Mental illness and menopause: a patient and family perspective

BACKGROUND

Menopause is a significant biological event in the life of every woman, including women with mental disorders. This brief report describes the results of a survey of 39 patients with mental illness and their family members regarding perceived effects of menopause on mental illness.

METHODS

The survey was distributed to participants attending a National Alliance for the Mentally Ill educational presentation on menopause and mental health.

RESULTS

Most participants (15/39; 38.5%) had depression or had a family member with depression. Groups with other mental disorders were less represented, with 8/39 (20.5%) having schizophrenia, 6/39 (15.4%) having bipolar illness, and 10/39 (25.6%) having other disorders such as anxiety disorders or personality disorders. The mean age of the individuals/family members with mental illness was 51.2 years. Most participants (21/39; 53.8%) felt that menopause might be affecting their emotional symptoms or those of their family members, while 11/39 (28.2%) felt that their illness or their family member's illness was worse because of menopause or approaching menopause. There was a trend for perception of menopause affecting mental illness to be stronger among individuals with bipolar illness and depression, as compared to individuals with schizophrenia and other disorders (P = .052).

CONCLUSIONS

Menopause is a significant life event among women with mental illness. Nearly 30% of individuals affected by mental illness perceive menopause to worsen symptoms of mental illness.

Efficacy of quetiapine and risperidone against depressive symptoms in outpatients with psychosis

BACKGROUND

The treatment of psychotic symptoms in patients with mood disorders is a complex challenge. Antipsychotic medications in these individuals may be associated with extrapyramidal symptoms (EPS), worsening of depression, and functional impairment. Atypical antipsychotics such as quetiapine and risperidone are associated with a decreased incidence of adverse events such as EPS. The objective of this study was to compare the efficacy and tolerability of quetiapine and risperidone for the treatment of depressive symptoms in outpatients with psychosis.

METHOD

In this 4-month, multicenter, open-label trial, patients were randomly assigned in a 3:1 ratio of quetiapine to risperidone, and both drugs were flexibly dosed. Eligible patients had psychoses and demonstrated 1 of several DSM-IV diagnoses, including schizoaffective disorder, bipolar I disorder, major depressive disorder, delusional disorder, Alzheimer's dementia, schizophreniform disorder, vascular dementia, and substance abuse dementia. Patients were classified as mood disordered if they had bipolar disorder, major depressive disorder, or schizoaffective disorder. Efficacy was assessed using the Positive and Negative Syndrome Scale and the Clinical Global Impressions scale. The Hamilton Rating Scale for Depression (HAM-D) was used to assess the level of depressive symptoms. The primary tolerability assessment was presence or absence of substantial EPS, defined as EPS severe enough to require an alteration in treatment.

RESULTS

A total of 554 patients were randomly assigned to quetiapine and 175 to risperidone. Mean doses at 16 weeks were 318 mg for quetiapine and 4.4 mg for risperidone. Although both agents produced improvements in mean HAM-D scores, quetiapine produced a greater improvement than risperidone in all patients (p =.0015). Within the mood-diagnosed population, incidences of both substantial EPS (p =.001) and at least moderate EPS (p =.0373) occurred significantly less frequently among patients taking quetiapine. For patients with non-mood diagnoses, incidences of substantial EPS were fewer for patients taking quetiapine than for those taking risperidone (p =.062); however, this was not statistically significant.

CONCLUSION

These results suggest that quetiapine may be a useful agent in the management of depressive symptoms in patients with psychosis.

Insight into illness and attitudes toward medications among inpatients with schizophrenia

This study assessed symptoms, severity of illness functional level, insight into illness, and attitudes toward medication in a sample of psychiatric patients who were newly admitted to a state hospital. The patients were evaluated before and after treatment with atypical, conventional, or mixed (atypical plus conventional) antipsychotic medication regimens with the Brief Psychiatric Rating Scale (BPRS), the Clinical Global Impression, the Global Assessment of Functioning, the Scale to Assess Unawareness of Mental Disorder, and the Drug Attitude Inventory. Overall, the patients showed significant improvement in symptoms, severity of illness, functional level, and insight into their illness during the course of hospitalization. Their attitudes toward medications changed minimally during treatment. Only the patients who were treated with conventional antipsychotics showed significant improvement in their attitudes toward medication. However, the change was not large enough to differentiate the conventional antipsychotic treatment group from the other treatment groups.

