A standardized psychiatric assessment scale for rating chronic psychotic patients

Value-based outcome evaluation methods used by occupational therapists in primary care: a scoping review

OBJECTIVE

This scoping review aimed to map how occupational therapists evaluate the outcomes of services they provide within primary care. This evidence was considered in relation to how identified outcome evaluation methods align to principles of value-based health care.

INTRODUCTION

Primary care services are experiencing unprecedented demands. Occupational therapy is an allied health profession that supports health and care provision in primary care, using a timely and proactive approach. There has been a notable increase in occupational therapy roles across primary care services in the past decade; however, the mechanisms for evaluating outcomes and the wider impact of these services remain under-researched. The aim of value-based health care, a global transformative approach, is to establish better health outcomes for individuals and communities through addressing value in system-wide care. However, it is not yet clear how evaluation methods used within occupational therapy align to the principles of a value-based agenda.

INCLUSION CRITERIA

Peer-reviewed journal articles and gray literature written in English were included to identify outcome evaluation methods used by occupational therapists to evaluate the effectiveness and impact of occupational therapy services provided in a primary care setting. Outcome evaluation methods used exclusively for the purpose of conducting research and not for capturing data within an occupational therapy primary care setting as part of routine clinical practice were excluded.

METHODS

This review followed JBI methodology for scoping reviews. The literature search was undertaken during June and July 2022. The following databases were searched from their earliest dates of availability: Cochrane Library, MEDLINE via Ovid, Embase via Ovid, CINAHL via EBSCOhost, Scopus, AMED, and Web of Science Core Collection. Two reviewers extracted data, supported by an extraction form developed by the reviewers. Findings were mapped using a framework developed based on key principles of value-based health care.

RESULTS

From 2394 articles, 16 eligible studies were included in the review. Of these, 9 were quantitative and 7 were of mixed methods design. Studies were from the UK, USA, Sweden, Spain, and Canada. The occupational therapy services represented were mainly heterogeneous. Four services were part of multidisciplinary programs of care and 12 services were specific to occupational therapy. Identified outcome evaluation methods broadly aligned to principles of value-based health care, with most alignment noted for measures demonstrating the aim of establishing better health. A wide range of evaluation methods were described to address both individual-level and service-level outcomes, with the use of patient-reported outcome measures identified in 13 studies. To capture patient experience, most studies reported a variety of methods. The aim of reducing the per capita cost of health care was least represented in the literature.

CONCLUSION

This scoping review highlights a multifaceted but inconsistent approach to measuring the outcomes of occupational therapy provided in primary care. This has implications for establishing effectiveness and capturing data at scale to assist with wider planning of care and to enable the profession to demonstrate its contribution to value-based health care.

REVIEW REGISTRATION

Open Science Framework https://osf.io/hnaq4/.

Clinician-Reported Negative Symptom Scales: A Systematic Review of Measurement Properties

BACKGROUND

Negative symptoms of schizophrenia are correlated with reduction of normal function and lower quality of life. They were newly defined by the NIMH-MATRICS Consensus in 2005, dividing the rating tools to assess them into first-generation scales, developed before the Consensus, and second-generation scales, based on the recently introduced definitions.

METHODS

The COnsensus-based Standards for the selection of health Measurement Instrument (COSMIN) guidelines for systematic reviews were used to evaluate the quality of psychometric data of the first-generation scales that cover the 5 negative symptom domains of the NIMHS Consensus: the Scale for the Assessment of Negative Symptoms (SANS), the High Royds Evaluation of Negativity Scale (HEN), and the Negative Symptom Assessment-16 (NSA-16).

RESULTS

The search strategy resulted in the inclusion of a total of 13 articles, 7 for the SANS, 4 for the NSA-16, and 2 for the HEN. For the SANS and the NSA-16, the overall results of the scales' measurement properties are mostly insufficient or indeterminate. The quality of evidence for the HEN is poor, due to a small number of validation studies/included patients.

CONCLUSIONS

After applying the COSMIN guidelines, we do not recommend the usage of these first-generation scales to rate negative symptoms. At the minimum they require further validation.

A network meta-analysis of efficacy, acceptability, and tolerability of antipsychotics in treatment-resistant schizophrenia

OBJECTIVE

Clozapine is considered as the standard treatment for this subgroup, but the evidence is not unequivocal. There are several potential alternatives being used because of the possible adverse effects of clozapine. We aimed to examine the efficacy and adverse events of different antipsychotics in treatment-resistant schizophrenia by performing a network meta-analysis.

METHODS

We searched the Cochrane Schizophrenia Group register for randomized-controlled trials (up to March 06, 2022) and MEDLINE (up to January 20, 2023). We included blinded and open studies and participants with a broad definition of treatment resistance. The primary outcome was overall symptoms of schizophrenia; secondary outcomes were response to treatment, positive and negative symptoms of schizophrenia, discontinuation, side effects, quality of life, and functioning. The study was registered in Open Science Framework ( https://osf.io/9nf2y/ ).

RESULTS

We included 60 studies involving 6838 participants in the network meta-analysis. In the primary outcome, clozapine and olanzapine were more efficacious than risperidone, haloperidol, fluphenazine, sertindole, chlorpromazine, and quetiapine (range of mean SMDs, - 0.11 to - 0.48). The difference between clozapine and olanzapine was trivial and uncertain (SMD - 0.05, 95% CI, - 0.21 to 0.11). The result of other efficacy outcomes as well as subgroup and sensitivity analyses were consistent with the primary analysis. Clozapine and olanzapine were associated with more weight gain, and clozapine was associated with more sedation events compared to many other antipsychotics.

CONCLUSIONS

Clozapine remains the gold standard for patients with treatment-resistant schizophrenia. Olanzapine seems to be second-best and could be tried before switching to clozapine.

Five-week music therapy improves overall symptoms in schizophrenia by modulating theta and gamma oscillations

Introduction

Some clinical studies have shown that music therapy as an adjunctive therapy can improve overall symptoms in patients with schizophrenia. However, the neural mechanisms of this improvement remain unclear due to insufficient neuroimaging evidence.

Methods

In this work, 17 patients with schizophrenia accepted a five-week music therapy (music group) that integrated listening, singing, and composing, and required patients to cooperate in a group to complete music therapy tasks. Meanwhile, 15 patients with schizophrenia received a five-week visual art intervention as the control group including handicraft and painting activities. We collected the Manchester Scale (MS) and Positive and Negative Symptom Scale (PANSS) scores and electroencephalography (EEG) data before and after intervention in two groups.

Results

Behavioral results showed that both interventions mentioned above can effectively help patients with schizophrenia relieve their overall symptoms, while a trend-level effect was observed in favor of music therapy. The EEG results indicated that music therapy can improve abnormal neural oscillations in schizophrenia which is reflected by a decrease in theta oscillation in the parietal lobe and an increase in gamma oscillation in the prefrontal lobe. In addition, correlation analysis showed that in the music group, both reductions in theta oscillations in the parietal lobe and increases in gamma oscillations in the prefrontal lobe were positively correlated with the improvement of overall symptoms.

Discussion

These findings help us to better understand the neural mechanisms by which music therapy improves overall symptoms in schizophrenia and provide more evidence for the application of music therapy in other psychiatric disorders.

The Brief negative Symptom Scale (BNSS): a systematic review of measurement properties

BACKGROUND

Negative symptoms of schizophrenia are linked with poor functioning and quality of life. Therefore, appropriate measurement tools to assess negative symptoms are needed. The NIMH-MATRICS Consensus defined five domains for negative symptoms, which The Brief Negative Symptom Scale (BNSS) covers.

METHODS

We used the COSMIN guidelines for systematic reviews to evaluate the quality of psychometric data of the BNSS scale as a Clinician-Rated Outcome Measure (ClinROM).

RESULTS

The search strategy resulted in the inclusion of 17 articles. When using the risk of bias checklist, there was a generally good quality in reporting of structural validity and hypothesis testing. Internal consistency, reliability and cross-cultural validity were of poorer quality. ClinROM development and content validity showed inadequate results. According to the updated criteria of good measurement properties, structural validity, internal consistency and interrater reliability showed good results, while hypothesis testing showed poorer results. Cross-cultural validity and test-retest reliability were indeterminate. The updated GRADE approach resulted in a moderate grade.

