the ability to discriminate between known groups. Effect sizes for mean change in the PSP based on 1-category improvement (0.72) or worsening (-0.88) versus no change in the CGI-S were moderate to large, demonstrating the ability to detect change. Estimates of between-group minimum important difference suggest that a 7-point improvement in the PSP may be clinically meaningful in a clinical trial setting. Initial reliability and validity assessments suggest the PSP may be a useful measure of social functioning in patients with stable schizophrenia.

Temporal relationship between change in cognition and change in functioning in schizophrenia

Most research establishing the relationship between cognition and functioning in schizophrenia has been conducted cross-sectionally, leaving unanswered the question of whether there is a predictive relationship between temporal change in cognition and temporal change in functioning. In the present study, we used longitudinal mixed models to examine the relationship between change in cognition and change in Quality of Life (QLS), as measured over three time-points spanning a 12-month period, for 151 schizophrenia outpatients participating in work therapy with or without cognitive remediation. Memory and executive function changes were significant predictors of improved QLS total. Whereas the relationship between memory and QLS total was in the expected direction, with improvements in memory associated with improvements in QLS, the relationship between executive function and QLS was negative, with QLS improvements associated with declines in executive function. Similar patterns were found for individual QLS domains. Finally, there were positive cross-sectional relationships between QLS and hours worked as well as gender (female gender associated with better QLS). Lag models supported these results. Differences between these findings and previous studies are discussed along with functional assessment issues and the potential moderators of the relationship between cognitive change and functioning.

Symptom rating scales and outcome in schizophrenia

BACKGROUND

Symptom rating scales are now well established in schizophrenia research but their scores are not the same as outcome.

AIMS

To appraise the usefulness of symptom rating scales in evaluating the outcome of people with schizophrenia.

METHOD

Literature on the use of the Brief Psychiatric Rating Scale (BPRS) the Positive and Negative Syndrome Scale (PANSS) and the Clinical Global Impression (CGI) in schizophrenia research was studied.

RESULTS

Scales were designed to make diagnoses, to categorise patients, syndromes or both, and to demonstrate antipsychotic efficacy, as well as to measure outcome. There is much redundancy both between and within scales. Early work suggests limited concurrent validity with external outcome variables. Data are at best ordinal and there are particular difficulties in equating outcome with percentage changes in scores. The concept of remission, which uses absolute item score thresholds with a duration criterion, is a promising outcome measure.

CONCLUSIONS

Symptom rating scale scores can only comprise a limited part of outcome measurement. Standardised remission criteria may present advantages in outcome research.

Aripiprazole augmentation in the management of residual symptoms in clozapine-treated outpatients with chronic schizophrenia: An open-label pilot study

OBJECTIVE

The aim of this study was to investigate whether augmentation of clozapine with aripiprazole improves clinically significant residual symptoms in stabilized outpatients with chronic schizophrenia.

METHODS

Twenty seven stabilized outpatients meeting criteria for chronic schizophrenia, who had residual symptoms despite clozapine treatment, were assigned to receive oral aripiprazole (15 mg/day) for a period of 16 weeks. Patients remained on clozapine (100-900 mg/day) for at least 12 months, prior to study initiation. Symptoms assessments were made with the Positive and Negative Symptom Scale (PANSS), the Montgomery-Asberg Depression Rating Scale (MADRS), and the Mini-Mental State Examination (MMSE), at baseline and at weeks 4, 8, 12, and 16. The Quality of Life Scale (QLS) was administered at baseline and at week 16.

RESULTS

There was a statistically significant improvement in the mean scores for PANSS (p<0.05), PANSS negative (p<0.001), MADRS (p<0.05), MMSE (p<0.01), and QLS (p<0.05), but not for PANSS positive (p>0.05). Extrapyramidal side effects (as assessed by the Simpson-Angus Scale and the Abnormal Involuntary Movement Scale) did not vary significantly at any point of the study. No statistically significant change was observed in prolactin levels and body weight. Results were similar for the intention-to-treat (n=27) and completer (n=23) groups.

CONCLUSIONS

Aripiprazole augmentation in a group of chronic schizophrenic outpatients treated with clozapine led to a substantial improvement in clinically significant residual symptoms, such as negative-depressive symptoms, cognitive impairment and quality of life, without worsening the side effect burden.

