Setting new standards in schizophrenia outcomes: symptomatic remission 3 years before versus after the Andreasen criteria

Symptomatic remission is often mentioned as one of the treatment goals for schizophrenia. However, the consistently with which this is documented in the schizophrenia literature since the introduction of the consensus criteria proposed by Andreasen and colleagues in 2005 has yet to be investigated. Similarly, additional treatment goals which are being discussed include improved functioning and quality of life, but whether these goals are being increasingly documented in the literature alongside symptomatic remission is as yet unknown. The objective of this article is therefore to review the use of the term 'remission' in the schizophrenia literature from Europe, U.S.A. and the rest of the world from 2002 to 2007, before and after the introduction of the Andreasen criteria. A second objective is to determine whether these manuscripts documenting symptomatic remission are also addressing other concepts such as functioning, quality of life and relationships. This literature review indicates that the use of the Andreasen criteria is indeed increasing, although there are manuscripts documenting alternative remission criteria or using the term remission without documentation of specific remission criteria. From 2004 to 2007 the number of manuscripts mentioning remission without documenting specific criteria has fallen by approximately 50%. Within these manuscripts there is increasing awareness of functioning and quality of life as outcome measures, in particular in manuscripts generated in Europe and the U.S.A. This review highlights the growing importance of co-assessment of symptomatic remission and functional outcomes, and calls for further consideration of the most appropriate and consistent way to evaluate functioning of schizophrenia patients.

Metabolic parameters in the short- and long-term treatment of schizophrenia with sertindole or risperidone

The presence of the metabolic syndrome is an important risk factor for cardiovascular disease and diabetes. The short- and long-term metabolic safety of sertindole was compared to that of risperidone in a subset of patients enrolled in the sertindole cohort prospective (SCoP) study, an open randomized study. In 261 randomized patients, there were moderate increases in mean weight, BMI, and waist circumference during treatment with either sertindole or risperidone; after 12 weeks, the increase in weight was 1.3 and 1.1 kg, respectively, and after 36 weeks, it was 2.2 and 2.0 kg, respectively. From baseline to last assessment (up to 60 weeks), weight gains of 1.8 and 1.7 kg for sertindole and risperidone, respectively, were observed. Similar proportions of patients (sertindole: 17% versus risperidone: 16%) had weight increases ≥7% from baseline to last assessment. The mean changes from baseline in triglycerides, total cholesterol, HDL-cholesterol, LDL-cholesterol, plasma glucose and blood pressure were small and not clinically relevant in both treatment groups. No patient in either of the groups developed type 2 diabetes during the study. At last assessment, the prevalence of metabolic syndrome (International Diabetes Federation) was 17% in the sertindole group and 26% in the risperidone group and the incidence of metabolic syndrome was 7% in the sertindole group and 10% in the risperidone group. Treatment with either sertindole or risperidone did not appear to be associated with an increased comparative risk of developing metabolic syndrome. In general, the metabolic effects of sertindole and risperidone were similar.

How are we assessing functioning in schizophrenia? A need for a consensus approach

Efforts to improve everyday living skills are important in schizophrenia. What constitutes appropriate functioning is however difficult to evaluate. Several instruments were tested in different settings throughout Europe (EGOFORS initiative), including two new questionnaires (FROGS, PSRS), to provide directions on domains to be assessed and tools to be used.

Effectiveness of injectable risperidone long-acting therapy for schizophrenia: data from the US, Spain, Australia, and Belgium

BACKGROUND

Because wide variations in mental health care utilization exist throughout the world, determining long-term effectiveness of psychotropic medications in a real-world setting would be beneficial to physicians and patients. The purpose of this analysis was to describe the effectiveness of injectable risperidone long-acting therapy (RLAT) for schizophrenia across countries.

METHODS

This was a pragmatic analysis of data from two prospective observational studies conducted in the US (Schizophrenia Outcomes Utilization Relapse and Clinical Evaluation [SOURCE]; ClinicalTrials.gov registration number for the SOURCE study: NCT00246194) and Spain, Australia, and Belgium (electronic Schizophrenia Treatment Adherence Registry [eSTAR]). Two separate analyses were performed to assess clinical improvement during the study and estimate psychiatric hospitalization rates before and after RLAT initiation. Clinical improvement was evaluated using the Clinical Global Impressions-Severity (CGI-S) and Global Assessment of Functioning (GAF) scales, and change from baseline was evaluated using paired t tests. Psychiatric hospitalization rates were analyzed using incidence densities, and the bootstrap resampling method was used to examine differences between the pre-baseline and post-baseline periods.