Treatment of bipolar disorder in older adults

BACKGROUND

It has been reported that 10% of all patients with bipolar disorder develop their illness after the age of 50, with bipolar disorder accounting for 5-19% of mood disorder presentations in the elderly. There has been a growing awareness regarding the manifestation of bipolar disorder among older adults due to both changes in national demographics, and developing sophistication in the treatment of bipolar illness. A persistent problem in our understanding of management of late life bipolar disorder is the paucity of research and rigorous published studies on the psychopharmacology of this condition.

OBJECTIVE

This paper reviews medication treatments, non-medication biological therapies, and psychosocial interventions for bipolar disorder in late life with a particular emphasis on age related modifiers of treatment.

METHODS

Findings are based upon review of the current literature.

RESULTS

There are multiple, significant gaps in our knowledge of bipolar disorder in late life which have important implications in the optimum treatment of elderly individuals with bipolar illness.

CONCLUSION

There are a number of areas of needed future research in late life bipolar disorder.

Gender related differences in clinical characteristics and hospital based resource utilization among older adults with schizophrenia

OBJECTIVE

This report is an analysis of gender related differences in clinical characteristics and hospital based health resource utilization among older adults with schizophrenia and schizoaffective disorder in an acute care, state hospital over a one-year period.

METHODS

This retrospective record review is an analysis of age of illness onset, psychiatric and medical comorbidity, hospital utilization, and psychotropic medication use.

RESULTS

There were a total of 66 individuals with either schizophrenia or schizoaffective disorder. Mean age of this group was 55.2 +/- 4.62 years. Women were significantly over-represented among individuals with late onset schizophrenia and schizoaffective disorder. Men with schizophrenia had more comorbid substance abuse compared to women with schizophrenia (p < 0.05). Women and men did not differ significantly in hospital length of stay, amount or type of antipsychotic medication prescribed, or in utilization of seclusion/restraint in hospital. Both genders had substantial utilization of antipsychotic medication. Use of conventional antipsychotic medication monotherapy was always associated with use of anti-extrapyramidal symptom (anti-EPS) medication, while use of atypical antipsychotic medication monotherapy was more rarely associated with use of anti-EPS medication.

CONCLUSIONS

In later life, women and men may have some areas of differing health care needs. Women in particular may benefit from psychoeducational approaches that address the experience of psychiatric illness of relatively recent onset (for example, symptom identification and acceptance of illness). Men may benefit from particular emphasis on treatment of comorbid substance abuse disorders.

The Effect of Short-Term Electroconvulsive Treatment Plus Neuroleptics in Treatment-Resistant Schizophrenia and Schizoaffective Disorder

The effect of electroconvulsive therapy (ECT) plus loxapine in nine patients with treatment-refractory schizophrenia or schizoaffective disorder was studied in an open trial. Five of the nine patients (55.6%) improved significantly (>/=20%) in the Brief Psychiatric Rating Scale total scores by the end of the course of ECT. Improvement was greater in positive than in negative symptoms. A sixth patient improved 3-6 weeks after the completion of the acute course of ECT. Five patients who responded to ECT received maintenance ambulatory ECT; two patients remained improved for at least 6-9 months, whereas the other three relapsed within 4 months. Further study of the indications for and the effectiveness of ECT plus neuroleptic drugs in treatment-resistant schizophrenia is indicated.

