Schizophrenia

BACKGROUND

The lifetime prevalence of schizophrenia is 1%. Schizophrenia is among the most severe mental illnesses and gives rise to the highest treatment costs per patient of any disease. It is characterized by frequent relapses, marked impairment of quality of life, and reduced social and work participation.

METHODS

The group entrusted with the creation of the German clinical practice guideline was chosen to be representative and pluralistic in its composition. It carried out a systematic review of the relevant literature up to March 2018 and identified a total of 13 389 publications, five source guidelines, three other relevant German clinical practice guidelines, and four reference guidelines.

RESULTS

As the available antipsychotic drugs do not differ to any great extent in efficacy, it is recommended that acute antipsychotic drug therapy should be sideeffect- driven, with a number needed to treat (NNT) of 5 to 8. The choice of treatment should take motor, metabolic, sexual, cardiac, and hematopoietic considerations into account. Ongoing antipsychotic treatment is recommended to prevent relapses (NNT: 3) and should be re-evaluated on a regular basis in every case. It is also recommended, with recommendation grades ranging from strong to intermediate, that disorder- and manifestation-driven forms of psychotherapy and psychosocial therapy, such as cognitive behavioral therapy for positive or negative manifestations (effect sizes ranging from d = 0.372 to d = 0.437) or psycho-education to prevent relapses (NNT: 9), should be used in combination with antipsychotic drug treatment. Further aspects include rehabilitation, the management of special treatment situations, care coordination, and quality management. A large body of evidence is available to provide a basis for guideline recommendations, particularly in the areas of pharmacotherapy and cognitive behavioral therapy.

CONCLUSION

The evidence-based diagnosis and treatment of persons with schizophrenia should be carried out in a multiprofessional process, with close involvement of the affected persons and the people closest to them.

Transitions in Mental Health Care: the European Psychiatric Association contribution to reform in Bulgaria

Background:

The Bulgarian Ministry of Health invited the European Psychiatric Association (EPA) to evaluate Bulgarian mental health care service provision in 2018. Bulgarian mental health services face very significant challenges including a legacy of historic underfunding, internal conflicts, poor planning, and the emigration of very high numbers of younger skilled staff that had followed accession to the European Union. There were significant disputes between stakeholders regarding the way forward and had been at least two unsuccessful previous external agency interventions that had attempted to find solutions.

Method:

This EPA position paper describes in detail the EPA mission to Bulgaria including methodology, findings, recommendations, and finally the positive actions and changes that are now underway as a result of the EPA report and intervention aimed at contributing towards improving Bulgarian mental health services.

Results:

After meetings with multiple stakeholders in the Bulgarian mental health system and analysis of data on service delivery, workforce, funding and configuration the EPA Panel agreed a list of twenty recommendations for change.

Conclusions:

The EPA mission, with the collaboration of multiple stakeholders in Bulgaria, was successful in stimulating high level government action to improve mental health services. Despite longstanding differences, it was possible to involve the stakeholders in constructive dialogue. The importance of “speaking with one voice” was a key lesson learned.

EPA guidance on the quality of mental health services

The main aim of this guidance of the European Psychiatric Association is to provide evidence-based recommendations on the quality of mental health services in Europe. The recommendations were derived from a systematic search of the best available evidence in the scientific literature, supplemented by information from documents retrieved upon reviewing the identified articles. While most recommendations could be based on empirical studies (although of varying quality), some had to be based on expert opinion alone, but were deemed necessary as well. Another limitation was that the wide variety of service models and service traditions for the mentally ill worldwide often made generalisations difficult. In spite of these limitations, we arrived at 30 recommendations covering structure, process and outcome quality both on a generic and a setting-specific level. Operationalisations for each recommendation with measures to be considered as denominators and numerators are given as well to suggest quality indicators for future benchmarking across European countries. Further pan-European research will need to show whether the implementation of this guidance will lead to improved quality of mental healthcare, and may help to develop useful country-specific cutoffs for the suggested quality indicators.

What are depressive symptoms in acutely ill patients with schizophrenia spectrum disorder?

Background:

Aim was to examine depressive symptoms in acutely ill schizophrenia patients on a single symptom basis and to evaluate their relationship with positive, negative and general psychopathological symptoms.