The relationship between patient satisfaction and treatment outcomes in schizophrenia

In recent years, the goals of treatment in schizophrenia have evolved from objective improvements in psychotic symptoms to encompass patient-related factors such as subjective response and quality of life. In order to examine factors that influence patient satisfaction with treatment, subjective quality of life and subjective response to treatment, two literature searches were performed using PubMed. The first searched for articles of any kind with no time limits using the search parameters 'schizophrenia AND satisfaction', 'antipsychotic AND satisfaction', 'schizophrenia AND subjective response', 'schizophrenia AND therapeutic alliance', 'schizophrenia AND psychosocial OR psychoeducation'. Secondly, PubMed was searched between January 1990 and December 2005 using the key words 'satisfaction', 'subjective response' and 'quality of life' in combination with an array of atypical agents. Results demonstrated that patient satisfaction with antipsychotic therapy is influenced by multiple factors. The most frequently reported reasons for dissatisfaction include drug side effects, lack of involvement in treatment planning or decision-making and lack of involvement of family members in the care plan. The majority of studies have demonstrated that the atypical antipsychotics are associated with significant improvements in quality of life, functional status and patient satisfaction compared with conventional agents. The therapeutic alliance is key to achieving optimal outcomes, by providing information and education to meet patients' needs, while facilitating compliance with drug therapy to ensure better clinical outcomes. A long-acting atypical antipsychotic that can ensure medication delivery will provide a platform for psychosocial interventions, and thus may further increase patient satisfaction and, ultimately, improve long-term outcomes in schizophrenia.

Measuring changes in functional status among patients with schizophrenia: the link with cognitive impairment

Cognitive impairment associated with schizophrenia (CIAS) includes neuropsychological deficits in attention, working memory, verbal learning, and problem solving. These deficits have been shown to be linked to impairment in functional status (eg, social behavior, work performance, and activities of daily living) among patients with schizophrenia in cross-sectional studies. Less is known about the relationship between cognitive and functional change over time, such as potential functional implications of treatment-related improvement in CIAS. The purpose of this review is to summarize research on the association between change in CIAS and change in functional status, to discuss responsiveness of functional outcomes measures, and to provide recommendations for future research and measure development. Nine longitudinal studies were located on the link between CIAS and functional status, and 8 functional outcomes measures were used across these studies. The 9 studies offer initial support for a link between change in cognitive function and change in functional status. However, inconsistent findings across studies indicate that available research is preliminary, and substantial questions remain unanswered. Shortcomings of functional status measures are noted: most instruments were not developed for the target population, and none have demonstrated responsiveness to cognitive change among schizophrenic patients. It is recommended that new functional outcome measures be developed that are specifically designed to be responsive to change in cognition, with domains previously shown to be related to cognitive ability. When creating new functional outcomes measures for assessment of patients with schizophrenia, responsiveness to change in CIAS should be evaluated as part of the development and validation process.

Assessing health-related quality of life in patients suffering from schizophrenia: a comparison of instruments

OBJECTIVE

To compare three different kinds of health-related quality of life (HRQL) questionnaires available for use in patients suffering from schizophrenia: the SF-36 (a generic instrument), the QoLI (an instrument designed to a broad range of mental illnesses), the S-QoL (a questionnaire specific to schizophrenic patients), in terms of external validity and sensitivity to change.

METHODS

Two hundred and five patients were included at D0 and one-third retested at D30. Socio-demographic data and clinical history were recorded, clinical evaluation comprised psychotic symptoms (PANSS), depression (Calgary depression scale for schizophrenia), global functioning (GAF), clinical severity (CGI), and extrapyramidal symptoms (ESRS). HRQL was assessed using the SF-36, the QoLI and the S-QoL.

RESULTS

A better agreement is observed between the SF-36 and the S-QoL than between the QoLI and the two other instruments. S-QoL and SF-36 are more strongly correlated with clinical status than QoLI. Compared to the SF-36 and the QoLI, the S-QoL better discriminates patients with comorbidity from others. The S-QoL shows better responsiveness than the QoLI and the SF-36.

CONCLUSION

For descriptive purpose, either generic tools like SF-36 or specific ones should be used, whereas when aiming at evaluating health treatment and care for schizophrenic patients, specific instruments like the S-QoL should be favoured.