Principles of effectiveness trials and their implementation in VA Cooperative Study #430: 'Reducing the efficacy-effectiveness gap in bipolar disorder'

Despite the availability of efficacious treatments for bipolar disorder, their effectiveness in general clinical practice is greatly attenuated, resulting in what has been called an 'efficacy-effectiveness gap'. In designing VA Cooperative Studies Program (CSP) Study #430 to address this gap, nine principles for conducting an effectiveness (in contrast to an efficacy) study were identified. These principles are presented and discussed, with specific aspects of CSP #430 serving as illustrations of how they can be implemented in an actual study. CSP #430 hypothesizes that an integrated, clinic-based treatment delivery system that emphasizes (1) algorithm-driven somatotherapy, (2) standardized patient education, and (3) easy access to a single primary mental health care provider to maximize continuity-of-care, will address the efficacy-effectiveness gap and improve disease, functional, and economic outcome. It is an 11-site, randomized controlled clinical trial of this multi-modal, clinic-based intervention versus usual VA care running from 1997 to 2003. The trial has enrolled 191 subjects in each arm, using minimal exclusion criteria to maximize the external validity of the study. Subjects are followed for 3 years. The intervention is highly specified in a series of operations manuals for each of the three components. Several continuous quality improvement (CQI) interventions, process measures, and statistical techniques deal with drift of care in both the intervention and usual care arms to ensure the internal validity of the study. CSP #430 is designed to have impact well beyond the VA, since it evaluates a basic health care operational principle: that augmenting ambulatory access for major mental illness will improve outcome and reduce overall treatment costs. If results are positive, this study will provide a reason to reconsider the prevailing trend toward limitation of ambulatory services that is characteristic of many managed care systems today.

Quetiapine alone and added to a mood stabilizer for serious mood disorders

BACKGROUND

Use of antipsychotic medication intermittently or over the long term may be necessary in treating patients with bipolar disorder whose symptoms have responded suboptimally to standard mood-stabilizing agents. Quetiapine fumarate is an effective novel antipsychotic with mixed serotonergic (5-HT2) and dopaminergic (D2) activity. This is an open-label, 12-week prospective study to assess the efficacy and tolerability of quetiapine in the treatment of patients with bipolar and schizoaffective disorder who were suboptimally responsive to mood stabilizers alone.

METHOD

Participants in the study were inpatients or outpatients with a DSM-IV diagnosis of bipolar or schizoaffective disorder. Baseline psychopathology was evaluated with the Brief Psychiatric Rating Scale (BPRS), the Young Mania Rating Scale (YMRS), and the Hamilton Rating Scale for Depression (HAM-D). Involuntary movements were rated with the Simpson-Angus Neurologic Rating Scale. Quetiapine was added on an open-label basis and increased to optimum clinical dosage. Psychopathology and Abnormal Involuntary Movement Scale ratings were repeated weekly for the first 4 weeks and then again at weeks 8 and 12.

RESULTS

Ten individuals with bipolar disorder and 10 with schizoaffective disorder received quetiapine therapy. Overall, patients improved, with significant improvement in BPRS (p < .001), YMRS (p = .043), and HAM-D scores (p = .002). Simpson-Angus score also significantly decreased (p = .02). Overall. quetiapine was well tolerated by patients in this group with serious mood disorders. The mean +/- SD quetiapine dose was 202.9 +/- 124.3 mg/day (range, 50-400 mg/day). Mean weight gain was 10.9 lb (4.9 kg).

CONCLUSION

Although limited by its small size, open-label design, and relative gender homogeneity, this study suggests that quetiapine therapy may be useful in the treatment of individuals with serious mood disorders who are suboptimally responsive to mood stabilizers alone. These preliminary findings should be explored in larger, controlled trials.

Admissions, length of stay, and medication use among women in an acute care state psychiatric facility

OBJECTIVE

Despite growing numbers of elderly persons with serious mental illness such as schizophrenia, little research has been conducted on the manifestation of serious mental illness in later life, and our understanding of the mental health care needs of this population is limited. This study examined length of stay and medication use among women age 50 and older admitted to an acute care state psychiatric facility.