CONCLUSIONS

We can potentially recommend the use of the BNSS as a concise tool to rate negative symptoms. Due to weaknesses in certain domains further validations are warranted.

Pineal Abnormalities in Psychosis and Mood Disorders: A Systematic Review

The pineal gland (PG) is a small interhemispheric brain structure that influences human physiology in many ways, most importantly via secretion of the hormone melatonin which is known to regulate sleep and wakefulness. Here, we systematically reviewed existing neuroimaging studies of PG structure, and/or melatonin release (MLT) in psychosis and mood disorders. Medline, PubMed, and Web of Science databases were searched (on 3 February 2023), yielding 36 studies (8 PG volume, 24 MLT). The findings showed smaller-than-normal PG volume in people with schizophrenia, regardless of symptom severity and illness stage; and smaller-than-normal PG volume in major depression, with some indication of this being present only in certain subgroups, or in those with high scores on the 'loss of interest' symptom. There was considerable evidence of lower-than-normal MLT as well as aberrant MLT secretion pattern in schizophrenia. A similar picture, though less consistent than that seen in schizophrenia, emerged in major depression and bipolar disorder, with some evidence of a transient lowering of MLT following the initiation of certain antidepressants in drug-withdrawn patients. Overall, PG and MLT aberrations appear to represent transdiagnostic biomarkers for psychosis and mood disorders, but further work is needed to establish their clinical correlates and treatment implications.

Long-term outcomes of the recovery approach in a high-security mental health setting: a 20 year follow-up study

Background

This study examined the outcomes of a descriptive, longitudinal cohort consisting of 241 patients initially examined in a population study at the high secure State Hospital for Scotland and Northern Ireland in 1992-93. A partial follow-up focusing on patients with schizophrenia was conducted in 2000-01, followed by a comprehensive 20 year follow-up that began in 2014.

Aims

To explore what happens to patients who required high secure care during a 20 year follow-up period.

Method

Previously collected data were amalgamated with newly collected information to examine the recovery journey since baseline. Various sources were employed, including patient and keyworker interviews, case note reviews, and extraction from health and national records, and Police Scotland datasets.

Results

Over half of the cohort (56.0%) with available data resided outside secure services at some point during the follow-up period (mean 19.2 years), and only 12% of the cohort were unable to transition out of high secure care. The symptoms of psychosis improved, with statistically significant reductions observed in reported delusions, depression, and flattened affect. Reported sadness [according to the Montgomery-Åsberg Depression Rating Scale (MADRS)] at baseline, first, and 20 year follow-up interviews was negatively correlated with the questionnaire about the process of recovery (QPR) scores at the 20 year follow-up. However, qualitative data depicted progress and personal development. According to societal measures, there was little evidence of sustained social or functional recovery. The overall conviction rate post-baseline was 22.7%, with 7.9% violent recidivism. The cohort exhibited poor morbidity and mortality, with 36.9% of the cohort dying, primarily from natural causes (91%).

Conclusions

Overall, the findings showed positive outcomes in terms of movement out of high-security settings, symptom improvement, and low levels of recidivism. Notably, this cohort experienced a high rate of deaths and poor physical morbidity, along with a lack of sustained social recovery, particularly among those who had negotiated a path through services and who were current residents in the community. Social engagement, enhanced during residence in low secure or open ward settings, diminished significantly during the transition to the community. This is likely a result of self-protective measures adopted to mitigate societal stigma and the shift from a communal environment. Subjective depressive symptoms may impact broader aspects of recovery.

Thinking biases and their role in persecutory delusions: A systematic review

AIM

Thinking biases are posited to be involved in the genesis and maintenance of delusions. Persecutory delusions are one of the most commonly occurring delusional subtypes and cause substantial distress and disability to the individuals experiencing them. Their clinical relevance confers a rationale for investigating them. Particularly, this review aims to elucidate which cognitive biases are involved in their development and persistence.

METHODS

MEDLINE, Embase, PsycINFO and Global Health were searched from the year 2000 to June 2020. A formal narrative synthesis was employed to report the findings and a quality assessment of included studies was conducted.

RESULTS

Twenty five studies were included. Overall, 18 thinking biases were identified. Hostility and trustworthiness judgement biases appeared to be specific to persecutory delusions while jumping to conclusions, self-serving attributional biases and belief inflexibility were proposed to be more closely related to other delusional subtypes. While the majority of the biases identified were suggested to be involved in delusion maintenance, hostility biases, need for closure and personalizing attributional biases were believed to also have aetiological influences.

CONCLUSIONS

These findings show that some cognitive biases are specific to paranoid psychosis and appear to be involved in the formation and/or persistence of persecutory delusions.

Relocation of long-stay general psychiatric in-patients

The need for severely disabled long-stay general psychiatric in-patients to be resettled within their own districts is likely to arise increasingly as area mental hospitals close. The White Paper, Caring for People, acknowledges that some of these patients will continue to require hospital care. Transfer between hospitals might be considered a major life event for these patients, some of whom will have spent many years in the area mental hospital. Conflicting results have been found in studies of mortality rate following relocation (Morriss et al, 1988). Pryce's (1977) study with long-stay chronic schizophrenic patients and other more recent studies with new long-stay patients yielded data suggesting optimal environmental factors in keeping with Wing & Brown's (1970) observations.

Evaluation of positive and negative symptoms in schizophrenia

Most investigators concur that schizophrenia is probably a heterogeneous group of disorders that share the common features of psychotic symptoms, partial response to neuroleptics, and a relatively poor outcome. The subdivision of schizophrenia into two subtypes, positive versus negative, has achieved wide acceptance throughout the world during recent years. This distinction has heuristic and theoretical appeal because it unites phenomenology, pathophysiology, and etiology into a single comprehensive hypothesis.

In spite of its wide appeal, the distinction has a number of problems. These include the failure to distinguish between symptom syndromes and diseases; failure to deal with the mixed patient; failure to take longitudinal course into account; and failure to address conceptually and methodologically the distinction between positive and negative symptoms.

This paper focuses primarily on the conceptual basis for two instruments designed to measure positive and negative symptoms, the Scale for the Assessment of Negative Symptoms (SANS) and the Scale for the Assessment of Positive Symptoms (SAPS), originally described in 1982. Since their description, these scales have been used in a variety of other centers. These scales are based on the hypothesis that negative symptoms represent a deficit or diminution in normal psychological functions wliile positive symptoms represent an excess or distortion of normal functions. Reliability data are now available from Italy, Spain, and Japan which suggest that these scales can be used reliably in cultural settings outside the United States. The results of these studies are summarized in this paper. In addition, a replication study involving a new sample of 117 schizophrenics collected at the University of Iowa is described. In this second study of the SANS and SAPS, internal consistency is found to be quite high in the SANS. Thus negative symptoms appear to be more internally correlated with one another than are positive symptoms. The implications of this result are discussed. A principal components analysis is used to explore the relationship between positive and negative symptoms. While the study reported in 1982 suggested that positive and negative symptoms are negatively correlated, in the present study they appear to be uncorrelated. Overall, the results suggest that the SANS and SAPS are useful comprehensive instruments for the evaluation of positive and negative symptoms. The relationship between these symptoms and external validators such as cognitive functioning or CT scan abnormalities will be reported in a subsequent investigation.

Dexamethasone suppression test in chronic schizophrenia

Dexamethasone suppresson test (DST) was administered to 26 chronic schizophrenic inpatients who were on stable doses of neuroleptics for over 3 months. Clinical assessments were made on the Brief Psychiatric Rating Scale (BPRS), the Manchester Scale (KGV) and the Scale for the Assessment of Negative Symptoms (SANS). Patients’ neuroleptic treatment was then stopped for 4 weeks and the clinical assessements and the DST repeated. Thirty two percent of the patients showed DST non-suppression which was mostly stable over the 4-week period of the study and was unaffected by the neuroleptic treatment. Contrary to some reports in the literature, the clinical rating scores (including those for depression and negative symptoms), in our patients, showed no relationship with the DST status. We suggest that the DST abnormality in chronic schizophrenies may result from two quite different mechanisms: one due to stress assoeiated with transient psychopathology such as agitation, anxiety, depression or psychotic perturbation which is transient, the other resulting from structural abnormalities in the brain and which remains stable over time.