Methods:

Two hundred and seventy-eight patients suffering from a schizophrenia spectrum disorder were analysed within a naturalistic study by the German Research Network on Schizophrenia. Using the Calgary Depression Scale for Schizophrenia (CDSS) depressive symptoms were examined and the Positive and Negative Syndrome Scale (PANSS) was applied to assess positive, negative and general symptoms. Correlation and factor analyses were calculated to detect the underlying structure and relationship of the patient’s symptoms.

Results:

The most prevalent depressive symptoms identified were depressed mood (80%), observed depression (62%) and hopelessness (54%). Thirty-nine percent of the patients suffered from depressive symptoms when applying the recommended cut-off of a CDSS total score of > 6 points at admission. Negligible correlations were found between depressive and positive symptoms as well as most PANSS negative and global symptoms despite items on depression, guilt and social withdrawal. The factor analysis revealed that the factor loading with the PANSS negative items accounted for most of the data variance followed by a factor with positive symptoms and three depression-associated factors.

Limitations:

The naturalistic study design does not allow a sufficient control of study results for the effect of different pharmacological treatments possibly influencing the appearance of depressive symptoms.

Conclusion:

Results suggest that depressive symptoms measured with the CDSS are a discrete symptom domain with only partial overlap with positive or negative symptoms.

The validity of self-rated psychotic symptoms in depressed inpatients

Background

Self-ratings of psychotic experiences might be biased by depressive symptoms.

Method

Data from a large naturalistic multicentre trial on depressed inpatients (n = 488) who were assessed on a biweekly basis until discharge were analyzed. Self-rated psychotic symptoms as assessed with the 90-Item Symptom Checklist (SCL-90) were correlated with the SCL-90 total score, the SCL-90 depression score, the Beck Depression Inventory (BDI), the Hamilton Depression Rating Scale 21 item (HAMD-21) total score, the Montgomery Åsberg Depression Rating Scale (MADRS) total score and the clinician-rated paranoid-hallucinatory score of the Association for Methodology and Documentation in Psychiatry (AMDP) scale.

Results

At discharge the SCL-90 psychosis score correlated highest with the SCL-90 depression score (0.78, P<0.001) and with the BDI total score (0.64, P<0.001). Moderate correlations were found for the MADRS (0.34, P<0.001), HAMD (0.37, P<0.001) and AMDP depression score (0.33, P<0.001). Only a weak correlation was found between the SCL-90 psychosis score and the AMDP paranoid-hallucinatory syndrome score (0.15, P<0.001). Linear regression showed that change in self-rated psychotic symptoms over the treatment course was best explained by a change in the SCL-90 depression score (P<0.001). The change in clinician-rated AMDP paranoid-hallucinatory score had lesser influence (P = 0.02).

Conclusions

In depressed patients self-rated psychotic symptoms correlate poorly with clinician-rated psychotic symptoms. Caution is warranted when interpreting results from epidemiological surveys using self-rated psychotic symptom questionnaires as indicators of psychotic symptoms. Depressive symptoms which are highly prevalent in the general population might influence such self-ratings.

European guidance–a project of the European Psychiatric Association

Evidence based medicine is a cornerstone of modern medicine including psychiatry. Treatment practice guidelines are nowadays available for guiding mental health care mainly with a focus on specific disorders. Many important clinical situations or problems beyond treatment, however, are lacking proper guidance. It is in this scope that a European Psychiatry Association (EPA) has developed its own program, the European Guidance Project. The present special issue presents six topics out of these series of guidance documents.