RESULTS

The initial sample comprised 3,069 patients (US, n = 532; Spain, n = 1,345; Australia, n = 784; and Belgium, n = 408). In all, 24 months of study participation, completed by 39.3% (n = 209), 62.7% (n = 843), 45.8% (n = 359), and 64.2% (n = 262) of patients from the US, Spain, Australia, and Belgium, respectively, were included in the clinical analysis. Improvements compared with baseline were observed on both clinical assessments across countries (P < 0.001 at all post-baseline visits). The mean improvement was approximately 1 point on the CGI-S and 15 points on the GAF. A total of 435 (81.8%), 1,339 (99.6%), 734 (93.6%), and 393 (96.3%) patients from the US, Spain, Australia, and Belgium, respectively, had ≥1 post-baseline visit and were included in the analysis of psychiatric hospitalization rates. Hospitalization rates decreased significantly in all countries regardless of hospitalization status at RLAT initiation (P < 0.0001) and decreased significantly in the US and Spain (P < 0.0001) when the analysis was limited to outpatients only.

CONCLUSIONS

RLAT in patients with schizophrenia was associated with improvements in clinical and functional outcomes and decreased hospitalization rates in the US, Spain, Australia, and Belgium, despite differences in health care delivery systems.

Age at onset of psychotic disorder: cannabis, BDNF Val66Met, and sex-specific models of gene-environment interaction

Discovering modifiable predictors for age at onset may help to identify predictors of transition to psychotic disorder in the "at-risk mental state." Inconsistent effects of sex, BDNF Val66Met (rs6265), and cannabis use on age of onset were previously reported. BDNF Val66Met and cannabis use before illness onset were retrospectively assessed in a sample of 585 patients with schizophrenia and their association with age at onset was evaluated. Cannabis use was significantly associated with earlier age at onset of psychotic disorder (AOP; average difference 2.7 years, P < 0.001), showing dose-response effects with higher frequency and earlier age at first use. There was a weak association between BDNF Val66Met genotype and AOP (difference 1.2 years; P = 0.050). No evidence was found for BDNF × cannabis interaction (interaction χ(2) (1) = 0.65, P = 0.420). However, a significant BDNF × cannabis × sex interaction was found (interaction χ(2) (1) = 4.99, P = 0.026). In female patients, cannabis use was associated with earlier AOP in BDNF Met-carriers (difference 7 years), but not in Val/Val-genotypes. In male patients, cannabis use was associated with earlier AOP irrespective of BDNF Val66Met genotype (difference 1.3 years). BDNF Val66Met genotype in the absence of cannabis use did not influence AOP, neither in female or male patients with psychotic disorder. Complex interactions between cannabis and BDNF may shape age at onset in female individuals at risk of psychotic disorder. No compelling evidence was found that BDNF genotype is associated with age at onset of psychotic disorder in the absence of cannabis use.

Prevalence and severity of antipsychotic related constipation in patients with schizophrenia: a retrospective descriptive study

Background

Antipsychotic are the cornerstone in the treatment of schizophrenia. They also have a number of side-effects. Constipation is thought to be common, and a potential serious side-effect, which has received little attention in recent literature.

Method

We performed a retrospective study in consecutively admitted patients, between 2007 and 2009 and treated with antipsychotic medication, linking different electronic patient data to evaluate the prevalence and severity of constipation in patients with schizophrenia under routine treatment conditions.

Results

Over a period of 22 months 36.3% of patients (99) received at least once a pharmacological treatment for constipation. On average medication for constipation was prescribed for 273 days. Severe cases (N = 50), non-responsive to initial treatment, got a plain x-ray of the abdomen. In 68.4% fecal impaction was found.

Conclusion

A high prevalence of constipation, often severe and needing medical interventions, was confirmed during the study period. Early detection, monitoring over treatment and early intervention of constipation could prevent serious consequences such as ileus.

Quality: A non-interventional study evaluating quality of life in schizophrenic patients treated with atypical antipsychotics in the ambulatory setting

Objectives

The QUALITY study evaluated Quality-of-Life in schizophrenic patients treated with atypical antipsychotics (AAPs) in the ambulatory setting.