Long-term studies of antipsychotic drugs in schizophrenia

Studies on long-term efficacy and safety should be a main concern in the evaluation of novel antipsychotics. The present paper is a review of important issues related to the design and performance of such trials. The variability of the natural course of schizophrenia, the variability in treatment response, and the variability of actions of different neuroleptics need to be considered. Long-term studies need to address maintenance of efficacy, prevention of relapse and recurrence, health economics, quality of life and a large number of safety issues in order to get approval for new drug applications and reimbursement on expensive new medicines. Assessment instruments for efficacy, tolerability and safety, need to be supplemented with rating scales for various aspects of psychopathology (positive, negative, deficit symptoms), social and work functioning, drug induced mental side effects, quality of life and accounts of total treatment costs.

Lifetime psychopathological characteristics associated with comorbid obsessive-compulsive disorder in clinically stable patients with chronic schizophrenia

Obsessive-compulsive symptoms (OCS) commonly occur in the course of schizophrenia. The aim of this study was to investigate the rate of obsessive-compulsive disorder (OCD) in patients with chronic schizophrenia and evaluate lifetime correlates of the comorbidity. Subjects were clinically stable patients with chronic schizophrenia (n = 320). Patients having comorbid OCD and those without OCD were compared in terms of symptoms dimensions and cognitive function. OCD was found in 20.6 % of subjects. Earlier age at onset, male gender, higher level of education, comorbid panic disorder, and specific phobia were associated with comorbid OCD. In terms of lifetime symptoms, depression (p = 0.001) and anxiety (p = 0.014) showed significant association with the comorbidity, which corroborates with our previous study findings regarding OCD in bipolar disorder. In addition, decreased emotional response (p = 0.016), less formal thought disorder (p = 0.007), and less prodromal impairment (p = 0.005) were independently associated with the comorbidity. The OCD group showed better performance in working memory domain (p = 0.027) while other cognitive domains did not show any significant difference between the two groups. Association of OCSs with depressive symptoms and other comorbid anxiety disorders seems to be a common finding across schizophrenia and bipolar disorder. This study also suggests that comorbidity of OCD in schizophrenia is associated with less impairment of thought process and cognitive function throughout the disease course.

Is Utena's Brief Objective Measures (UBOM) useful in real-world behavioral assessment of functioning? Validity and utility testing in patients with schizophrenia

AIM

Utena's Brief Objective Measures (UBOM) was developed to assess psychophysiological functions proximal to real-world functioning in individuals with psychiatric disorders, including schizophrenia (SCZ), to facilitate shared decision-making. However, the validity of UBOM has not been fully examined.

METHODS

We conducted a cross-sectional observational study to evaluate the validity of each of the three tests in UBOM: UBOM-Pulse, UBOM-Ruler, and UBOM-Random. We investigated associations: (i) between UBOM and existing cognitive- and autonomic-function tests; and (ii) between UBOM and daily social functioning. The participants included SCZ individuals and healthy controls. We evaluated the cognitive and autonomic function using UBOM, the heart rate variability test, the simple reaction time test, and the Brief Assessment of Cognition in Schizophrenia, Japanese version. We also assessed the daily social functioning using the WHO Disability Assessment Schedule 2.0 and the modified Global Assessment of Functioning, Japanese version.

RESULTS

Thirty-one SCZ individuals and 35 healthy control individuals participated in this study. In the SCZ group, UBOM-Ruler was significantly associated with the Cognition and Getting Along domains of WHO Disability Assessment Schedule 2.0. UBOM-Random was significantly associated with the Brief Assessment of Cognition in Schizophrenia's Working Memory, Verbal Fluency and Attention domains, and the modified Global Assessment of Functioning in the SCZ group.

CONCLUSION

The validity of the current version of UBOM is imperfect and further improvements will be necessary to attain the originally intended goal of developing a brief assessment tool for real-world functioning in SCZ.

Childhood maltreatment and treatment outcome in psychotic disorders: a systematic review and meta-analysis

OBJECTIVE

Childhood maltreatment (CM) plays an important role in the aetiology and course of psychotic disorders and is associated with characteristics that could be relevant for treatment. We aimed to conduct a systematic review and meta-analysis on the association between CM and treatment outcome in psychotic disorders.

METHODS

Treatment outcome was defined as change in psychotic symptoms or in social or occupational functioning between first and last reported measurement in the course of a pharmacological and/or psychological treatment.

RESULTS

Twelve treatment results from seven studies (636 patients, average treatment duration: 59.2 weeks) were included. CM was related to poorer treatment outcomes in psychotic disorders (OR = 1.51, 95% CI = [1.08, 2.10]). There is evidence that this association might increase with illness duration and increasing age and might be stronger in schizophrenia samples.

CONCLUSIONS

Childhood maltreatment is highly understudied with regard to treatment outcome in psychotic disorders. The need for more studies is emphasized by the fact that this meta-analysis reveals evidence for a poorer treatment response in patients with CM. If this association is confirmed, the identification of patients with CM and the consideration of associated clinical and biological conditions could contribute to improve treatment outcome in psychotic disorders.

Are family warmth and positive remarks related to outcomes in psychosis? A systematic review

BACKGROUND

Affective attitudes and behaviours manifested within the family environment have been characterised as expressed emotion (EE). High EE environments have been robustly shown to put psychosis patients at a greater risk of relapse compared with low EE exposure. Positive EE dimensions (warmth; positive remarks) have received far less attention than negative EE dimensions such that EE has become synonymous with a negative family atmosphere; the predictive value of positive EE dimensions is largely ignored. A systematic review examining the relationship between positive family EE and outcomes in psychosis is needed.

METHODS

A systematic search was conducted. Studies reporting bias and study quality were assessed.

RESULTS

A total of 2368 studies were identified. Of these, 27 met eligibility criteria reporting outcomes including relapse, symptomatology, social functioning and life satisfaction. Relapse was the most commonly measured outcome. Stronger evidence emerged for the association between EE warmth and outcomes compared with EE positive remarks, with effects mostly evident in the early phase of psychosis. Evidence for protective effects of warmth on relapse was found up to 9 months follow-up. No effects were evident between positive remarks and relapse. Studies assessing symptom outcomes showed inconsistent findings. Evidence for an association with social functioning was evident, primarily in at risk mental states. Warmth and positive remarks predicted life satisfaction.

CONCLUSIONS

The positive aspects of EE require further investigation with longitudinal research designs. Clinical interventions should focus not only on reducing negative aspects of EE but also foster warmth within families in the context of psychosis.

An investigation of associations between experience of childhood trauma and political violence and theory of mind impairments in schizophrenia

There has been little examination of the association between trauma and cognitive deficits seen in individuals diagnosed with schizophrenia. Theory of Mind (ToM) impairments are a significant feature of schizophrenia but it remains unclear as to why these deficits are so prevalent in this population. This study aimed to explore associations between ToM deficits and specific forms of childhood adversities in a schizophrenia population. The study sample comprised of 66 adults with a confirmed diagnosis of schizophrenia, attending mental health services in Northern Ireland. Assessments were completed to ascertain if individuals had prior experience of sexual or physical abuse, emotional neglect or experience of the political violence of Northern Ireland's "Troubles", and the Gardner Hinting Test was applied to assess ToM ability. Backwards stepwise regression analyses demonstrated that emotional neglect, specifically during early childhood (0-6 years) predicted ToM impairments in this group. Conflict-related trauma was also associated with ToM but was not an independent significant predictor of ToM deficits. This is the first study to examine links between specific forms of childhood adversity and ToM impairments in individuals diagnosed with schizophrenia. Potential underpinning psychological mechanisms are considered and implications for clinical practice are discussed.