Smartphone applications for depression: a systematic literature review and a survey of health care professionals' attitudes towards their use in clinical practice

Smartphone applications ("apps") may contribute to closing the treatment gap for depression by reaching large populations at relatively low costs. The general public seems open towards the use of apps for mental disorders but less is known about the attitudes of health care professionals. Therefore, the aim of this study was to examine the available evidence on the effectiveness of apps for depression and to explore the attitudes of health care professionals towards their use in practice. A systematic literature search was performed aimed at studies utilizing smartphone applications for depression. In addition, a survey was conducted to explore health care professionals' attitudes towards using these treatment apps in clinical practice. Twelve articles were identified in the systematic literature review. All included trials reported a decline in depressive symptoms after the intervention periods. In the survey, 72 health care professionals participated. Significant differences were found between the level of technology experience and how much the health care professional would consider the use of mobile applications in clinical practice. Survey participants reported openness towards therapeutic app use but very little knowledge and experience in the field. Apps appear to be a promising self-management tool for reducing depressive symptoms. Despite some concerns, health care professionals' attitudes towards the use of smartphone applications in clinical practice are quite positive. The provision of information on the potential benefits of e-health interventions as well as the training of professionals in the application of new technologies may increase health care professionals' awareness and knowledge about mobile apps for the treatment of mental disorders.

[Revised S3 guidelines on schizophrenia : Developmental process and selected recommendations]

Schizophrenia is one of the most severe mental diseases and leads to significant personal and social impairments for affected persons. The illness is characterized by frequent relapses, results in increased mortality and is associated with the highest socioeconomic costs of all diseases. Moreover, patients with schizophrenia are often stigmatized in everyday life and also in most treatment settings. In 1998 the first German schizophrenia guidelines were published, followed by the first S3 guidelines for schizophrenia in 2006. The revision process started in 2012 coordinated by the German Association for Psychiatry, Psychotherapy and Psychosomatics (DGPPN) and the revised guidelines were published in 2019. The target group for the revised S3 guidelines includes all persons involved in the care of patients with schizophrenia in all sectors of the German healthcare system, including decision makers and insurance funds. Starting with an introduction of the biological, clinical and epidemiological basis of the disorder, recommendations for the diagnostics of schizophrenia, the detection of comorbidities, the use of antipsychotic medication and other somatic procedures, for psychotherapy, psychosocial interventions, handling of special treatment conditions and rehabilitation are made. Finally, recommendations for an evidence-based and optimal coordination within the healthcare system are made, followed by a discussion of the cost-effectiveness of treatment and presentation of strategies for improved quality management. The most important aspect of the revised S3 guidelines on schizophrenia is the multiprofessional cooperation in all phases of the disorder and an empathic and respectful therapeutic alliance.

A randomized double-blind controlled trial to assess the benefits of amisulpride and olanzapine combination treatment versus each monotherapy in acutely ill schizophrenia patients (COMBINE): methods and design

This report presents the rationale and design of a multi-center clinical trial that examines the efficacy and safety of antipsychotic combination treatment in acutely ill schizophrenia patients compared to antipsychotic monotherapy. Antipsychotic combination treatment is common in clinical practice worldwide, despite clinical guidelines generally not recommending such practice due to lacking evidence for its efficacy and safety. Olanzapine has a related chemical structure and comparable receptor-binding profile as clozapine, which demonstrated superior efficacy in combination studies, but has a more unfavorable side-effect profile compared to olanzapine. Amisulpride and olanzapine have shown promising therapeutic efficacy in meta-analyses in monotherapy for people with schizophrenia. Combining amisulpride and olanzapine, complementary receptor-binding properties may enhance efficacy and possibly reduce (or at least not augment) side effects due to the different receptor profiles and metabolization pathways. Accordingly, we hypothesize that patients treated with amisulpride plus olanzapine show greater improvement on the Positive and Negative Syndrome Scale total score after 8 weeks versus either monotherapy. A randomized, double-blind controlled trial is performed at 16 German centers comparing flexibly dosed monotherapy of oral amisulpride (400-800 mg/day), and olanzapine (10-20 mg/day) and amisulpride-olanzapine co-treatment. Sample size was calculated to be n = 101 per treatment arm, assuming an effect size of 0.500 and a two-sided alpha = 0.025 and beta = 0.90. Recruitment for this trial started in June 2012. Until December 2018, 328 patients have been randomized. Trial conduct has been extended to reach the projected sample size. Publication of the study results is expected in 2019 informing an evidence-based recommendation regarding specific antipsychotic combination treatment.