Methods

This study was a 9-month, observational, multicentre prospective study. Patients (18–65 years-old) diagnosed with schizophrenia and treatment started with one AAP before visit-1 (minimum: 4-weeks, maximum: 8-weeks) were enrolled into this Belgian study. At visit-1 patients’ demographics and medical history were recorded with follow-up visits after 3-, 6- and 9-months. At each visit, patients completed the Subjective Well-being under Neuroleptic treatment short form (SWN-K), while investigators assessed the Positive and Negative Symptom Scale (PANSS-8) and Global Assessment of Functioning.

Results

121 patients were enrolled: 91 male, mean age 36.7 ± 10.8years. The main AAPs were risperidone (38/121), apripirazole (28/121) and quetiapine (25/121). On average, most mean changes from baseline in SWN-K-subscale scores were positive (between −0.5 and +0.5, range −1.8–1.6) suggesting patients felt better, although there were no treatment-group differences. The associations between baseline SWN-K-subscales and age were small (RC [regression co-efficient] range: −0.03–0.01). PANSS-8-score changes were slightly negative (means between −0.77 and −0.43) suggesting decreased symptom severity. Patients with more severe negative symptoms considered their mental- and physical-functioning to be better throughout the study, indicated by significant correlations between these SWN-K-subscale scores and negative PANSS-scores (RC = 0.19, p = 0.0282; RC = 0.15, p = 0.0258). The associations between SWN-K-scores and positive PANSS-scores were small (RC: 0.01–0.14). The number of hospitalizations decreased during the study (9.6% between visit-1 and 2 vs. 7.5% visit-3 and −4).

Conclusions

Quality-of-life for all patients seemed to improve slightly, without any differences between treatment-groups.

Ziprasidone vs olanzapine in recent-onset schizophrenia and schizoaffective disorder: results of an 8-week double-blind randomized controlled trial

INTRODUCTION

Head-to-head comparisons of antipsychotics have predominantly included patients with chronic conditions. The aim of the present study was to compare the efficacy and tolerability of ziprasidone and olanzapine in patients with recent-onset schizophrenia.

METHODS

The study was an 8-week, double-blind, parallel-group, randomized, controlled multicenter trial (NCT00145444). Seventy-six patients with schizophreniform disorder, schizophrenia or schizoaffective disorder (diagnosis < 5 y), and a maximum lifetime antipsychotic treatment < 16 weeks participated in the study. Efficacy of ziprasidone (80-160 mg/d) and olanzapine 10-20 mg was measured using the Positive and Negative Syndrome Scale (PANSS), the Clinical Global Impression (CGI) Scale, the Calgary Depression Scale for Schizophrenia (CDSS), and the Heinrich Quality of Life Scale (HQLS); tolerability assessments included laboratory assessments, body weight, and electroencephalogram.

RESULTS

Olanzapine (n = 34) and ziprasidone (n = 39) showed equal efficacy as measured by the PANSS, CDSS, CGI, and HQLS. However, mean weight gain was significantly higher in the olanzapine group (6.8 vs 0.1 kg, P < .001). Ziprasidone was associated with decreasing levels of triglycerides, cholesterol, and transaminases, while these parameters increased in the olanzapine group (all P values < .05). There were no significant differences in fasting glucose and prolactin levels or in cardiac or sexual side effects. Patients on ziprasidone used biperiden for extrapyramidal side effects more frequently (P < .05).

DISCUSSION

The results of this study indicate that ziprasidone and olanzapine have comparable therapeutic efficacy but differ in their side effect profile. However, there is a risk of a type II error with this sample size. Clinically significant weight gain and laboratory abnormalities appear early after initiating treatment and are more prominent with olanzapine, while more patients on ziprasidone received anticholinergic drugs to treat extrapyramidal symptoms.

A systematic evaluation and comparison of the guidelines for screening and monitoring of cardiometabolic risk in people with schizophrenia