Attractor-like Dynamics in Belief Updating in Schizophrenia

Subjects with a diagnosis of schizophrenia (Scz) overweight unexpected evidence in probabilistic inference: such evidence becomes "aberrantly salient." A neurobiological explanation for this effect is that diminished synaptic gain (e.g., hypofunction of cortical NMDARs) in Scz destabilizes quasi-stable neuronal network states (or "attractors"). This attractor instability account predicts that (1) Scz would overweight unexpected evidence but underweight consistent evidence, (2) belief updating would be more vulnerable to stochastic fluctuations in neural activity, and (3) these effects would correlate. Hierarchical Bayesian belief updating models were tested in two independent datasets (n = 80 male and n = 167 female) comprising human subjects with Scz, and both clinical and nonclinical controls (some tested when unwell and on recovery) performing the "probability estimates" version of the beads task (a probabilistic inference task). Models with a standard learning rate, or including a parameter increasing updating to "disconfirmatory evidence," or a parameter encoding belief instability were formally compared. The "belief instability" model (based on the principles of attractor dynamics) had most evidence in all groups in both datasets. Two of four parameters differed between Scz and nonclinical controls in each dataset: belief instability and response stochasticity. These parameters correlated in both datasets. Furthermore, the clinical controls showed similar parameter distributions to Scz when unwell, but were no different from controls once recovered. These findings are consistent with the hypothesis that attractor network instability contributes to belief updating abnormalities in Scz, and suggest that similar changes may exist during acute illness in other psychiatric conditions.SIGNIFICANCE STATEMENT Subjects with a diagnosis of schizophrenia (Scz) make large adjustments to their beliefs following unexpected evidence, but also smaller adjustments than controls following consistent evidence. This has previously been construed as a bias toward "disconfirmatory" information, but a more mechanistic explanation may be that in Scz, neural firing patterns ("attractor states") are less stable and hence easily altered in response to both new evidence and stochastic neural firing. We model belief updating in Scz and controls in two independent datasets using a hierarchical Bayesian model, and show that all subjects are best fit by a model containing a belief instability parameter. Both this and a response stochasticity parameter are consistently altered in Scz, as the unstable attractor hypothesis predicts.

Patterns of schizophrenia symptoms: hidden structure in the PANSS questionnaire

The clinical presentation of patients with schizophrenia has long been described to be very heterogeneous. Coherent symptom profiles can probably be directly derived from behavioral manifestations quantified in medical questionnaires. The combination of machine learning algorithms and an international multi-site dataset (n = 218 patients) identified distinctive patterns underlying schizophrenia from the widespread PANSS questionnaire. Our clustering approach revealed a negative symptom patient group as well as a moderate and a severe group, giving further support for the existence of schizophrenia subtypes. Additionally, emerging regression analyses uncovered the most clinically predictive questionnaire items. Small subsets of PANSS items showed convincing forecasting performance in single patients. These item subsets encompassed the entire symptom spectrum confirming that the different facets of schizophrenia can be shown to enable improved clinical diagnosis and medical action in patients. Finally, we did not find evidence for complicated relationships among the PANSS items in our sample. Our collective results suggest that identifying best treatment for a given individual may be grounded in subtle item combinations that transcend the long-trusted positive, negative, and cognitive categories.

A clinimetric analysis of a BPRS-6 scale for schizophrenia severity

OBJECTIVE

A restricted Brief Psychiatric Rating Scale (BPRS-6) with the six schizophrenia specific items from the Positive and Negative Syndrome Scale (PANSS) has been investigated. These six items from the PANSS have recently been found to have both clinical validity and 'unidimensionality' in measuring the severity of schizophrenic states. The primary objective of this study was to evaluate the clinical validity of the BPRS-6. The secondary objective was to evaluate the 'unidimensionality' of the BPRS-6 by an 'item response theory' model.

METHODS

The BPRS-6 was scored independently by two psychiatrists and two psychologists while viewing six open-ended videotaped interviews in patients with a DSM-III diagnosis of schizophrenia. The interviews were conducted by Heinz E. Lehmann, an experienced psychiatrist. They were focused on the psychopathology that contributed most to the 'severity' of the patient's clinical state.

RESULTS

The BPRS-6 with three positive symptoms (delusions, conceptual disorganisation, hallucinations) and three negative symptoms (blunted affect, emotional withdrawal, poverty of speech) was found to be clinically valid and captured the variables that contribute most to the severity of schizophrenia. The BPRS-6 was also found to have acceptable 'unidimensionality' (coefficient of homogeneity 0.45) and inter-rater reliability (inter-class-coefficient 0.81).

CONCLUSION

The BPRS-6 was found to capture the information that translates into the severity of schizophrenia. It has also acceptable psychometric validity.

Folic acid/methylfolate for the treatment of psychopathology in schizophrenia: a systematic review and meta-analysis

RATIONALE

This study aims to examine whether folate/folic acid/methylfolate/folinic acid supplemented to antipsychotics (FA + AP) is beneficial in schizophrenia treatment.

OBJECTIVE

We conducted a comprehensive systematic review and meta-analysis of double-blind, placebo-controlled, randomized clinical trials (RCTs) of FA + AP for schizophrenia.

METHODS

The primary outcome was an improvement in total symptoms. Other outcomes were psychopathology subscales (positive, negative, general, and depressive symptoms), discontinuation due to all-cause and adverse events, and individual adverse events. The meta-analysis evaluated the effect size based on a random-effects model.

RESULTS

Although we included ten RCTs with 925 patients in total (seven folic acid RCTs (n = 789), two methylfolate RCTs (n = 96), and one folinic acid RCT (n = 40)) in the systematic review, only seven RCTs were included in the meta-analysis. Pooled FA + AP treatments were not superior to placebo + AP in the improvement of total (N = 7, n = 340; standardized mean difference (SMD) = - 0.20, 95% confidence interval (CI) = - 0.41, 0.02, p = 0.08, I² = 0%), positive, general, or depressive symptoms. Pooled FA + AP treatments were more effective than placebo + AP for negative symptoms (N = 5, n = 281; SMD = -0.25, 95% CI = -0.49, -0.01, p = 0.04, I² = 0%). Although pooled FA + AP treatments were associated with a lower incidence of serious adverse events than placebo treatments (N = 4, n = 241; risk ratio = 0.32, 95% CI = 0.12-0.82, p = 0.02, I² = 0%; number needed to harm = not significant), there were no significant differences in other safety outcomes between both treatments.

CONCLUSIONS

Our findings suggest that pooled FA + AP treatment improves negative symptoms in schizophrenia patients. Moreover, this treatment was well tolerated. However, because our results might exhibit a small-study effect, future studies with a larger sample should be conducted to obtain more robust results.

A systematic scoping review of psychological therapies for psychosis within acute psychiatric in-patient settings

BACKGROUND

People with psychotic disorders account for most acute admissions to psychiatric wards. Psychological therapies are a treatment adjunct to standard medication and nursing care, but the evidence base for such therapies within in-patient settings is unclear.AimsTo conduct a systematic scoping review of the current evidence base for psychological therapies for psychosis delivered within acute in-patient settings (PROSPERO: CRD42015025623).

METHOD

All study designs, and therapy models, were eligible for inclusion in the review. We searched PubMed, PsycINFO, EThOS, ProQuest, conference abstracts and trial registries.

RESULTS

We found 65 studies that met criteria for inclusion in the review, 21 of which were randomised controlled trials (RCTs). The majority of studies evaluated cognitive-behavioural interventions. Quality was variable across all study types. The RCTs were mostly small (n<25 in the treatment arm), and many had methodological limitations including poorly described randomisation methods, inadequate allocation concealment and non-masked outcome assessments. We found studies used a wide range of different outcome measures, and relatively few studies reported affective symptoms or recovery-based outcomes. Many studies described adaptations to treatment delivery within in-patient settings, including increased frequency of sessions, briefer interventions and use of single-session formats.

CONCLUSIONS

Based on these findings, there is a clear need to improve methodological rigour within in-patient research. Interpretation of the current evidence base is challenging given the wide range of different therapies, outcome measures and models of delivery described in the literature.Declaration of interestNone.

Including the 'Spiritual' Within Mental Health Care in the UK, from the Experiences of People with Mental Health Problems

Spirituality as a dimension of quality of life and well-being has recently begun to be more valued within person-centred treatment approaches to mental health in the UK. The aim of this paper is to provide indicators of the extent to which accessing a spiritual support group may be useful within mental health recovery from the view point of those in receipt of it. The study design was a small-scale exploratory study utilising mixed methods. Quantitative methods were used to map the mental health, general well-being and social networks of the group. These were complimented by a semi-structured open-ended interview which allowed for Interpretative Phenomenological Analysis (IPA) of the life-history accounts of nine individuals with mental health problems who attended a 'spirituality support group'. Data from unstructured open-ended interviews with five faith chaplains and a mental health day centre manager were also analysed using thematic analysis. The views of 15 participants are therefore recounted. Participants reported that the group offered them: an alternative to more formal religious organisations, and an opportunity to settle spiritual confusions/fears. The 'group' was also reported to generally help individual's subjective feelings of mental wellness through social support. Whilst the merits of spiritual care are appealing, convincing services to include it within treatment may still be difficult.