Mental, behavioral and neurodevelopmental disorders in the ICD-11: an international perspective on key changes and controversies

An update of the chapter on Mental, Behavioral and Neurodevelopmental Disorders in the International Classification of Diseases and Related Health Problems (ICD) is of great interest around the world. The recent approval of the 11th Revision of the ICD (ICD-11) by the World Health Organization (WHO) raises broad questions about the status of nosology of mental disorders as a whole as well as more focused questions regarding changes to the diagnostic guidelines for specific conditions and the implications of these changes for practice and research. This Forum brings together a broad range of experts to reflect on key changes and controversies in the ICD-11 classification of mental disorders. Taken together, there is consensus that the WHO's focus on global applicability and clinical utility in developing the diagnostic guidelines for this chapter will maximize the likelihood that it will be adopted by mental health professionals and administrators. This focus is also expected to enhance the application of the guidelines in non-specialist settings and their usefulness for scaling up evidence-based interventions. The new mental disorders classification in ICD-11 and its accompanying diagnostic guidelines therefore represent an important, albeit iterative, advance for the field.

Antisaccade and prosaccade eye movements in individuals clinically at risk for psychosis: comparison with first-episode schizophrenia and prediction of conversion

Saccadic eye movements are well-described markers of cerebral function and have been widely studied in schizophrenia spectrum populations. However, less is known about saccades in individuals clinically at risk for schizophrenia. Therefore, we studied individuals in an at-risk mental state (ARMS) (N = 160), patients in their first episode of schizophrenia (N = 32) and healthy controls (N = 75). N = 88 ARMS participants showed an early at-risk mental state (E-ARMS), defined by cognitive-perceptive basic symptoms (COPER) or a combination of risk and loss of function, whereas N = 72 were in a late at-risk mental state (L-ARMS), defined by attenuated psychotic symptoms or brief limited intermittent psychotic symptoms. We examined prosaccades, reflecting overt attentional shifts, and antisaccades, measuring inhibitory control, as well as their relationship as an indicator of the interplay of bottom-up and top-down influences. L-ARMS but not E-ARMS participants had increased antisaccade latencies compared to controls. First-episode patients had higher antisaccade error rates compared to E-ARMS participants and controls, and increased latencies compared to all other groups. Prosaccade latencies did not differ between groups. We observed the expected negative correlation between prosaccade latency and antisaccade error rate, indicating that individuals with shorter prosaccade latencies made more antisaccade errors. The magnitude of the association did not differ between groups. No saccadic measure predicted conversion to psychosis within 2 years. These findings confirm the existence of antisaccade impairments in patients with schizophrenia and provide evidence that volitional response generation in the antisaccade task may be affected even before onset of clinically overt psychosis.

Remission in schizophrenia - What are we measuring? Comparing the consensus remission criteria to a CGI-based definition of remission and to remission in major depression

BACKGROUND

Despite being recommended for use in clinical trials, the consensus remission criteria were found to leave patients with persisting symptoms, relevant areas of functional impairment and a decreased sense of wellbeing. Therefore, to evaluate the appropriateness of the schizophrenia consensus criteria, a definition of remission based on the Clinical Global Impression Scale (CGI) was developed and remitter subgroups were compared.

METHODS

239 patients with a schizophrenia spectrum disorder were evaluated regarding their remission status after inpatient treatment. Remission in schizophrenia was defined according to the symptom-severity component of the consensus criteria by Andreasen et al. and a CGI based definition was calculated using sensitivity and specificity using receiver operating curves (asymptomatic remitter). Both remitter groups (schizophrenia consensus versus asymptomatic remitters) were compared regarding different clinical variables at discharge as well as the likelihood to relapse within a 1-year follow-up period. Both schizophrenia remitter subgroups were compared to remitters in major depression as a reference value.

RESULTS

Following the consensus criteria, 63% of the schizophrenia patients were in remission compared to only 18% following the asymptomatic criterion. The schizophrenia consensus remitters were less likely to be concurrent treatment responders (p < 0.0001), had a significantly greater illness severity (p < 0.0001) and less functioning (p = 0.0358) as well as a significantly greater risk to relapse (p = 0.0174) compared to the schizophrenia asymptomatic remitters as well as the depressed remitters.

CONCLUSION

It should be critically re-evaluated if the currently proposed consensus criteria are adequate to measure what is traditionally understood to be remission.