METHODS

A computerized record search for all women discharged from a large urban state psychiatric facility over a one-year period was undertaken. Demographic and resource utilization data, including total length of stay and pharmacy utilization, were obtained from the hospital database.

RESULTS

The database search produced the records of 564 women, with a mean age of 37.5 years. Women constituted 60 percent of patients over age 50. The mean length of stay was 16.1 days for the entire group; for women under age 50 (N=492), mean length of stay was 15 days, and for women age 50 and older (N=72), it was 23.1 days (p=. 01). Among those age 50 and older, 58.3 percent had a diagnosis of schizophrenia or schizoaffective disorder, compared with only 38 percent of those under age 50.

CONCLUSIONS

Our data suggest that women constitute the majority of patients over age 50 in a state psychiatric facility and that they have longer stays than younger women.

An assessment of clinical practice of clozapine therapy for veterans

Clozapine therapy for 2,996 patients with treatment-refractory schizophrenia was examined over a five-year period in the Veterans Affairs health care system. Patients were assessed with the Brief Psychiatric Rating Scale (BPRS) and the Abnormal Involuntary Movement Scale (AIMS). BPRS scores, which were available for 522 patients, indicated a significant improvement, as did AIMS scores, which were available for 252 patients. Compared with individuals who showed a modest improvement, those with a more robust response to clozapine had higher initial BPRS scores and were three times more likely to have been suicidal in the month before starting clozapine therapy.

Olanzapine therapy in elderly patients with schizophrenia

Compared to young adults, elderly individuals with schizophrenia may have a six-fold increase in the prevalence of tardive dyskinesia. The atypical antipsychotic, olanzapine, may offer particular benefit for this population. This is a prospective, open-label trial of olanzapine therapy in elderly schizophrenic patients. Individuals aged 65 years or older with DSM-IV schizophrenia and a history of neuroleptic responsiveness were given olanzapine as an add-on therapy to their existing medication regimen. Other antipsychotic medication was gradually discontinued. Psychopathology was assessed using the Brief Psychiatric Rating Scale (BPRS). Abnormal movements were assessed with the Simpson-Angus Neurological Rating Scale (SA), the Barnes Akathisia Scale (BA), and the Abnormal Involuntary Movement Scale (AIMS). Cognitive status was assessed with the Mini-Mental State Evaluation (MMSE). Twenty-seven individuals received a mean dosage of 8.4 (+/- 4.2) mg/day. Mean age of the group was 70.6 (+/- 4.1) with a range of 65 to 80 years. Patients had a mean of 1.6 (+/- 1.4) significant comorbid medical illnesses. Change in BPRS scores were not significant for the group as a whole, whereas SA score change was substantial, with a pre-treatment mean of 13.7 (+/- 10.3), compared with a mean of 4.8 (+/- 4.1) for those treated with olanzapine (p < .0002). Changes in AIMS and BA score were also significant on olanzapine therapy. MMSE score change was not statistically significant. Comorbid medical illnesses were not adversely affected. Olanzapine is an effective antipsychotic medication in older adults with schizophrenia, and is associated with significant improvement in extrapyramidal side effects. Implications for effect on cognitive status should be explored in larger, long-term trials.

Implementing effectiveness research and improving care for schizophrenia in real-world settings

OBJECTIVE

To review recent advances in medication practices and standards of care in the treatment of schizophrenia and examine the disparity between the knowledge base and clinical practice.

DATA SOURCES

Key literature on medication practices, novel pharmacotherapies, and the evolution of practice guidelines for schizophrenia were reviewed.

DISCUSSION

Emerging data demonstrate a lack of consistent application of current knowledge and best practices, in part due to major structural inconsistencies in the public mental health system. Implementation of results from effectiveness research as well as the incorporation of practice guidelines may help bridge this gap.

CONCLUSION

As standards of care for schizophrenia are developed, the following issues will need particular attention: coordination with the criminal justice system, comprehensive treatment of comorbid illnesses, outcomes based on symptoms in all domains, and continuous and integrated collection of data to produce rational cost justification.