Metabolic and cardiovascular health problems have become a major focus for clinical care and research in schizophrenia. To evaluate the content and quality of screening guidelines for cardiovascular risk in schizophrenia we performed a systematic review and quality assessment of guidelines/recommendations published between 2000–2010, using the Appraisal of Guidelines for Research and Evaluation (AGREE). AGREE domain scores varied between 18 identified guidelines. Most guidelines scored best on the domains ‘Scope and Purpose’ and ‘Clarity of Presentation’. The domain ‘Rigour of Development’ was problematic in most guidelines, while the domains ‘Stakeholder Involvement’ and ‘Editorial Independence’ scored the lowest. The following parameters were recommended, in order of frequency: fasting glucose, BMI, fasting triglycerides, fasting cholesterol, waist, HDL/LDL, blood pressure, symptoms of diabetes. In terms of interventions most guidelines recommended advise on physical activity, advise on diet psycho-education of the patent, treatment of lipid abnormalities, treatment of diabetes, referral for advise and treatment, psycho-education of family and smoking cessation advice. Compared across all domains and content, 4 European guidelines could be recommended. Four of the evaluated guidelines are of good quality and should guide clinicians’ screening and monitoring practices. Future guideline development could be improved by increasing its rigour and assuring user and patient involvement. Although good guidelines are available research shows that the implementation in daily clinical practice remains poor.

Improvement in patient symptoms and functioning during long-term treatment with olanzapine long-acting injection (OLAI)

Introduction, objectives and aims

To evaluate the outcome of patients with schizophrenia during maintenance treatment with OLAI.

Methods

Data from three studies with OLAI were pooled and patients classified according to a cluster analysis [Lipkovich, Psychiatry Res, 2009] into five categories according severity of psychiatric symptoms (sx) and functional impairment (imp):A

Improvement was defined as a change from B or C to A, or from D or E to A, B or C. Changes between the categories in the 6 months were analyzed. Stepwise logistic regression modeling was done to determine factors associated with improvement.

Results

1182 patients were classified. Patients who remained in the studies at 6 months had lower baseline CGI-S (3.04 vs 3.28, p < 0.001), lower PANSS (61.38 vs 64.05, p = 0.012) and higher QLS (1.76 vs 1.39, p = 0.001). (Table 1) As patients in category A couldn’t improve and in category D&E couldn’t worsen, 261(39%) patients from categories B, C, D and E improved and only 55(10%) from categories A, B and C got worse during 6 months. Baseline factors associated with improvement were: baseline category (p < 0.001), CGI-S score (p = 0.022), and PANSS positive (p = 0.003)

Conclusions

Majority of patients with schizophrenia who stay on 6 months treatment with OLAI improve or maintain their symptoms and functioning level. The strongest factor associated with a higher chance of improvement was poor baseline category.

Impact of the “puente project” on the public disease expenditure of a patient with schizophrenia in belgium

Introduction

The “Puente project”, rises up the adherence rate with 38% (1). The aim of the study was to analyse the economic impact of this disease management prgramme of patients with a schizophrenic disorder.

Subjects and methods

“Puente” stands for a programme of LAAP with active outreaching of patients with schizophrenia. The details of the data collection and the subjects have been described elsewhere (1).The hospitalisation rate and the length of stay of the 117 case control pairs have been compared. The cost of hospitalisation in Belgium, recently adjusted by De Ridder et al. (2), have been used in order to map the differences.

Results

The number of hospital days totalised by 23 cases, was 2,152 days, in comparison to 6,371 realised by 42 controls,wich gives 18,6 hospital days per year for the cases and 38.9 days for the controls. Given an hospital cost per day in Belgium of 163.8 € per day, a crude saving of 3,328.5 € per case per year can be realised, correespondng with a net diminution of 2,428.5 € per patient year. Enrolling 1,675 cases per year, creates a saving of 4,066,533 € per year, an equivalent of 24,826 hospital days, or the cost of a psychiatric hospital of 85 beds occupied at 80%.

Conclusion

The Puente programme realised a substantial drop in public patient expenditure of 3,328.5 € per patient year. This is a very strong argument to implement, to finance and to support “Puente” like disease programmes in Belgium.

Clock genes and body composition in patients with schizophrenia under treatment with antipsychotic drugs

CONTEXT

In the healthy population, several pathways are known to exert an effect on basal metabolic factors. Previous studies have found associations between single nucleotide polymorphisms in clock genes or downstream hormone receptors such as the leptin receptor (LEPR) or glucocorticoid receptor (NR3C1) and obesity in the healthy population, but this association remains to be examined in patients with schizophrenia treated with antipsychotics.

OBJECTIVE

To assess anthropomorphic parameters in patients taking second-generation antipsychotics (SGA) as a function of nine polymorphisms in three core genes of the clock pathway, and two genes of downstream hormone receptors.