Lack of extrapyramidal side effects predicts quality of life in outpatients treated with clozapine or with typical antipsychotics

We compared symptom severity and quality of life (QOL) in schizophrenic patients adequately treated with typical antipsychotics (TAP) or clozapine (CZP). Groups did not differ in symptom severity or QOL. Clozapine caused fewer extrapyramidal symptoms. Negative and extrapyramidal symptoms predicted QOL. Similar outcome in both groups suggests a common ceiling to antipsychotic efficacy.

Bipolar disorder and health-related quality of life : review of burden of disease and clinical trials

Bipolar disorder is a chronic psychiatric disorder with a variable course and significant impact on patients' social, occupational, and general functioning and wellbeing. Although there are effective pharmaceutical and psychosocial interventions for patients with bipolar disorder, many patients receive poor-quality care. Prospective longitudinal studies demonstrate that less than half of bipolar disorder patients have a good long-term response to treatment, long-term outcome is highly variable, and many patients do not fully recover. There is substantial evidence that bipolar disorder is associated with significant impairment to functioning and wellbeing.However, few clinical trials comparing treatments for bipolar disorder have incorporated health-related quality-of-life (HR-QOL) assessments. Existing studies suggest that, while treatment improves HR-QOL, there is limited evidence for differences between the mood stabilisers in terms of HR-QOL outcomes. Additional clinical trials are needed to evaluate patient-reported outcomes associated with the most frequently used pharmacological treatments to determine whether there are meaningful differences between treatments. There are challenges in measuring HR-QOL in patients with acute mania, and future studies should assess the psychometric qualities of HR-QOL instruments in these and other bipolar disorder patients. HR-QOL outcome data may be useful in informing psychiatrists, patients and patient family members of the effects of treatment for bipolar disorder on patients' everyday lives, functioning and wellbeing.

Demographic, clinical, and neurocognitive predictors of quality of life in schizophrenia patients receiving conventional neuroleptics

We sought to evaluate demographic, clinical, and neurocognitive predictors of self-rated life quality and hospitalization in schizophrenia patients without the potentially cognition-enhancing influence of newer generation neuroleptic medication. A sample of 55 atypical neuroleptic-naive schizophrenia patients was assessed at index and 3 years later. Index neurocognitive measures included general intellectual ability (IQ), executive ability (Wisconsin Card Sorting Test [WCST]), verbal memory (California Verbal Learning Test [CVLT]), and manual dexterity (Purdue Pegboard). These measures, along with demographic (age, sex, education) and clinical (symptoms, prior hospitalizations) variables, were entered into regression equations to predict life quality (Sickness Impact Profile [SIP]) at follow-up, as well as rehospitalization during the 3-year period. Stability data were also analyzed. Demographic and cognitive data predicted subjective quality of life, but not rehospitalization. Changes in memory over time rather than performance levels related to life quality at follow-up. Rehospitalization was related only to demographic data and previous hospital admissions. The findings support the predictive value of selected aspects of neurocognition in relation to a subjective outcome domain in schizophrenia.

Quetiapine in hospitalized patients with schizophrenia refractory to treatment with first-generation antipsychotics: a 4-week, flexible-dose, single-blind, exploratory, pilot trial

This short-term, single-blind, pilot trial was initiated to investigate the usefulness of quetiapine therapy in the treatment of schizophrenic patients refractory to first-generation antipsychotics. Following a neuroleptic-free period prior to study entry (at least 1 week for oral formulations and 6 weeks for depot formulations), quetiapine was started at 50 mg/day and titrated up to 500 mg/day by Day 6. This 500 mg daily dose was then maintained or increased up to a maximum of 750 mg/day, at the discretion of the treating physician, who was aware of the antipsychotic prescribed. Efficacy measures were represented by changes in total and component PANSS score from baseline to different intervals. Safety and tolerability were evaluated by monitoring the spontaneously referred moderate-to-severe adverse events, changes from baseline in SAS, BARS, and AIMS scores, supplementary use of flurazepam, lorazepam, and benztropine, clinically relevant physical changes, abnormalities in vital signs, blood chemistry, and hematology, and modifications in QTc interval and body weight. Rating scale assessments, categorization of adverse events, determination of physical examination, vital signs, and body weight were performed by a qualified physician blind to the particular antipsychotic under investigation and the aims of the study. All 12 patients completed the 4-week quetiapine treatment course. Mean total PANSS scores were significantly reduced between baseline and study endpoint (p=0.006). Five out of six PANSS subcomponent scores also showed significant decreases (p < 0.05). Six patients showed a reduction of > or = 20% in PANSS total score by the final day of quetiapine treatment, so were classified as responders. There were responders in all schizophrenia diagnostic subgroups (undifferentiated, paranoid, and disorganized). Two patients reported moderate adverse events. One patient received 3 days of benztropine therapy for EPS and five received flurazepam for insomnia. Weight change was minimal and mean SAS, BARS, and AIMS scores all showed nonsignificant decreases between baseline and endpoint. The 50% quetiapine response rate reported here in refractory patients is comparable with those previously reported for other atypical antipsychotics in populations of both refractory and intolerant patients.