Health resource utilization and clinical outcomes with risperidone therapy in patients with serious mental illness

This report is an analysis of our experience with risperidone therapy in a veteran population with severe, suboptimally responsive psychosis from a perspective of clinical response and health resource utilization. We conducted a computer search for all patients who received risperidone therapy at our facility from February 1994 until July 1, 1996. Risperidone at our facility is prescribed when psychiatric symptoms appear to be refractory or suboptimally responsive to conventional antipsychotic therapy. A control group of patients on conventional antipsychotic therapy were also selected via the electronic data base. One hundred twenty-nine patients received risperidone therapy at a mean dosage of 5.05+/-2.4 mg/d, for a mean duration of 247.4+/-223.5 days. The largest proportion of patients (48.1%) had marked improvement on risperidone therapy. There were 35 patients who received at least 1 year of risperidone therapy. These patients had a significant decrease in hospital length of stay (LOS) from 80.7 to 28.7 days (P = .003) on risperidone with no compensatory increase in outpatient visits. The group of patients who received conventional antipsychotic therapy during the study time period had a more modest mean reduction in LOS over a 2-year time period from 78.9 days during the initial identified year of conventional antipsychotic therapy to 56.4 days during the second identified year of conventional antipsychotic therapy (P = .2). However, when change in LOS for the entire group was compared, the difference in change in LOS between risperidone and conventional antipsychotic treated patients did not reach statistical significance (P = .2). This preliminary study concurs with other reports that risperidone therapy may be effective in severely mentally ill patients and may be associated with significant reductions in health resource utilization. Comparison of resource utilization between patients receiving risperidone and conventional antipsychotic therapy is still unclear and should be explored in larger and prospective studies.

Nefazodone therapy in patients with treatment-resistant or treatment-intolerant depression and high psychiatric comorbidity

Given the potentially severe functional impairment, morbidity, and high costs associated with refractory depression, it is important to explore all treatment options that may benefit patients with this disorder. This is a retrospective, uncontrolled analysis of our experience with nefazodone therapy in treatment-resistant and treatment-intolerant depression. Potential candidates for nefazodone therapy were referred by their treating psychiatrist. Documentation of failure to respond to previous antidepressant therapy, a diagnosis of clinical depression according to criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, and completion of a Beck Depression Inventory (BDI) were required before initiation of nefazodone. A follow-up BDI was obtained after > or =4 weeks of nefazodone therapy. A Clinical Global Inventory (CGI) score was obtained retrospectively based on documentation of target symptoms in the clinical record of the last clinic visit. The study group consisted of 20 patients with treatment-resistant or treatment-intolerant major depression who received nefazodone therapy. The mean (+/- SD) age of the group was 48.1+/-9.4 years. The mean number of previously failed antidepressant trials was 1.9+/-0.6. Psychiatric comorbidity in this group was substantial, with posttraumatic stress disorder (PTSD) found in 11 (55%) patients, substance abuse in 3 (15%) patients, and personality disorder found in 2 (10%) patients. After treatment with nefazodone, 11 of 20 patients (55%) were rated on the CGI as much or very much improved. In addition, 9 patients (45%) had >20% improvement on BDI, 3 patients (15%) had 10% to 20% improvement, and 6 patients (30%) had <10% change. Two patients (10%) discontinued nefazodone therapy due to adverse effects. Analysis of our experience with nefazodone therapy in a population with treatment-resistant depression and a high degree of psychiatric comorbidity suggests that approximately 50% of patients may have substantial response to treatment, with a smaller proportion having a more modest clinical response. While receiving nefazodone therapy, most patients continued to take concurrently prescribed psychotropic medications, primarily anxiolytics or other antidepressants. Of interest was the positive drug response among a subgroup of individuals with depression and chronic, severe PTSD. Larger, controlled studies are needed to determine whether these preliminary observations are confirmed.