METHODS

Clinical parameters were evaluated in 261 patients with schizophrenia spectrum disorder. Polymorphisms in LEPR, MC3R, NR3C1, PER2 and SDC3 were genotyped. In order to control for multiple testing, permutation tests were used to generate corrected empirical p-values using the Max(T) procedure in PLINK.

RESULTS

A significant effect of the rs6196 polymorphism in the NR3C1 on weight (β=-4.18; SE=2.02; p=0.018), BMI (β=-1.88; SE=0.64; p=0.004), waist (β=-5.77; SE=1.75; p=0.001) and waist/hip ratio (β=-0.03; SE=0.012; p=0.009) was found. Permutation tests confirmed the findings for BMI (p=0.037) and waist (p=0.024). Carriers of the G allele consistently displayed better parameters than patients with the wild type allele. A weak effect of rs4949184 in SDC3 on BMI was found, but this did not sustain permutation testing (β=-1.27; SE=0.58; p=0.030, p=0.270 after permutations).

CONCLUSION

Variations in genes implicated in circadian regulation or its related downstream pathways may be important in the regulation of antropomorphic parameters in patients with schizophrenia during long-term treatment with SGA.

[Aripiprazole-induced parkinsonism in a 64-year-old female patient diagnosed with bipolar disorder]

A 64-year-old female patient, diagnosed with bipolar disorder, developed parkinsonism 18 days after aripiprazole had been initiated. Twenty-six days after the patient had stopped taking aripiprazole the parkinson syndrome disappeared completely. Aripiprazole is usually associated with a low incidence of extrapyramidal symptoms. So far, little is known about the pathophysiology of parkinsonism and the possible role of aripiprazole. The case-study includes some hypotheses and recommendations.

[Clinical assessment of the ultra high risk of developing a a psychotic disorder; review and critical reflection]

BACKGROUND

It may be possible to improve the prognosis of psychotic disorders by the timely recognition and treatment of the early stages of these disorders. Since the first psychotic episode is often preceded by a period of non-specific symptoms and functional decline, it could be worthwhile investigating whether this early phase can be detected.

AIM

To review existing diagnostic approaches and clinical instruments that are currently used for prospective identification of the prodromal phase.

METHOD

We searched the literature between 1995 and 2009 using the search terms 'prodromal' or 'ultra high risk' in combination with 'psychosis' or 'schizophrenia' and 'assessment'.

RESULTS

In international literature we found four diagnostic approaches to ultra high risk of psychosis: the attenuated positive symptom approach, the basic symptom approach, the clinical high risk approach and the strictly phenomenological approach. Within each of these approaches specific screening instruments had been developed and tested with regard to their ability to correctly predict a first psychotic episode.

CONCLUSION

None of the current diagnostic approaches produces a sufficiently reliable prediction of the risk of a first psychotic episode. Within the group of persons assumed, based on screening, to be at very high risk, only a small percentage will actually develop a psychotic disorder.

The management of schizophrenia: focus on extended-release quetiapine fumarate

Effective management of schizophrenia remains a significant clinical challenge. While antipsychotic medications have proven efficacy in this disease, there remains an opportunity to further improve symptom control and long-term relapse prevention. Also, a number of factors, including tolerability and complex dosing regimens, can result in nonadherence to medication. Quetiapine is an atypical antipsychotic with proven efficacy and an established tolerability profile in schizophrenia. The once-daily extended-release formulation (quetiapine XR) offers a simplified dosing regimen and titration schedule. Short-term clinical studies have shown that quetiapine XR (400-800 mg/d) is efficacious in the acute treatment of schizophrenia, while a long-term study has shown that quetiapine XR was significantly more effective than placebo at preventing relapse. Furthermore, an investigation in which stable patients switched from the immediate-release formulation (quetiapine IR) to quetiapine XR showed that quetiapine XR is generally well tolerated and has no loss of efficacy compared with quetiapine IR. In patients who experienced insufficient efficacy or poor tolerability on their previous antipsychotic, switching to quetiapine XR significantly improved efficacy compared with the previous treatment. In conclusion, quetiapine XR is an effective and generally well tolerated treatment for schizophrenia. Furthermore, once-daily dosing may improve patient adherence, which may impact positively on patient outcomes.

[Body-directed techniques on psychomotor therapy for people with schizophrenia: a review of the literature]

BACKGROUND

Patients with schizophrenia frequently undergo a disturbance of body experience. This can occur during an acute psychotic phase or during a period of remission.

AIM

To investigate the scientific evidence of the effects of introducing body-directed techniques into psychomotor therapy for patients with schizophrenia.