Efficacy of high-frequency repetitive transcranial magnetic stimulation in schizophrenia patients with treatment-resistant negative symptoms treated with clozapine

BACKGROUND

Repetitive transcranial magnetic stimulation (rTMS) is a promising augmentation treatment for schizophrenia, however there are few controlled studies of rTMS augmentation of clozapine.

METHODS

Using data from the 'rTMS for the Treatment of Negative Symptoms in Schizophrenia' (RESIS) trial we examined the impact of rTMS on PANSS total, general, positive and negative symptoms among participants on clozapine. rTMS was applied to the left dorsolateral prefrontal cortex (DLPFC) for five treatment sessions/week for 3-weeks as augmentation for patients with a predominant negative syndrome of schizophrenia, as rated on PANSS.

RESULTS

26 participants from the RESIS trial were on clozapine, receiving active (N=12) or sham (N=14) rTMS treatment. In our Linear Mixed Model (LMM) analysis, time×group interactions were significant in the PANSS positive subscale (p=0.003) (not being the corresponding behavioral output for DLPFC stimulation), the PANSS general subscale (p<0.001), the PANSS total scale (p=0.015), but not the PANSS negative subscale (p=0.301) (primary endpoint of the RESIS trial), when all PANSS measurements from screening to day 105 were included. Descriptive data suggests that in the active group the improvement was more pronounced compared to the sham rTMS group.

CONCLUSIONS

In this largest available clozapine cohort, active rTMS may be more effective than sham rTMS when added to clozapine for positive and total psychotic symptoms. These findings should be interpreted with caution given this is a secondary analysis with a limited number of participants.

Predictors of treatment response to psychological interventions in people at clinical high risk of first-episode psychosis

AIM

Psychological interventions, such as cognitive behavioural therapy (CBT) and supportive counselling (SC), are used to treat people with schizophrenia and people at clinical high risk (CHR) of psychosis. However, little information is available on predictors of treatment response. This study aims to identify such predictors of psychological interventions in CHR.

METHODS

A total of 128 help-seeking CHR outpatients were randomized into two groups-integrated psychological intervention (IPI), including CBT, and SC-for 12 months. Multiple regression analysis was used to identify demographic, symptomatic and functional variables that predict improvement in positive (PANSS Positive), negative (PANSS Negative) and basic symptoms (Basic symptom total score) and improvement in functioning (GAF) at 1-year follow up.

RESULTS

In the merged group (IPI + SC), people who lived independently, were younger and presented with higher baseline functioning showed more improvement in symptomatic outcomes at follow up. Negative symptoms at baseline predicted less improvement in positive and basic symptoms. Being married or cohabiting and living in the primary family were found to correlate with good functioning at 1-year follow up.

CONCLUSIONS

Younger CHR individuals and those who are functioning well may particularly benefit from early intervention. Treatment might need to be modified for low-functioning CHR and those who already display higher scores of negative symptoms. Registration number: NCT00204087.

Innovations and changes in the ICD-11 classification of mental, behavioural and neurodevelopmental disorders

Following approval of the ICD-11 by the World Health Assembly in May 2019, World Health Organization (WHO) member states will transition from the ICD-10 to the ICD-11, with reporting of health statistics based on the new system to begin on January 1, 2022. The WHO Department of Mental Health and Substance Abuse will publish Clinical Descriptions and Diagnostic Guidelines (CDDG) for ICD-11 Mental, Behavioural and Neurodevelopmental Disorders following ICD-11's approval. The development of the ICD-11 CDDG over the past decade, based on the principles of clinical utility and global applicability, has been the most broadly international, multilingual, multidisciplinary and participative revision process ever implemented for a classification of mental disorders. Innovations in the ICD-11 include the provision of consistent and systematically characterized information, the adoption of a lifespan approach, and culture-related guidance for each disorder. Dimensional approaches have been incorporated into the classification, particularly for personality disorders and primary psychotic disorders, in ways that are consistent with current evidence, are more compatible with recovery-based approaches, eliminate artificial comorbidity, and more effectively capture changes over time. Here we describe major changes to the structure of the ICD-11 classification of mental disorders as compared to the ICD-10, and the development of two new ICD-11 chapters relevant to mental health practice. We illustrate a set of new categories that have been added to the ICD-11 and present the rationale for their inclusion. Finally, we provide a description of the important changes that have been made in each ICD-11 disorder grouping. This information is intended to be useful for both clinicians and researchers in orienting themselves to the ICD-11 and in preparing for implementation in their own professional contexts.

