Family psychoeducation in schizophrenia and schizophrenia related disorder, treatment compliance, and suicidal risk reduction: questions about their relationship from a naturalistic observation

Introduction

The Profamille V3.2 multi-family psycho-educational program directed at caregivers of relatives with schizophrenia or schizophrenia related disorder has been shown to decrease the annual prevalence of suicide attempts. It has been reported that psychoeducation of families can sometimes improve compliance with treatment. This study investigates whether the Profamille program improves compliance and thus reduces the risk of suicide among patients.

Method

This is a retrospective study of 179 groups of family caregivers, encompassing 1946 participants enrolled in Module 1 of the Profamille program and followed up one year after completion of the module. Evaluations were conducted using questionnaires filled out by family caregivers at three distinct times: prior to beginning the program, upon its completion, and again one year following its conclusion. The annual prevalence of suicide attempts was measured both before the program began and one year after its conclusion, while compliance to treatment was evaluated at the start and end of the program.

Result

After the Profamille program, the annual prevalence of suicide attempts fell by a factor of 2 (p-value = 0.00002) and patient compliance improved (p-value <0.000001). This reduction in suicide attempts was observed independently of improved compliance. Compliance seems to have an additional effect, but only after participation in the program.

Conclusion

The Profamille program reduces patients' risk of suicide even when patients are not taking the treatment. When family psychoeducation is not proposed in schizophrenia or schizophrenia related disorder, this can represent a loss of chance for patients.

[Suicidal risk prevention in schizophrenia: Importance of family psychoeducation]

OBJECTIVES

Although mortality by suicide in schizophrenia seems to have decreased in some countries over the last 30 years, it remains much higher than in the general population. Studies have shown this risk to impact around 5% of patients, corresponding to a risk almost 2.5 times higher than in the general population. Family psychoeducation in schizophrenia has been demonstrated to lead to symptom reductions and to an improvement of the quality of life, two factors that should contribute to decreasing the suicidal risk. Therefore, if families attend an efficient psychoeducation program, we can expect a decrease in the patient suicidal risk. Attending a family psychoeducation program at the beginning of the disease would also be associated with a stronger preventive effect on suicidal mortality. The objective of this study is to describe the suicide attempt rate of patients who suffer from schizophrenia before and one year after one of their relatives participated to the family psychoeducation program Profamille.

METHOD

We performed a retrospective study on 1209 people who attended the Profamille (V3.2 version) Family Psychoeducation Program. This program has 2 modules: an initial training module of 14 weekly or fortnightly sessions, and a consolidation module of 4 sessions over 2 years. Sessions last 4 hours and follow a precise and structured course. Data were collected from 40 different centers in France, Belgium and Switzerland and were based on participants assessed at the beginning and one year after the first module. Self-assessment from the relatives participating in the program provided the measure of patients' suicide attempts. An assessment at T0 explored the attempts over the 12 months before the beginning of the program while the assessment at T1 analyzed those during the 12 months following the end of the Program. The Chi² test was used to compare the suicide attempt rates for each period, using a significance threshold of 0.05. Since the risk of suicide is greater in the first years of the illness, rates of attempts are also calculated according to the age of disorder. The analysis was carried out with the statistical software R.

RESULTS

The number of participants reporting that their relative had attempted suicide in the previous 12 months decreased from 41 to 21. The annual attempts rate was evaluated at 6.4 % before the Profamille program and decreased to 2.4 % a year after the end of the program (P=0.0003). The reduction of the attempt rate was observed even for patients with schizophrenia for more than 10 years.

CONCLUSION

This study shows the positive impact of Profamille on reducing the rate of suicide attempts in patients with schizophrenia. It has been shown that the risk is highest at the beginning of the disorder. Therefore, based on our results, it would seem appropriate to propose the Profamille program at an early stage.