Clinical practice guidelines for bipolar disorder from the Department of Veterans Affairs

BACKGROUND

For the last several years, the Department of Veterans Affairs (VA) has been involved in the development of practice guidelines for major medical, surgical, and mental disorders. This article describes the development and content of the VA-Clinical Practice Guidelines for Bipolar Disorder, which are available in their entirety on the Journal Web site (http://www. psychiatrist.com).

METHOD

A multidisciplinary work group composed of content experts in the field of bipolar disorder and practitioners in general clinical practice was convened by the VA's Office of Performance and Quality and the Mental Health Strategic Health Group. The work group was instructed in algorithm development and methods of evidence evaluation. Draft guidelines were developed over the course of 6 months of meetings and conference calls, and that draft was then sent to nationally prominent content experts for final critique.

RESULTS

The Bipolar Guidelines are part of the family of the VA Clinical Guidelines for Management of Persons with Psychosis and consist of explicit algorithms supplemented by annotations that explain the specific decision points and their basis in the scientific literature. The guidelines are organized into 5 modules: a Core Module for diagnosis and assignment to mood state plus 4 treatment modules (Manic/Hypomanic/Mixed Episode, Bipolar Depressive Episode, Rapid Cycling, and Bipolar Disorder With Psychotic Features). The modules specify particular diagnostic and treatment tasks at each step, including both somatotherapeutic and psychotherapeutic interventions.

CONCLUSION

The VA Bipolar Guidelines are designed for easy clinical reference in decision making with individual patients, as well as for use as a scholarly reference tool. They also have utility in training activities and quality improvement programs.

Clozapine therapy for older veterans

OBJECTIVE

The effectiveness of clozapine treatment in a treatment-refractory sample of older adult veterans with primary psychosis was examined.

METHODS

Data were collected over a five-year period for patients age 55 and older who were given clozapine because of a history of treatment-refractory or treatment-intolerant psychosis. At initiation of clozapine therapy, baseline demographic, clinical, and psychopathology data were collected. At baseline and quarterly, patients' psychopathology was rated with the Brief Psychiatric Rating Scale (BPRS), and involuntary movements were rated with the Abnormal Involuntary Movement Scale (AIMS).

RESULTS

The 329 patients age 55 or older who received clozapine during the study period represented 10 percent of all patients on clozapine therapy in the VA system. Of the 312 patients for whom demographic information was available, 294 were men and 18 were women. Overall, patients improved on clozapine therapy, although wide variation in drug response was observed. Complete BPRS and AIMS data were available for 97 patients. The 55- to 64-year-old group had a mean improvement in total BPRS score of 19.8 percent, with 42.6 percent showing more than a 20 percent improvement; those age 65 and older had a mean improvement of 5.7 percent, with 17.2 percent showing an improvement greater than 20 percent. The 97 patients with complete AIMS data showed a mean improvement of 16.6 percent in total score.

CONCLUSIONS

Clozapine is an important therapeutic agent for older adults with treatment-refractory psychosis. Patients between the ages of 55 and 64 may have a better response than those age 65 and older.

Subjective and expressive emotional responses in depression

Twenty-four depressed and twenty-three nondepressed male patients rated pleasantness of slides varying in hedonic content. Depressed patients rated positive slides as less pleasant and less arousing but did not differ from nondepressed patients in subjective response to normatively unpleasant images. Analysis of videotapes of facial expressions while watching the slide images showed that depressives exhibited more negative expressions than nondepressives to negative slides. Groups did not differ in facial expression to positive stimuli, but neither group displayed much affect to those stimuli. These data suggest a possible dissociation between self-reported and observable responsivity to emotional stimuli in depression and that diminished subjective emotional response in depression is restricted to hedonically positive stimuli and does not reflect generalized diminished emotional responsivity. These results also imply that clinical assessment of emotional responsivity in depression should be made using modalities in addition to observer evaluation of expressed emotion.