METHOD

PubMed, PEDro, CINAHL, psycINFO and SPORTDiscus were searched form 1 January, 2000, tot 1 January 2011, for reports of randomised controlled trials, controlled clinical trials and for studies wit a different design. The Tijdschrift voor Psychiatrie (the Dutch Journal of Psychiatry), the Tijdschrift voor Vaktherapie (The Journal for Special therapies) and Actuele Themata (Actual Themes) in psychomotor therapy were also screened. The quality of the methodology was assessed with the help of a checklist. Evidence for the efficacy of the interventions was summarised on the basis of a best-evidence synthesis.

RESULT

Eleven studies satisfied our inclusion and exclusion criteria. There was a strong evidence for the reduction of psychiatric symptoms after yoga and reduced feelings of anxiety and stress after progressive muscle relaxation. There is limited evidence for yoga in reducing feelings of anxiety and stress and for body-directed group techniques in reducing negative symptoms. Qualitative research reported that mindfulness – and massage-techniques were able to considerably reduce feelings of stress. There is no evidence for the beneficial effects of dancing techniques.

CONCLUSION

A body-directed approach can be effective an deserves to be included in the multidisciplinary treatment of schizophrenia.

Cognitive deficits in nonaffective functional psychoses: a study in the Democratic Republic of Congo

Cognition has been studied extensively in schizophrenia in Western countries. Far less research is devoted, however, to cognitive functioning in brief psychotic disorder and schizophreniform disorder. Moreover, few studies have been performed in third world countries. In this study, we want to fill this gap by comparing the cognitive functioning of three groups of ambulant, first-episode patients with a non-affective psychosis in the Democratic Republic of Congo. To test if cognitive dysfunction is a core symptom of psychosis in an African population, 153 healthy control subjects are compared with a sample of 68 patients with brief psychotic disorder, 50 patients with schizophreniform disorder, and 70 patients with schizophrenia in a cross-sectional study on several distinctive cognitive domains including verbal, visual, and working memory, attention, visuomotor control, motor speed, verbal fluency, and executive functions. In addition, these three groups of patients are compared among themselves on these cognitive domains. Results indicate that patients perform significantly worse than healthy controls on all cognitive domains with cognitive deficits being most pronounced in verbal and working memory, attention, motor speed, and executive functions. No major differences were found, however, between the three patient groups.

Physical health management in psychiatric settings

Severe mental disorders have a chronic course associated with a high risk for co-morbid somatic illnesses and premature mortality, but despite this increased risk, general health care needs in this population are often neglected. Over recent years, several groups have developed screening and monitoring guidelines for metabolic and cardiovascular risk assessment in patients treated with antipsychotics. The psychiatrist needs to be aware of the potential metabolic side-effects of antipsychotic medication and to include them in the risk/benefit assessment when choosing a specific antipsychotic. He should also be responsible for the implementation of the necessary screening assessments and referral for treatment of any physical illness. Multidisciplinary assessment of psychiatric and medical conditions is needed. The somatic treatments offered to people with severe and enduring mental illness should be at par with general health care in the non-psychiatrically ill population. In our University Centre, a structured and elaborate screening and monitoring protocol was introduced in late 2003. This paper describes the practical aspects of this monitoring protocol and the results obtained 4 years after its implementation.

Effects on cognitive functioning after olanzapine-ziprasidone crossover in recent-onset schizophrenia

INTRODUCTION

To enhance functional outcome in schizophrenia improvement of cognitive symptoms is crucial.

EXPERIMENTAL PROCEDURES

Using a comprehensive test battery, this follow-up examines cognitive effects in patients with recent-onset schizophrenia after a change of medication following insufficient clinical response and intolerance.

RESULTS

After eight weeks cognitive outcomes had not improved in the patients having switched from olanzapine to ziprasidone (n=11; mean dose 136 mg) nor in those having switched from ziprasidone to olanzapine (n=10; mean 16 mg), while the symptoms of patients maintaining olanzapine (n=18; mean 10.9 mg) or ziprasidone (n=18; mean 88.9 mg) treatment had not improved further.

DISCUSSION

The findings suggest that also in early-stage schizophrenia the antipsychotics tested affect cognitive symptoms similarly.

Safety of sertindole versus risperidone in schizophrenia: principal results of the sertindole cohort prospective study (SCoP)

OBJECTIVE

To explore whether sertindole increases all-cause mortality or cardiac events requiring hospitalization, compared with risperidone.