A protocol in action: Recovery approach for patients within high secure care: A 20+ year follow-up

OBJECTIVES

A person-centred approach to recovery is increasingly represented within mainstream mental health literature. Little examination of recovery among forensic mental health patients is evidenced. This study plans to address that insufficiency.

METHODS

This protocol paper details a novel approach to exploring recovery among a cohort of 241 patients detained under conditions of high secure care in Scotland during August 1992 to August 1993. Under discussion is the repurposing of previous research to circumnavigate length of inpatient stay commonly associated with forensic mental health care. The methodology adopted, while considering data leakage given the vulnerable participant group, will be discussed.

RESULTS

Repurposing and extending previous research attempts to address the file cabinet effect with 85% of health care research being wasted and future uncertainty regarding research funding in a post-Brexit era. This is an ongoing study. Ethical, confidentiality, privacy issues, and permissions are considered within the methodology.

CONCLUSIONS

Ethical arguments can be made for tracing and attempting contact with vulnerable groups under-represented in the literature. A well-considered methodology putting the focus on participant welfare and confidentiality at every step is essential. The reported methodology provides an opportunity to expand and re-examine previously collected data through a contemporary lens.

Atypical antipsychotics and the negative symptoms of schizophrenia

The concept of positive and negative symptoms in schizophrenia can be traced back to Hughlings Jackson (1889) who taught that disease does not create, it sets free, and accordingly positive symptoms could be seen as ‘release’ phenomena resulting from ‘dissolution’ of the highest cerebral centres of the nervous system. Crow (1980) revived the dichotomy and proposed a Type I syndrome, characterised by positive symptoms, and a Type II syndrome, characterised by negative symptoms. He thought the latter was due to cortical atrophy and responded poorly to antipsychotic medication. In their review of the distinction, Walker & Lewine (1988) found a stronger relationship between premorbid dysfunction and negative symptoms than with positive symptoms. They also found there was a stronger influence of genetic factors on negative symptoms than positive symptoms.

New psychological treatments in schizophrenia

The first line of treatment for patients with psychotic disorders such as schizophrenia is neuroleptic medication. Neuroleptics have provided substantial benefits to patients with this type of severe mental illness since their discovery as a treatment for psychosis in the 1950s. Despite this, there are still a large number of patients who do not respond fully to neuroleptic medication or who are not able to tolerate it. For example, although as many as 70% of patients are substantially improved following drug treatment, a considerable proportion continue to experience persistent, distressing and recurrent symptoms. In a survey of patients in a London psychiatric hospital, Curson et al (1988) found that just under half of the patients continued to experience hallucinations and delusions despite the prescription of medication. In addition, many patients experience intolerable side-effects or do not wish to comply with neuroleptic medication, yet look for some effective alternative. Depression, anxiety and a high rate of suicide are additional problems faced by patients with schizophrenia.

Can we rehabilitate everyone?

There is an increasing momentum for the provision of care for people with chronic mental illness to be made in settings other than mental hospitals. One concern arising from this shift in emphasis is with those patients who may find it particularly difficult to live in the community.

The SafetyNet project

SafetyNet is a computerised, networked patient care system currently under development in the South Camden sector of Bloomsbury Health Authority. The project is primarily targeted at the clinical monitoring of people suffering from schizophrenia and the system incorporates measures which can provide a basis for quality assurance of care and a clinically driven approach to audit. SafetyNet is being designed to help keep track of individual sufferers, chart their needs as they change over time, prompt the services to action and knit together the responses needed from different agencies. It is a modular system which can be adapted to the needs of people with different kinds of mental illness and to different community populations.

The South Camden Schizophrenia Survey: An experience of community-based research

The South Camden Schizophrenia Survey was started in 1985 with Regional Funding through the Locally Organised Research Scheme. Its overall aim is to explore the disabilities and needs of those individuals recognised by the services within an inner-city area as suffering from schizophrenia. The survey has also been the first step towards setting up a computerised case monitoring system, named ‘Safety Net’, which is being developed as a means of keeping track of the needs and progress of these vulnerable individuals. This enterprise will develop a community-wide perspective directed at targetting the deployment of services to those most in need. This article gives a preliminary account of the progress so far and highlights our experience of carrying out research within the community.

Role of the community psychiatric nurse in the management of schizophrenia

This paper will describe the increasingly important role of the community psychiatric nurse (CPN) in the treatment and management of people with schizophrenia, and draw attention to new training programmes which have a focus on skills acquisition in evidence-based methods. However, before describing the way in which these programmes of training improve CPN skills, it is worth examining the history of community psychiatric nursing.

Current developments and challenges in the assessment of negative symptoms

Reliable and valid assessment of negative symptoms is crucial to further develop etiological models and improve treatments. Our understanding of the concept of negative symptoms has undergone significant advances since the introduction of quantitative assessments of negative symptoms in the 1980s. These include the conceptualization of cognitive dysfunction as separate from negative symptoms and the distinction of two main negative symptom factors (avolition and diminished expression). In this review we provide an overview of existing negative symptom scales, focusing on both observer-rated and self-rated measurement of negative symptoms. We also distinguish between measures that assess negative symptoms as part of a broader assessment of schizophrenia symptoms, those specifically developed for negative symptoms and those that assess specific domains of negative symptoms within and beyond the context of psychotic disorders. We critically discuss strengths and limitations of these measures in the light of some existing challenges, i.e. observed and subjective symptom experiences, the challenge of distinguishing between primary and secondary negative symptoms, and the overlap between negative symptoms and related factors (e.g. personality traits and premorbid functioning). This review is aimed to inform the ongoing development of negative symptom scales.

Intensive case management for severe mental illness

BACKGROUND

Intensive Case Management (ICM) is a community-based package of care aiming to provide long-term care for severely mentally ill people who do not require immediate admission. Intensive Case Management evolved from two original community models of care, Assertive Community Treatment (ACT) and Case Management (CM), where ICM emphasises the importance of small caseload (fewer than 20) and high-intensity input.

OBJECTIVES

To assess the effects of ICM as a means of caring for severely mentally ill people in the community in comparison with non-ICM (caseload greater than 20) and with standard community care. We did not distinguish between models of ICM. In addition, to assess whether the effect of ICM on hospitalisation (mean number of days per month in hospital) is influenced by the intervention's fidelity to the ACT model and by the rate of hospital use in the setting where the trial was conducted (baseline level of hospital use).

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's Trials Register (last update search 10 April 2015).

SELECTION CRITERIA

All relevant randomised clinical trials focusing on people with severe mental illness, aged 18 to 65 years and treated in the community care setting, where ICM is compared to non-ICM or standard care.

DATA COLLECTION AND ANALYSIS

At least two review authors independently selected trials, assessed quality, and extracted data. For binary outcomes, we calculated risk ratio (RR) and its 95% confidence interval (CI), on an intention-to-treat basis. For continuous data, we estimated mean difference (MD) between groups and its 95% CI. We employed a random-effects model for analyses.We performed a random-effects meta-regression analysis to examine the association of the intervention's fidelity to the ACT model and the rate of hospital use in the setting where the trial was conducted with the treatment effect. We assessed overall quality for clinically important outcomes using the GRADE approach and investigated possible risk of bias within included trials.