Clinical characteristics and health resource use of men and women veterans with serious mental illness

In this retrospective analysis of gender-specific differences among veterans with serious mental illness, the clinical characteristics and health service utilization of 57 women and 114 men were compared. Women had fewer comorbid psychiatric illnesses than men, and substance use disorders were the most frequent comorbid psychiatric illness for both genders. Unlike nonveteran samples with serious mental illness, the veterans in this study showed no gender differences in hospital length of stay. Atypical antipsychotics, used for only suboptimally responsive illness in the study group, were prescribed for 50 percent of women with primary psychosis, compared with 15.3 percent of men with primary psychosis. The results suggest that psychosis among women veterans is more severe or refractory than that among men veterans.

Association between mood-stabilizing medication and mental health resource use in the management of acute mania

OBJECTIVE

To better understand how mood-stabilizing agents other than lithium have changed treatment and outcomes in bipolar disorder, this study examined health service utilization among patients with acute mania who were being treated with a variety of regimens using mood stabilizers.

METHODS

Demographic, clinical, and resource utilization data were collected from the records of 96 inpatients with a discharge diagnosis of bipolar mania. Patients were categorized into four major treatment groups: lithium monotherapy, anticonvulsant monotherapy, treatment with multiple mood stabilizers, and treatment with no mood stabilizers.

RESULTS

The mean +/- SD age of the sample was 50 +/- 12.3 years. Lithium was the most commonly prescribed antimanic agent, with 29 of the 96 patients on lithium monotherapy, 17 on anticonvulsant monotherapy, 42 taking multiple mood stabilizers, and eight taking no mood stabilizers. The mean inpatient stay was significantly longer for patients on multiple mood stabilizers (30.3 +/- 20.7 days) than for those on lithium monotherapy (20.7 +/- 14.4 days), anticonvulsant monotherapy (17 +/- 9.3 days), and no mood stabilizers (17.3 +/- 14.4 days). Patients who were not taking a mood stabilizer had a higher rate of leaving the hospital against medical advice than the other groups. Patients on anticonvulsant monotherapy had significantly more comorbid psychiatric illnesses than patients taking multiple mood stabilizers. Inpatient use of seclusion or restraint and of concurrent antipsychotic medications did not differ significantly between the treatment groups. Compliance with outpatient follow-up was poor in all treatment groups, and almost absent in the group taking no mood stabilizers.

CONCLUSIONS

Changes in the pharmacological management of acute mania will have an impact on clinical outcomes and health resource utilization.

Outcome of clozapine therapy for elderly patients with refractory primary psychosis

OBJECTIVE

The objective was to analyze outcome of clozapine therapy in elderly patients with treatment refractory primary psychosis.

DESIGN

This was an open-label clozapine trial in elderly patients. Patient psychopathology was assessed before and after clozapine therapy.

SETTING

A psychiatry service at a large urban/suburban Veterans Administration Medical Center.

PATIENTS

Inpatients and outpatients age 65 years or older with primary psychotic disorders established to be resistant to conventional antipsychotic therapy (Kane et al., 1988). Ten patients met study inclusion criteria out of a total of 134 patients receiving clozapine at the Cleveland VAMC (7.5%). Mean age of the group was 70.6 years.

MEASURES

Patients were rated with the Brief Psychiatric Rating Scale (BPRS; Overall and Gorham, 1962). Additional data on patient demographics, comorbid non-psychiatric diagnoses and concurrent psychotropic medication were collected via chart review.

RESULTS

Mean clozapine dosage was 204 mg/day for a mean duration of 430 days. 7/10 patients had some degree of clinical improvement and 3/10 patients had significant improvement documented by BPRS change of 20% or greater. Patients had a mean of 1.4 comorbid physical illnesses, which were not worsened by clozapine therapy. 4/10 patients discontinued clozapine therapy due to adverse effects or inability to comply with bloodwork; however; only 2/10 were truly treatment intolerant.

CONCLUSIONS

Clozapine is a useful alternative treatment option for elderly individuals with refractory primary psychosis. As in younger patients, inability to tolerate drug-related adverse effects or weekly bloodwork may lead to drug discontinuation.