METHOD

Multinational randomized, open-label, parallel-group study, with blinded classification of outcomes, in 9858 patients with schizophrenia.

RESULTS

After 14147 person-years, there was no effect of treatment on overall mortality (sertindole 64, risperidone 61 deaths, Hazard Ratio (HR) = 1.12 (90% CI: 0.83, 1.50)) or cardiac events requiring hospitalization [sertindole 10, risperidone 6, HR = 1.73 (95% CI: 0.63, 4.78)]: Of these, four were considered arrhythmia-related (three sertindole, one risperidone). Cardiac mortality was higher with sertindole (Independent Safety Committee (ISC): 31 vs. 12, HR=2.84 (95% CI: 1.45, 5.55), P = 0.0022; Investigators 17 vs. 8, HR=2.13 (95% CI: 0.91, 4.98), P = 0.081). There was no significant difference in completed suicide, but fewer sertindole recipients attempted suicide (ISC: 68 vs. 78, HR=0.93 (95% CI: 0.66, 1.29), P = 0.65; Investigators: 43 vs. 65, HR=0.67 (95% CI: 0.45, 0.99), P = 0.044).

CONCLUSION

Sertindole did not increase all-cause mortality, but cardiac mortality was higher and suicide attempts may be lower with sertindole.

[Validity of nonaffective functional psychosis of the DSM IV in a Congolese population. A transversal clinical trial]

BACKGROUND

The fourth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM IV) distinguishes schizophrenia, schizophreniform disorder and brief psychotic disorder only according to the duration of the illness. Thus, the validity of these nosological concepts sounds uncertain.

AIM

The aim of this study was to evaluate the validity of the DSM IV concepts schizophrenia, schizophreniform disorder and brief psychotic disorder.

POPULATION AND METHODS

Seventy schizophrenics, 68 patients with brief psychotic disorder and 50 with schizophreniform disorder, all Congolese people, selected from the 'Telema' Mental Health Centre and the 'Neuropsychopathological centre of the University of Kinshasa, from 5(th) August 2003 to 14(th) March 2005 were compared with respect to the following clinical parameters: family schizophrenia and brief psychoses history, precipitating psychosocial factors, mode of onset of the disease, clinical syndromes linked to psychoses and general functioning. Statistical analyses included analysis of variances 'one way' (Anova), post hoc Tukey's test, discriminant analysis, and analysis of covariances.

RESULTS

Brief psychotic disorder differed from schizophrenia and schizophreniform Disorder in respect with positive syndrome (F=8.76, df=2; 179, p=0.0002), cognitive syndrome (F=3.79, df=2; 179, P=0.024), syndrome of excitement (F=3.23, df=2; 179, P=0.042), general functioning (F=13.73, df=2; 179, P<0.0001), family history of schizophrenia (χ(2)=8.65; P=0.013), precipitating psychosocial factors (χ(2)=19.82; P<0.0001), and mode of onset of the disease (χ(2)=91.3; P<0.0001). Schizophreniform disorder differered from schizophrenia only by a more frequent acute onset and a better general functioning. Two nosological realities were thus distinguishable: brief psychotic disorder and schizophrenia-schizophreniform disorder complex. Surprisingly, negative syndrome could not distinguish brief psychotic disorder from schizophrenia and schizophreniform (F=2.80, df=2; 179, P=0.063). Data of the discriminant analysis based on scores on general functioning, positive, negative, depressive, cognitive and excitement syndromes was conclusive (F=6.41, df=2; 185, P<0.0001) and allowed correct classification rates of 75% for brief psychotic disorder, 48% for schizophreniform disorder, 54% for schizophrenia. Schizophreniform disorder was thus the less distinguishable group; this is in the line with longitudinal studies, which demonstrated the lowest diagnostic stability of this affection, compared with the two other diseases. Total error rate was 41%.

CONCLUSIONS

Brief psychotic disorder could constitute a distinct affection from schizophrenia and schizophreniform disorder, whereas schizophreniform disorder and schizophrenia could be the same affection; the first being an acute and "good functioning" form of the second. However, these viewpoints need to be confirmed by data on long-term course. The data of this study validate ultimately a binary model of the major nonaffective functional psychoses, like that of the tenth edition of the International classification of mental and behavioural disorders (ICD-10).