MAIN RESULTS

The 2016 update included two more studies (n = 196) and more publications with additional data for four already included studies. The updated review therefore includes 7524 participants from 40 randomised controlled trials (RCTs). We found data relevant to two comparisons: ICM versus standard care, and ICM versus non-ICM. The majority of studies had a high risk of selective reporting. No studies provided data for relapse or important improvement in mental state.1. ICM versus standard careWhen ICM was compared with standard care for the outcome service use, ICM slightly reduced the number of days in hospital per month (n = 3595, 24 RCTs, MD -0.86, 95% CI -1.37 to -0.34,low-quality evidence). Similarly, for the outcome global state, ICM reduced the number of people leaving the trial early (n = 1798, 13 RCTs, RR 0.68, 95% CI 0.58 to 0.79, low-quality evidence). For the outcome adverse events, the evidence showed that ICM may make little or no difference in reducing death by suicide (n = 1456, 9 RCTs, RR 0.68, 95% CI 0.31 to 1.51, low-quality evidence). In addition, for the outcome social functioning, there was uncertainty about the effect of ICM on unemployment due to very low-quality evidence (n = 1129, 4 RCTs, RR 0.70, 95% CI 0.49 to 1.0, very low-quality evidence).2. ICM versus non-ICMWhen ICM was compared with non-ICM for the outcome service use, there was moderate-quality evidence that ICM probably makes little or no difference in the average number of days in hospital per month (n = 2220, 21 RCTs, MD -0.08, 95% CI -0.37 to 0.21, moderate-quality evidence) or in the average number of admissions (n = 678, 1 RCT, MD -0.18, 95% CI -0.41 to 0.05, moderate-quality evidence) compared to non-ICM. Similarly, the results showed that ICM may reduce the number of participants leaving the intervention early (n = 1970, 7 RCTs, RR 0.70, 95% CI 0.52 to 0.95,low-quality evidence) and that ICM may make little or no difference in reducing death by suicide (n = 1152, 3 RCTs, RR 0.88, 95% CI 0.27 to 2.84, low-quality evidence). Finally, for the outcome social functioning, there was uncertainty about the effect of ICM on unemployment as compared to non-ICM (n = 73, 1 RCT, RR 1.46, 95% CI 0.45 to 4.74, very low-quality evidence).3. Fidelity to ACTWithin the meta-regression we found that i.) the more ICM is adherent to the ACT model, the better it is at decreasing time in hospital ('organisation fidelity' variable coefficient -0.36, 95% CI -0.66 to -0.07); and ii.) the higher the baseline hospital use in the population, the better ICM is at decreasing time in hospital ('baseline hospital use' variable coefficient -0.20, 95% CI -0.32 to -0.10). Combining both these variables within the model, 'organisation fidelity' is no longer significant, but the 'baseline hospital use' result still significantly influences time in hospital (regression coefficient -0.18, 95% CI -0.29 to -0.07, P = 0.0027).

AUTHORS' CONCLUSIONS

Based on very low- to moderate-quality evidence, ICM is effective in ameliorating many outcomes relevant to people with severe mental illness. Compared to standard care, ICM may reduce hospitalisation and increase retention in care. It also globally improved social functioning, although ICM's effect on mental state and quality of life remains unclear. Intensive Case Management is at least valuable to people with severe mental illnesses in the subgroup of those with a high level of hospitalisation (about four days per month in past two years). Intensive Case Management models with high fidelity to the original team organisation of ACT model were more effective at reducing time in hospital.However, it is unclear what overall gain ICM provides on top of a less formal non-ICM approach.We do not think that more trials comparing current ICM with standard care or non-ICM are justified, however we currently know of no review comparing non-ICM with standard care, and this should be undertaken.

Developing a Virtual Reality-Based Vocational Rehabilitation Training Program for Patients with Schizophrenia

Maintaining employment is difficult for patients with schizophrenia because of deterioration of psychosocial and cognitive functions. Such patients usually require vocational rehabilitation training, which is both demanding and costly. In this study, we developed a virtual reality-based vocational rehabilitation training program (VR-VRTP) for such patients and evaluated its feasibility as an alternative to traditional rehabilitation programs. We developed the VR-VRTP to include various situations commonly encountered in two types of occupations: convenience store employee and supermarket clerk. We developed practical situations, as well as a system for providing feedback, to ensure patients would not lose interest during training. Nine participants each performed the VR-VRTP repeatedly per week for a total of 8 weeks. At baseline and after training, all participants were evaluated using the following clinical and neuropsychological tests: Manchester Scale, Clinical Global Impression, Personal and Social Performance Scale (PSP), Hamilton Depression Rating Scale, Zung Depression Rating Scale, Beck Anxiety Inventory, Wisconsin Card Sorting Test, Stroop Test, Rey-Osterrieth Complex Figure Test (RCFT), and Auditory Verbal Learning Test (AVLT). After training, patient scores improved on the PSP, general symptoms on the Manchester Scale, AVLT, and delayed recall on the RCFT. The Manchester positive symptom score showed a trend of improvement. No significant changes were observed for other measures. The VR-VRTP may improve general psychosocial function and memory, potentially influencing real-world vocational performance. These findings provide preliminary evidence regarding the utility of the VR-VRTP in patients with schizophrenia.

Time Use of People Living with Schizophrenia in a North London Catchment Area

Time use provides one means to study the lifestyles and community participation of people with disabilities. Previous clinical studies suggest that people with a mental illness experience difficulty in using their time meaningfully. This study examines the time use of 229 adults diagnosed with schizophrenia from an epidemiological survey in London, England. Twenty-four hour time budgets were collected and time use was calculated for 10 major categories of occupations.

Few of the participants were engaged in work, active leisure, education or volunteer occupations, their predominant occupations being sleeping, personal care and passive leisure. The women spent significantly more time in domestic occupations and less time in passive leisure occupations than the men. The younger participants spent significantly more time in social occupations than the other age-groups. The older participants, and those attending day centres, spent most time in passive leisure.

These findings indicate that many people diagnosed with schizophrenia are not engaged in occupations that support active lifestyles or social inclusion, highlighting the need to improve their opportunities to participate in mainstream social, active and productive occupations. Occupational therapists must work with service users and agencies beyond the mental health system to enable service users' participation in such occupations. Barriers to participation also require further exploration to address these occupational needs better.

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.

Negative symptoms and longitudinal grey matter tissue loss in adolescents at risk of psychosis: preliminary findings from a 6-year follow-up study

BACKGROUND

Negative symptoms are perhaps the most disabling feature of schizophrenia. Their pathogenesis remains poorly understood and it has been difficult to assess their development over time with imaging techniques.

AIMS

To examine, using tensor-based structural imaging techniques, whether there are regions of progressive grey matter volume change associated with the development of negative symptoms.

METHOD

A total of 43 adolescents at risk of psychosis were examined using magnetic resonance imaging and whole brain tensor-based morphometry at two time points, 6 years apart.

RESULTS

When comparing the individuals with significant negative symptoms with the remaining participants, we identified five regions of significant grey matter tissue loss over the 6-year period. These regions included the left temporal lobe, the left cerebellum, the left posterior cingulate and the left inferior parietal sulcus.

CONCLUSIONS

Negative symptoms are associated with longitudinal grey matter tissue loss. The regions identified include areas associated with psychotic symptoms more generally but also include regions uniquely associated with negative symptoms.

The longitudinal trends in the relationship between drug-induced extrapyramidal symptoms and personal and social performance in a population of the patients with schizophrenia: A latent growth model

The aim of this study was to explore the longitudinal trends in the relationship between personal and social functioning and drug-induced extrapyramidal symptoms (DIEPS). The baseline sample included 484 patients with schizophrenia. Participants were assessed at baseline, weeks 4 (time 2), 8 (time 3), and 12 (time 4) regarding social functioning, and DIEPS. In latent growth analysis, the path coefficient between the intercept for the DIEPSS and the intercept for the PSP indicated a significant cross-sectional relationship between these two variables. And the path coefficient between the intercept of the DIEPSS and the slope of the PSP was also significant, indicating that patients who initially had more serious side effects tended to exhibit less improvement in their personal and social functioning over time. Similarly, a significant path coefficient between the slopes of the two variables indicated a dynamic and possibly reciprocal association over time. In addition, K-PSP scale showed good construct validity and reliability. Based on the standardized PSP scale, our results demonstrate DIEPSS induced by antipsychotic treatment dynamically affect personal and social functioning over time, a negative association between psychosocial aspects and the DIEPS.

Self-perceived cognitive deficits and their relationship with internalized stigma and quality of life in patients with schizophrenia

BACKGROUND

We investigated self-perceived cognitive deficits and their relationship with internalized stigma and quality of life in patients with schizophrenia in order to shed light on the clinical correlates of subjective cognitive deficits in schizophrenia.

METHODS

Seventy outpatients with schizophrenia were evaluated. Patients' self-perceived cognitive deficits, internalized stigma, and subjective quality of life were assessed using the Scale to Investigate Cognition in Schizophrenia (SSTICS), the Internalized Stigma of Mental Illness Scale (ISMI), and the Schizophrenia Quality of Life Scale Revision 4 (SQLS-R4), respectively. Correlation and regression analyses controlling for the severity of symptoms of schizophrenia were performed, and a mediation analysis was conducted to examine the hypothesis that internalized stigma mediates the relationship between self-perceived cognitive deficits and subjective quality of life.