[Physiological adolescence, pathological adolescence]

The uncertainties of looming adulthood, nostalgia for childhood, and a general malaise explain the crisis of adolescence. Rebellion, conflict, occasional failure at school or in society, and at-risk behaviors are not always signs of future psychiatric illness. In contrast, the physician must be in a position to identify tell-tale signs such as dysmorphophobia, existential anxiety, a feeling of emptiness, and school or social breakdown. Most psychiatric disorders that begin in adolescence are only diagnosed several years after onset. Yet early diagnosis is of utmost importance, as treatment becomes less effective and the long-term prognosis worsens with time. Suicide is the second cause of death during adolescence. All signs of suicidal behavior require hospitalization and evaluation in a psychiatric unit. Antidepressants may be necessary in adolescence. The recent controversy concerning a possible increase in the suicidal risk during antidepressant treatment should not mask the fact that the real public health issue is depression, and not antidepressants. Eating disorders are especially frequent among adolescent girls; it is important to identify psychiatric comorbidities such as schizophrenia, depression and obsessive-compulsive disorders, and to assess the vital risk. Illicit drug and alcohol consumption are frequent during adolescence; for example, close to half of all French adolescents have tried cannabis at least once. Once again, it is important to detect psychiatric comorbidities in substance-abusing adolescents. Phobia is an underdiagnosed anxiety disorder among adolescents; it may become chronic if proper treatment is not implemented, leading to suffering and disability. Finally, two major psychiatric disorders--schizophrenia and bipolar disorder--generally begin in adolescence. Treatment efficacy and the long-term prognosis both depend on early diagnosis. Treatment must be tailored to the individual patient. "Borderline" states are over-diagnosed, hindering more precise diagnosis and delaying appropriate treatment.

[Prodromal symptoms of schizophrenia]

The concept of prodromal symptoms of schizophrenia has frequently been subject to debate. Authors widely admit the existence of early specific and non-specific signs preceding the first psychotic episode; however, they have yet to clearly demonstrate their ability to predict and specify the outbreak of a psychosis. These prodromal symptoms consist of behavioral abnormalities, pseudo-neurotic signs, subtle cognitive and affective changes. All these symptoms vary from patient to patient. In general, it is widely believed that future patients go through a variety of abnormal, subjective experiences that progressively develop during their pre-puberty and puberty periods. However, the limit of this assessment is that an individual could present the same prodromal symptoms without necessarily developing a psychotic illness, as a result of toxic intake, a situational crisis, etc. Furthermore, while the prodrome is a retrospective concept, its value and specificity can only be prospective, given that patients' descriptions of pre-morbid changes may be corrupted by inefficient memory reconstruction. DSM III-R included prodromal symptoms; individual presenting such symptoms would potentially present psychopathological vulnerability to psychosis regardless of associated genetic risk. Several investigations have shed doubts on their measurement's reliability; therefore, this classification is no longer present in the latest version (DSM IV). Moreover, recent neurodevelopemental hypothesis on schizophrenia have paved the way for possible early intervention, especially because early treatments could well improve illness prognosis. This viewpoint is reinforced by the improved tolerance of new anti-psychotic treatment. In this report, we review the key Articles published over the last 15 Years on this matter. We distinguish two schools of thought: on one hand, the German school referring to the validity of particular neuro-psychological symptoms: attention, perception, proprioperception which can be assessed with many evaluation tools: PAS, TDI, BSABS, SPI-A. The German school points to the fact that patients experimenting such changes could potentially be aware of their state. On the other hand, the Anglo-Saxon school refers to the detection of an "at risk" population. The Anglo-Saxons no longer refer to "prodromal symptoms" but rather to a "prodromal period" that extends to about one Year. This period would begin with the patient's first behavioral changes and extend until the first psychotic episode. Both schools agree that, at this stage, neither the recognition nor the description of the period preceding psychosis allows to effectively predict it. As a result, some Authors continue to refer to psychological changes forming a risk factor for the development of subsequent psychosis, rather than clear predictors of inevitable illness. As for relapses, prodromal signs and symptoms found in schizophrenic patients are both specific and non-specific. In most cases, patients experiment perceptions and behavioral changes before psychosis exacerbation. It is not uncommon for a substantial increase in prodromal symptoms to be followed by degradation in psychotic symptoms. On the other hand, many such increases in psychotic symptoms were not preceded by increases in possible prodromal symptoms; hence their importance in identifying the timing of an intervention, but many relapses will occur regardless of the detection of said symptoms.