Ten-year use of hospital-based services by geriatric veterans with schizophrenia and bipolar disorder

OBJECTIVE

To increase understanding of the needs of elderly patients with serious mental illness, the study analyzed and compared use of hospital-based services by geriatric patients with bipolar disorder and schizophrenia.

METHODS

The sample consisted of 23 patients with bipolar disorder and 49 patients with schizophrenia age 65 or older admitted to the Cleveland Veterans Affairs Medical Center over a two-year period. Patients' charts were reviewed to assess psychiatric and medical hospitalizations over the past ten years. Comorbid medical diagnoses, prescription patterns, and competency status were also reviewed.

RESULTS

Patients in both diagnostic groups used inpatient services relatively frequently, with a mean of four hospitalizations in ten years. Length of stay among patients with schizophrenia (mean = 58.2 days) was almost twice as long as that of patients with bipolar disorder. Hospitalization for medical reasons was infrequent. Mood-stabilizing medications, usually lithium, were prescribed to most patients with bipolar disorder, and antipsychotics were prescribed to most patients with schizophrenia and less than half of the patients with bipolar disorder. More than half of the patients with schizophrenia had legal guardians, but few patients with bipolar disorder did so.

CONCLUSIONS

Findings of this and other studies suggest that although the prognosis for persons with serious mental illnesses may have improved over the last several decades, these illnesses do not "burn out" in older adults. Elderly patients continue to make frequent use of inpatient psychiatric hospitalization and pharmacological interventions.

Risperidone therapy in treatment refractory acute bipolar and schizoaffective mania

This pilot study evaluated the efficacy of risperidone therapy in patients with bipolar I or schizoaffective mania who were treatment resistant or treatment intolerant. Patient psychopathology and involuntary movements were evaluated with a variety of scales, and risperidone was administered on an open-label basis. Five of six patients (all bipolar) discontinued risperidone therapy because of adverse drug effects (2 patients), lack of significant drug response and subjective clinical worsening (1 patient), or worsening of manic symptoms (2 patients). One patient with schizoaffective illness improved. Risperidone used without the addition of a mood stabilizer was ineffective in treating pure manic psychosis. In some vulnerable bipolar patients, risperidone monotherapy may have antidepressant activity that could exacerbate mania. If risperidone proves to have antidepressant activity, it may become an important agent in the therapy of patients with depressive symptoms and psychosis.

Outcome of risperidone therapy in elderly patients with chronic psychosis

OBJECTIVE

This report reviews the efficacy and tolerability of risperidone therapy in elderly patients with chronic psychosis.

METHODS

A computer search was conducted for all patients who were sixty-five years or older at the time of risperidone therapy at the Cleveland VAMC. Data collected included psychiatric diagnosis, risperidone dosage/side effects, concurrent medications, comorbid medical diagnosis, and response to treatment. Treatment response was quantified on a graduated scale.

RESULTS

Twenty-six patients age sixty-five or older were included in this sample. Mean age of the group was 70.4 years. Mean risperidone dosage was 3.8 mg/day for a mean duration of 251 days. Eighteen of twenty-six patients (69%) had schizophrenia, two of twenty-six (8%) had schizoaffective disorder, two of twenty-six (8%) had bipolar disorder, and four of twenty-six (15%) had other psychotic disorders. Patients had a mean of 2.4 medical diagnoses in addition to their primary psychiatric diagnosis. Twenty-two of twenty-six patients (85%) had clinical improvement on risperidone, and twenty of twenty-six (77%) had improvement that was either marked or moderate. Risperidone therapy was very well tolerated in this elderly population with nineteen of twenty-six patients (73%) remaining on risperidone therapy at completion of this study. Medical illness did not appear to be worsened or complicated by risperidone therapy.

CONCLUSION

Risperidone appears to be an effective and well tolerated antipsychotic for elderly patients with chronic psychosis.