RESULTS

Pearson's partial correlation analysis showed significant correlations among the SSTICS, ISMI, and SQLS-R4 scores (P<0.01). Multiple regression analysis showed that the SSTICS and ISMI scores significantly predicted the SQLS-R4 score (P<0.01). Mediation analysis revealed that the strength of the association between the SSTICS and SQLS-R4 scores decreased from β=0.74 (P<0.01) to β=0.56 (P<0.01), when the ISMI score was statistically controlled. The Sobel test revealed that this difference was significant (P<0.01), indicating that internalized stigma partially mediated the relationship between self-perceived cognitive deficits and quality of life.

CONCLUSION

The present study indicates that self-perceived cognitive deficits are significantly associated with internalized stigma and quality of life. Furthermore, internalized stigma was identified as a partial mediator of the relationship between self-perceived cognitive deficits and quality of life. These findings suggest that clinicians should be aware that patients with schizophrenia experience significantly greater self-stigma when they suffer subjective cognitive deficits, and that this may further compromise their quality of life.

The role of sleep dysfunction in the occurrence of delusions and hallucinations: A systematic review

BACKGROUND

Sleep dysfunction is extremely common in patients with schizophrenia. Recent research indicates that sleep dysfunction may contribute to psychotic experiences such as delusions and hallucinations.

OBJECTIVES

The review aims to evaluate the evidence for a relationship between sleep dysfunction and individual psychotic experiences, make links between the theoretical understanding of each, and highlight areas for future research.

METHOD

A systematic search was conducted to identify studies investigating sleep and psychotic experiences across clinical and non-clinical populations.

RESULTS

66 papers were identified. This literature robustly supports the co-occurrence of sleep dysfunction and psychotic experiences, particularly insomnia with paranoia. Sleep dysfunction predicting subsequent psychotic experiences receives support from epidemiological surveys, research on the transition to psychosis, and relapse studies. There is also evidence that reducing sleep elicits psychotic experiences in non-clinical individuals, and that improving sleep in individuals with psychosis may lessen psychotic experiences. Anxiety and depression consistently arise as (partial) mediators of the sleep and psychosis relationship.

CONCLUSION

Studies are needed that: determine the types of sleep dysfunction linked to individual psychotic experiences; establish a causal connection between sleep and psychotic experiences; and assess treatments for sleep dysfunction in patients with non-affective psychotic disorders such as schizophrenia.

Lithium for schizophrenia

BACKGROUND

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

OBJECTIVES

To assess whether:1. Lithium alone is an effective treatment for schizophrenia, schizophrenia-like psychoses and schizoaffective psychoses; and2. Lithium augmentation of antipsychotic medication is an effective treatment for the same illnesses.

SEARCH METHODS

In July 2012, we searched the Cochrane Schizophrenia Group's Study-Based Register of Trials which is based on regular searches of CINAHL, BIOSIS, AMED, EMBASE, PubMed, MEDLINE, PsycINFO, and registries of clinical trials. This search was updated on January 20, 2015. For the first version of the review, we also contacted pharmaceutical companies and authors of relevant studies to identify further trials and obtain original participant data.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of lithium compared with antipsychotics or placebo (or no intervention), whether as sole treatment or as an adjunct to antipsychotic medication, in the treatment of schizophrenia or schizophrenia-like psychoses or both.

DATA COLLECTION AND ANALYSIS

We extracted data independently. For dichotomous data, we calculated random-effects meta-analyses, risk ratios (RRs), and 95% confidence intervals (CI) on an intention-to-treat basis. For continuous data, we calculated mean differences (MD) and 95% confidence intervals. We used Grading of Recommendations Assessment, Development and Evaluation (GRADE) to create 'Summary of findings' tables and assessed risk of bias for included studies.

MAIN RESULTS

The update search in 2012 detected two further studies that met our inclusion criteria. We did not find any further studies that met our inclusion criteria in the 2015 search. This review now includes 22 studies, with a total of 763 participants (median mean age: 35 years, range: 26 to 72 years). Most studies were small, of short duration, and incompletely reported. As we detected a high risk of bias in many studies, the overall methodological quality of the included sample was rather low.Three small studies comparing lithium with placebo as the sole treatment showed no difference in any of the outcomes we analysed.In eight studies comparing lithium with antipsychotic drugs as the sole treatment, more participants in the lithium group left the studies early (eight RCTs; n = 270, RR 1.77, 95% CI 1.01 to 3.11, low quality evidence).Thirteen studies examined whether the augmentation of antipsychotic drugs with lithium salts is more effective than antipsychotic drugs alone. More participants who received lithium augmentation had a clinically significant response (10 RCTs; n = 396, RR 1.81, 95% CI 1.10 to 2.97, low quality evidence). However, this effect became non-significant when we excluded participants with schizoaffective disorders in a sensitivity analysis (seven RCTs; n = 272, RR 1.64, 95% CI 0.95 to 2.81), when we excluded non-double-blind studies (seven RCTs; n = 224, RR 1.82, 95% CI 0.84 to 3.96), or when we excluded studies with high attrition (nine RCTs; n = 355, RR 1.67, CI 0.93 to 3.00). The overall acceptability of treatment (measured by the number of participants leaving the studies early) was not significantly different between groups (11 RCTs; n = 320, RR 1.89, CI 0.93 to 3.84, very low quality evidence). Few studies reported on side effects. There were no significant differences, but the database is too limited to make any judgement in this regard. For example, there were no data on thyroid dysfunction and kidney problems - two major and well-known side effects of lithium.

AUTHORS' CONCLUSIONS

The evidence base for the use of lithium in schizophrenia is limited to 22 studies of overall low methodological quality. There is no randomised trial-based evidence that lithium on its own is an effective treatment for people with schizophrenia. There is some GRADE low quality evidence that augmentation of antipsychotics with lithium is effective, but the effects are not significant when more prone-to-bias open RCTs are excluded. Nevertheless, further large and well-designed trials are justified. These should concentrate on two target groups: (1) people with no affective symptoms, so that trialists can determine whether lithium has an effect on the core symptoms of schizophrenia, and (2) people with schizoaffective disorders for whom lithium is widely used in clinical practice, although there is no evidence to support this use.

An investigation of attributional style, theory of mind and executive functioning in acute paranoia and remission

This study assessed associations between attributional style and ToM measures in patients with paranoid symptoms and non-clinical controls, as well associations between these aspects of social cognition and executive skills. Using a longitudinal design, we further assessed performance on measures following the remission of paranoid symptoms. Patients and controls completed the Internal Personal and Situational Attributions Questionnaire (IPSAQ), ToM tasks, the Stroop, the modified Wisconsin Card Sorting Test (WCST) and a measure of premorbid IQ at time one. Following the remission of paranoid symptoms, the patient group repeated the assessment process. Patients had a higher personalising bias for negative events and impairments in second order false belief and executive skills compared to control participants. Personalising bias for negative events was associated with poorer IQ, a tendency to make perseverative errors, a poorer performance on the second order false belief task and more severe symptoms. Personalising bias for negative events, performance on the second order false belief task or the tendency to make perseverative errors did not significantly change following symptom remission. The findings increase understanding of the mechanisms that potentially underpin the development and maintenance of paranoia. Specifically targeting personalising attributions for negative events in remitted patients may be an important goal of psychological therapy.

Fluphenazine decanoate (depot) and enanthate for schizophrenia

BACKGROUND

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

OBJECTIVES

To assess the effects of fluphenazine decanoate and enanthate versus oral anti-psychotics and other depot neuroleptic preparations for individuals with schizophrenia in terms of clinical, social and economic outcomes.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's Trials Register (February 2011 and October 16, 2013), which is based on regular searches of CINAHL, BIOSIS, AMED, EMBASE, PubMed, MEDLINE, PsycINFO, and registries of clinical trials.

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

We reliably selected, assessed the quality, and extracted data of the included studies. For dichotomous data, we estimated risk ratio (RR) with 95% confidence intervals (CI). Analysis was by intention-to-treat. We used the mean difference (MD) for normal continuous data. We excluded continuous data if loss to follow-up was greater than 50%. Tests of heterogeneity and for publication bias were undertaken. We used a fixed-effect model for all analyses unless there was high heterogeneity. For this update. we assessed risk of bias of included studies and used the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach to create a 'Summary of findings' table.