MTHFR and risk of metabolic syndrome in patients with schizophrenia

OBJECTIVE

Meta-analyses have implicated polymorphisms in MTHFR, encoding a critical enzyme in folate and homocysteine metabolism, in both schizophrenia and CVD.

METHOD

A possible association between the C677T and A1298C polymorphisms of the MTHFR gene on the one hand, and metabolic syndrome on the other, was examined in a naturalistic cohort of 518 patients with a schizophrenia spectrum disorder screened for metabolic disturbances at the Catholic University of Louvain, Belgium.

RESULTS

MTHFR A1298C, but not C677T, was associated with the metabolic syndrome, C/C genotypes having a 2.4 times higher risk compared to A/A genotypes (95% CI 1.25-4.76, p=0.009). Haplotype analysis revealed similar findings, showing greater risk for metabolic syndrome associated with the 677C/1298C haplotype compared to the reference 677C/1298A haplotype (OR 1.72, 95% CI 1.24-2.39, p=0.001). These associations were not explained by circulating folate levels. Differences between A1298C genotype groups were considerably greater in the subsample treated with clozapine or olanzapine (OR C/C versus A/A 3.87, 95% CI 1.51-9.96) than in subsample treated with any of the other antipsychotics (OR C/C versus A/A 1.30, 95% CI 0.47-3.74), although this did not formally reach statistical significance in the current cross-sectional study (gene-by-group interaction chi(2)=3.0, df=1, p=0.08).

CONCLUSION

These data provide evidence supporting an association between MTHFR and risk of metabolic syndrome in patients with schizophrenia. Prospective studies evaluating the course of metabolic outcomes after initiation of antipsychotic medication are needed to evaluate possible gene-by-treatment interaction more specifically.

The prevention of deep venous thrombosis in physically restrained patients with schizophrenia

BACKGROUND

Physical restraint and seclusion are associated with several risks. Antipsychotic drug use increases this risk.

OBJECTIVE

To evaluate whether the risk of thromboembolism in physical restraint and seclusion of patients with psychosis, treated with antipsychotic medication, was considered by taking preventive measures.

METHOD

Anonymous data on all consecutively admitted patients with schizophrenia, treated with antipsychotic medication, between 2002 and 2009, were analysed. Diagnostic information and data about seclusion procedures and medication were collected. Preventive measures of thromboembolism in patients in physical restraint were assessed by reviewing case notes and the medication prescribed at the time of seclusion.

RESULTS

Seclusion of patients with psychosis is common. Out of 679 identified patients, 170 had been secluded (472 events). Physical restraint use was not a rare event (N seclusions with restraint use 296, 62.7%). Pharmacological preventive measures (use of heparine drugs) were taken frequently to prevent deep vein thrombosis (DVT) by physical restraint or isolation. Sixty-five (38.2%) out of 170 secluded patients, including a majority of patients who had been under physical restraint, had been administered anticoagulants at the time of seclusion. No cases of DVT occurred.

CONCLUSIONS

Preventive measures were routinely administered in clinical practice and were effective in the prevention of DVT. For a clinical setting, it is important to establish a clear and detailed management plan on seclusion and fixation taken into account in all possible risks of physical restraint.

Considering a frame of reference for physical activity research related to the cardiometabolic risk profile in schizophrenia

This article reviews evidence that researchers and mental health service providers need to take into account four modifiable factors that affect the prevalence of the metabolic syndrome in people with schizophrenia: (a) physical activity as part of a health-related lifestyle, (b) physical fitness, (c) mental health status and (d) antipsychotic medication. The implementation of physical activity in order to prevent and treat cardiometabolic risk factors in people with schizophrenia is discussed. English language articles published until July 2009 were identified by PubMed, CINAHL, PsychINFO, and Cochrane Central Register of Controlled Trials. The search terms schizophrenia and metabolic syndrome, physical activity, health, fitness, and lifestyle were used. Physical activity interventions result in positive effects on metabolic outcomes, physical fitness, health-related behavior and mental health. Considering present knowledge, physical therapists should take into account the emotional (negative symptoms, self-esteem, self-efficacy, and stress) and physiological (cardiometabolic parameters) components of mental illness when offering physical activity interventions. The physical activity stimulus should be adapted to the individual's physical fitness level and the side effects of the antipsychotic medications. More research is needed to assist in the practical development of effective evidence-based preventive and curative strategies in psychiatric services for metabolic syndrome in persons with schizophrenia.