Psychotic disorder symptom rating scales: Are dichotomous or multi-point scales more clinically useful?-An ICD-11 field study

Classifications of psychotic disorders are moving towards utilizing dimensional symptom domains as the preferred mechanism for describing psychotic symptomatology. The ICD-11 has proposed six symptom domains (Positive symptoms, Negative symptoms, Depressive symptoms, Manic symptoms, Psychomotor symptoms, and Cognitive symptoms) that would be rated in addition to providing a psychotic disorder diagnosis. This study investigated clinicians' use of dichotomous versus multi-point scales for rating these six domains. Global mental health professionals (n = 273) rated case vignettes using both a 2-point and 4-point version of a rating scale for the six domains. Clinicians were more accurate using the 2-point scale in absolute terms, but after correcting for chance guessing and disagreements, the two versions of the scale were equally accurate. Clinicians believed the 2-point scale would be easier to use, although they also indicated that the 4-point scale would provide richer clinical information. Participants were able to detect the presence of psychotic symptom domains in the vignettes with good reliability with no special training using either scale. We recommend that clinicians and researchers use the version of the scale that best matches their purpose (i.e., to maximize accuracy or enhance case description). Future work should develop the implementation characteristics of the scale to improve its potential for global application.

Negative schemata about the self and others and paranoid ideation in at-risk states and those with persisting positive symptoms

BACKGROUND

The objective of this study is to test the conflicting theories concerning the association of negative self and other schemata and paranoid ideation.

METHODS

A risk-based approach, including risk stratification, is used to gain insight into the association of the negative self and other schemata that may be shared by individuals or differentiate between individuals at clinical high risk (CHR) for a first-episode psychosis and those with full-blown psychosis. The dataset includes a sample of individuals at CHR (n = 137) and a sample of individuals with persisting positive symptoms (PPS, n = 211). The CHR sample was subdivided according to a prognostic index yielding 4 CHR sub-classes with increasing risk for transition to psychosis.

RESULTS

Negative beliefs about the self were associated with paranoid ideation in CHR and a lower risk state. In the highest risk state and full-blown psychosis, there is an association with negative beliefs about others.

CONCLUSION

These findings are in line with theories suggesting a switch from a predominantly activated negative self-schema to a malevolent others-schema in association with paranoid ideation along the risk-continuum. However, due to methodological limitations these results should be replicated by future studies.

Clinical utility of ICD-11 diagnostic guidelines for high-burden mental disorders: results from mental health settings in 13 countries

In this paper we report the clinical utility of the diagnostic guidelines for ICD-11 mental, behavioural and neurodevelopmental disorders as assessed by 339 clinicians in 1,806 patients in 28 mental health settings in 13 countries. Clinician raters applied the guidelines for schizophrenia and other primary psychotic disorders, mood disorders (depressive and bipolar disorders), anxiety and fear-related disorders, and disorders specifically associated with stress. Clinician ratings of the clinical utility of the proposed ICD-11 diagnostic guidelines were very positive overall. The guidelines were perceived as easy to use, corresponding accurately to patients' presentations (i.e., goodness of fit), clear and understandable, providing an appropriate level of detail, taking about the same or less time than clinicians' usual practice, and providing useful guidance about distinguishing disorder from normality and from other disorders. Clinicians evaluated the guidelines as less useful for treatment selection and assessing prognosis than for communicating with other health professionals, though the former ratings were still positive overall. Field studies that assess perceived clinical utility of the proposed ICD-11 diagnostic guidelines among their intended users have very important implications. Classification is the interface between health encounters and health information; if clinicians do not find that a new diagnostic system provides clinically useful information, they are unlikely to apply it consistently and faithfully. This would have a major impact on the validity of aggregated health encounter data used for health policy and decision making. Overall, the results of this study provide considerable reason to be optimistic about the perceived clinical utility of the ICD-11 among global clinicians.