MAIN RESULTS

This review now includes 73 randomised studies, with 4870 participants. Overall, the quality of the evidence is low to very low.Compared with placebo, use of fluphenazine decanoate does not result in any significant differences in death, nor does it reduce relapse over six months to one year, but one longer-term study found that relapse was significantly reduced in the fluphenazine arm (n = 54, 1 RCT, RR 0.35, CI 0.19 to 0.64, very low quality evidence). A very similar number of people left the medium-term studies (six months to one year) early in the fluphenazine decanoate (24%) and placebo (19%) groups, however, a two-year study significantly favoured fluphenazine decanoate (n = 54, 1 RCT, RR 0.47, CI 0.23 to 0.96, very low quality evidence). No significant differences were found in mental state measured on the Brief Psychiatric Rating Scale (BPRS) or in extrapyramidal adverse effects, although these outcomes were only reported in one small study each. No study comparing fluphenazine decanoate with placebo reported clinically significant changes in global state or hospital admissions.Fluphenazine decanoate does not reduce relapse more than oral neuroleptics in the medium term (n = 419, 6 RCTs, RR 1.46 CI 0.75 to 2.83, very low quality evidence). A small study found no difference in clinically significant changes in global state. No difference in the number of participants leaving the study early was found between fluphenazine decanoate (17%) and oral neuroleptics (18%), and no significant differences were found in mental state measured on the BPRS. Extrapyramidal adverse effects were significantly less for people receiving fluphenazine decanoate compared with oral neuroleptics (n = 259, 3 RCTs, RR 0.47 CI 0.24 to 0.91, very low quality evidence). No study comparing fluphenazine decanoate with oral neuroleptics reported death or hospital admissions.No significant difference in relapse rates in the medium term between fluphenazine decanoate and fluphenazine enanthate was found (n = 49, 1 RCT, RR 2.43, CI 0.71 to 8.32, very low quality evidence), immediate- and short-term studies were also equivocal. One small study reported the number of participants leaving the study early (29% versus 12%) and mental state measured on the BPRS and found no significant difference for either outcome. No significant difference was found in extrapyramidal adverse effects between fluphenazine decanoate and fluphenazine enanthate. No study comparing fluphenazine decanoate with fluphenazine enanthate reported death, clinically significant changes in global state or hospital admissions.

AUTHORS' CONCLUSIONS

There are more data for fluphenazine decanoate than for the enanthate ester. Both are effective antipsychotic preparations. Fluphenazine decanoate produced fewer movement disorder effects than other oral antipsychotics but data were of low quality, and overall, adverse effect data were equivocal. In the context of trials, there is little advantage of these depots over oral medications in terms of compliance but this is unlikely to be applicable to everyday clinical practice.

Relationship between cognitive insight and subjective quality of life in outpatients with schizophrenia

BACKGROUND

The concept of cognitive insight refers to the cognitive processes involved in patients' re-evaluation of their anomalous experiences and of their misinterpretations. The purpose of the present study was to examine the relationship between cognitive insight and subjective quality of life in patients with schizophrenia to further shed light on the nature of cognitive insight and its functional correlates in schizophrenia.

METHODS

Seventy-one stable outpatients with schizophrenia were evaluated for cognitive insight and subjective quality of life using the Beck Cognitive Insight Scale (BCIS) and the Schizophrenia Quality of Life Scale Revision 4 (SQLS-R4). The symptoms of schizophrenia were also assessed. Pearson's correlation analysis and partial correlation analysis that controlled for the severity of symptoms were performed to adjust for the possible effects of symptoms.

RESULTS

The self-reflectiveness subscale score of the BCIS had significant positive correlations with the SQLS-R4 psychosocial domain and total SQLS-R4 scores, indicating that the higher the level of cognitive insight, the lower the subjective quality of life. In partial correlation analysis controlling for symptoms, the BCIS self-reflectiveness subscale score still had a significant correlation with the SQLS-R4 psychosocial domain score. The correlation coefficient between the BCIS self-reflectiveness and total SQLS-R4 scores was reduced to a nonsignificant statistical tendency.

CONCLUSION

The results of our study suggest that cognitive insight, particularly the level of self-reflectiveness, is negatively associated with the level of subjective quality of life in outpatients with schizophrenia and that this relationship is not wholly due to the confounding effect of symptoms. Future studies are necessary to explore possible mediating and moderating factors and to evaluate the effects of therapeutic interventions on the relationship.

What Are the Primary Goals of Cognitive Behavior Therapy for Psychosis? A Theoretical and Empirical Review

Despite a rise in the popularity of cognitive behavior therapy for psychosis (CBTp) over the past 15 years, recent systematic reviews and meta-analyses have concluded that CBTp has only modest effects on psychotic syndrome outcomes and that empirical evidence of its superiority over other psychosocial treatments is poor (Jones, Hacker, Meaden, Cormac, & Irving, 2012; Wykes, Steel, Everitt, & Tarrier, 2008). However, for some time now, some authors prominent in the development of CBTp have argued the primary goals of CBTp not to be global syndrome reduction but the amelioration of emotional distress and behavioral disturbance in relation to individual psychotic symptoms (Birchwood & Trower, 2006). A review of the theoretical and empirical literature related to CBTp reveals broad support for this position. Implications and recommendations for research into the efficacy of CBTp are discussed.

A cross-national factor analytic comparison of three models of PANSS symptoms in schizophrenia

The 30-item Positive and Negative Syndrome Scale (PANSS) is used worldwide in the assessment of symptom severity in schizophrenia. The present study uses confirmatory factor analysis (CFA) to compare three different factorial models and to evaluate the best-fitting representation of schizophrenia symptom structure on the PANSS across four samples of patients diagnosed with schizophrenia from the US (the CATIE schizophrenia trial), São Paulo, Brazil, and from Beijing and Changsha, China. We examine the goodness of fit of several previously proposed models. The traditional trifactorial model for the PANSS and two five-factor models were evaluated using absolute and incremental indices. Single group CFA found that the five-factor model proposed by NIMH researchers based on an extensive literature review demonstrates the best fit in each of the four samples. This model used 20 of the 30 PANSS items grouped into five factors: positive, negative, disorganized, excited, and depressed symptoms. Subgroups defined by age, gender, nationality, hospitalization status, and severity of illness also did not differ in overall symptom structure as assessed by several standard indices. Our findings suggest that the five factor NIMH model showed the best representation among all four samples from different countries and potentially contrasting cultures.

Developments in Cognitive-Behaviour Therapy for Persistent Psychotic Symptoms

This paper is a review of studies on psychological treatments for positive psychotic symptoms, and a detailed description of two of these studies, the Manchester Symptom Project, which aimed to decrease positive symptoms by training patients in effective coping strategies, and the Liverpool Auditory Hallucination project, which aimed to provide a cognitive-behavioural treatment for individuals with persistent and distressing voices. The results from these studies indicate that enduring positive symptoms which have not responded to neuroleptic medication can be effectively treated by psychological methods.

Lack of effect of electroconvulsive therapy on CSF peptide concentrations in schizophrenic patients

The effects of a series of 6 ECT treatments were observed on the CSF concentrations of neurotensin and substance-P in eight patients suffering from schizophrenia. Four patients were previously drug free. No significant effects of ECT were observed.

The effects of relocation on long-stay psychiatric patients

Objective: To assess the effects of relocation on the social behaviour and mental state of a group of 43 long stay psychiatric patients transferred from an old institution to a modern hospital. Method: Each patient was assessed using the MRC Social Behaviour Schedule and the Manchester Scale. Assessments were carried out prior to relocation and at six weeks and six months after transfer. Results: Some deterioration was apparent in the patients' social behaviour at six weeks following relocation but this trend was reversed to definite improvement at six months. There was an overall marked reduction in hostility and violence following relocation. Patients who showed most improvement in terms of social behaviour were the lower functioning group where greater emphasis was placed on promoting basic self care and social skills rather than on occupational therapy. Changes in mental state, following relocation, were minimal but a slight deterioration occurred especially in the area of negative symptoms. Conclusions: Relocations caused no serious adverse effects in the majority of these patients. The improvement observed in certain aspects of behaviour are attributable to the improved physical and psychological milieu of the receiving hospital.