Prevalence of smoking in psychiatric patients

Compelling evidence that tobacco-smoking is a form of drug addiction exists. The aim of this study is to determine the following: (1) prevalence of tobacco-smoking and of nicotine dependence in French psychiatric patients; (2) rates and patterns of tobacco smoking and of nicotine dependence according to diagnosis; (3) relationship between current smoking status and antipsychotic medications; and (4) relationship between cigarette smoking and neurological side effects induced by neuroleptics. A population of 711 psychiatric in- and outpatients was assessed using: (1) a detailed smoking self-questionnaire for smoking history and nicotine dependence; and (2) a questionnaire for staff covering treatments and DSMIII-R diagnoses. Data were analyzed using chi2 analysis of variance (ANOVA) tests (one factor) for quantitative comparisons between groups of patients, and analysis of covariance (ANCOVA) test with age covariate was performed for age-dependent variables. Prevalence of smoking in the population of psychiatric patients was significantly higher than in the French general population. Diagnoses among current smokers were mainly substance-related disorder and schizophrenia. The authors established correlations between prevalence of smoking and age, sex, marital and socioeconomic status, alcohol use, coffee consumption and other psychoactive substance use or abuse. The authors did not find relationship between smoking prevalence and institutionalization. Neuroleptic neurological side effects were significantly fewer among smokers compared to nonsmokers. However, the rate of smokers was significantly higher in psychiatric patients receiving neuroleptic drugs. Nicotine abuse in psychiatric patients, and especially in schizophrenic patients, could support the hypothesis that smoking is consistent with self-medication.

[Antipsychotic drugs and cardiovascular safety: current studies of prolonged QT interval and risk of ventricular arrhythmia]

Cardiovascular mortality is higher among schizophrenic patients than in the general population, and it is possible that most unexplained sudden deaths among these patients are due to ventricular arrhythmias for which antipsychotic drugs are either the cause or a predisposing factor. Most antipsychotic agents show electrophysiological effects resembling those of class 1a antiarrhythmic agents, and may be responsible for prolonging the QT interval, potentially going on to cause torsades de pointes. Some of the antipsychotic agents carry a high risk of arrhythmias, related to their effects on the QT interval. These include thioridazine, pimozide, sultopride, droperidol, and to a lesser extent haloperidol and chlorpromazine. In the case of the new atypical antipsychotic agents, it is possible to rank the risks of different drugs, with sertindole (now withdrawn from sale) having the highest risk, and ziprasidone somewhat lower, followed by risperidone and finally by quetiapine, clozapine and olanzapine which have negligible effects on the QT interval. A number of risk factors have been demonstrated, particularly: hypokalaemia and hypomagnesaemia, bradycardia, congenital long QT syndrome, and any underlying cardiac pathology. Lastly, the risk associated with any given antipsychotic agent is increased if it is combined either with any other drug known to prolong the QT interval and provoke torsades de pointes, or with any drug capable of inhibiting the hepatic metabolism of the antipsychotic agent. A list of such drugs is provided, together with advice on the action to be taken when prescribing an antipsychotic agent to a patient with a long QT interval.

[First clinical episode of bipolar disorders: a study within a population of bipolar I and bipolar II French patients]

Clinical symptoms of bipolar disorders onset act as a prognostic risk-factor. Discrepancies of data are related with geographical or cultural conditions. Within a patient population of bipolar (ICD 10) in and out patients of a psychiatric department, manic or hypomanic disorders initiate the space disease in 33% of the cases theses features are similar within the western psychiatric population. In a maghrebian population this proportion reaches 50%. A percentage of 65% of bipolar 1 patients was found within our sample. Sex ratio is 1 for bipolar 1, when, for bipolar 2 disorders sex-ratio was superior to 1, in favor of females. Mean age of the first episode of the disease was younger for patients with a familial history of the disease.