Development and validation of a patient-based health-related quality of life questionnaire in schizophrenia: the S-QoL

We developed a self-administered instrument to assess health-related quality of life (HRQL) among people with schizophrenia. The S-QoL, based on Calman's approach to the subject's point of view, is a multidimensional instrument that is sensitive to change. The scale is a 41-item questionnaire with eight subscales (psychological well-being, self-esteem, family relationships, relationships with friends, resilience, physical well-being, autonomy and sentimental life) and a total score. In-depth interviews with patients determined the pertinent issues for item development. The validation study, performed with 207 patients, showed high internal consistency reliability, reproducibility and responsiveness. Construct validity was confirmed using established clinical and HRQL measures. S-QoL covers domains that differ from areas tapped in other measures, with greater responsiveness. The S-QoL is an efficient instrument for the measurement of the impact of schizophrenia on individuals' lives.

Development of an abbreviated schizophrenia quality of life scale using a new method

The goal of the study was to develop and apply a predictive model approach to reduce the number of items collected for scales that yield a total summary score. A parsimonious subset of items from the 21-item Quality of Life Scale (QLS) that can accurately predict the total scale score was sought and evaluated in 198 patients with schizophrenia, using a statistical modeling approach. Two additional data sets were used for model validation: the subset of 101 patients used in the model construction who had the QLS administered approximately 1 year later and a new sample of 37 patients. Using only seven QLS items as predictors, the correlation was 0.9831 between the predicted and true QLS totals. Applying the model based for these seven QLS items, the correlations from the first and second validation data sets were 0.9791 and 0.9637, respectively. The study demonstrates that a small subset of items of the QLS predicts the entire 21-item scale with high accuracy. Two validation samples have confirmed the finding. This reduces the effort associated with scale administration and is likely to increase the assessment of an important functional domain. Such models can guide efforts for item reduction in other rating instruments.

Differential effects of high-dose amisulpride versus flupentixol on latent dimensions of depressive and negative symptomatology in acute schizophrenia: an evaluation using confirmatory factor analysis

While many acutely ill schizophrenic patients suffer from depressive symptoms, most studies on the efficacy of antipsychotic drugs focus on positive and negative symptoms. Dimensional models of schizophrenic symptoms, based on confirmatory factor analysis (CFA) using structural equation modelling, offer a methodological alternative to compare antipsychotics on empirically justified latent factors. The present report is a refined analysis of a published double-blind study on the D2/D3-selective antagonist amisulpride (ASP) versus the mixed D1-5/5-HT2 antagonist flupentixol (FPX). CFA was applied to Brief Psychiatric Rating Scale, Scale for the Assessment of Negative Symptoms, Bech-Rafaelsen Melancholia Scale and Simpson-Angus Scale subscores to examine differential effects of high doses of ASP and FPX on negative and depressive symptom dimensions in 126 acutely ill schizophrenic patients. A four-factor model comprising the full spectrum of acute symptomatology and a three-factor model ('negative', 'anhedonia-apathy', 'depressive') restricted to negative and depressive symptoms were yielded with an identical 'depressive' dimension in both models. Analyses of CFA-derived factor scores showed that ASP was significantly superior to FPX regarding the latent 'depressive' dimension, independent of baseline scores, dosage and changes in akinesia. Neither the negative' dimension nor 'anhedonia-apathy' showed significantly different treatment effects. CFA-based analyses appear to be suitable for psychotropic drug evaluation when more refined and data-related information on drug efficacy profiles are required.