Update on Cognitive Behavioral Psychotherapy for Schizophrenia: Review of Recent Studies

Cognitive-behavioral psychotherapy (CBT) for schizophrenia has been the focus of clinical trials. This article reviews 17 recent studies including 5 from the United States or Canada. CBT interventions vary by the patient group to whom they are provided. Both individual and group CBT therapies have been developed, some of which have been combined with other psychosocial treatments. There is inconsistency among the study results, but evidence is strongest for the benefit to outpatients who have residual symptoms including hallucinations, delusions, or negative symptoms. Methodological issues include the type of comparison group used, the adequacy of the sample size, and patient attrition. Future investigations of CBT would be improved by a greater standardization of study procedures and by stratifying patients according to clinical characteristics to better understand which patients are more likely to benefit.

Should CBT Target the Social Impairments Associated With Schizophrenia?

Adjunctive cognitive behavior therapy (CBT) has been found to reduce the impact of symptoms among individuals with schizophrenia; however, CBT has not been used to address the social deficits in this clinical population. The current article elaborates the rationale for targeting social functioning with CBT. These reasons include the following: (a) Social dysfunction is a core feature of schizophrenia that is not directly improved with medication; (b) Improved social functioning is a treatment goal of many patients with schizophrenia, and thus treatments designed to improve social functioning may increase treatment motivation and reduce attrition; (c) Adaptive social functioning is a critical component of mental and physical health; and (d) Social dysfunction appears to be responsive to psychosocial intervention. This article concludes with a description of functional cognitive behavior therapy (FCBT), a CBT intervention that has been developed with enhanced focus on social impairments.

The SMILES program: a group program for children with mentally ill parents or siblings

The Simplifying Mental Illness + Life Enhancement Skills program, for children with a mentally ill parent or sibling, is a 3-day program that aims to increase children's knowledge of mental illness and to better equip them with life skills considered beneficial for coping in their family. Self-report data from 25 children who attended 3 of these programs, in Canada and Australia, indicate that these aims were achieved. Their parents also report benefits for their children.

Comparison of characteristics between geriatric and younger subjects with schizophrenia in community

Relatively little is known about the different characteristics of non-institutionalized geriatric and younger subjects with schizophrenia. This study compared demographic and clinical characteristics of all the geriatric, middle-age and young subjects with schizophrenia living in a Chinese rural community. Geriatric (age >/= 65 years) (N = 51), middle-age (age 41-64 years) (N = 263) and young subjects with schizophrenia (age 15-40 years) (N = 196) in a rural community were assessed with the Present State Examination and Social Disability Screening Schedule. Age at first onset was significantly older in geriatric male and female groups. While there were no significant differences of negative symptoms among the three groups, the rates of lifetime nuclear syndrome were significantly lower in geriatric subjects compared to the other two groups. Geriatric subjects were less likely to have been hospitalized (9.8%) than middle-age (19.0%) and younger subjects (24.8%). Although the duration of illness was significantly longer in geriatric subjects than in the other two groups, the clinical outcome was significantly better in the geriatric group and social functioning scores were similar among the three groups. Geriatric subjects were more likely to be female, with longer duration of illness, fewer "core" symptoms, relatively stable social functioning and clinical outcome. The pathogenesis and psychopathology of geriatric subjects may be different compared to younger subjects with schizophrenia.

Neurological soft signs discriminating mood disorders from first episode schizophrenia

OBJECTIVE

To investigate the specificity of neurological soft signs (NSS) for first episode schizophrenia compared with mood disorders.

METHOD

We assessed NSS in a sample of 60 healthy controls, 191 first episode psychosis patients and 81 mood disorder patients. We used a principle component analysis to identify dimensions of NSS. We subsequently investigated the specificity of these dimensions for schizophrenia and their relationships with medication and symptom scores.

RESULTS

We identified five dimensions; coordination disorders, movement disorders, increased reflexes, dyskinesia and catatonia. These dimensions were related to neural circuits associated with schizophrenia and mood disorders and included the fronto-striatal-thalamic and the fronto-cerebellar pathway. The movement disorder dimension, which was suggestive for the involvement of the fronto-striatal-thalamic pathway, was specific for first episode schizophrenia independent from medication.

CONCLUSION

NSS are the result of circuitry dysfunctions rather than overall dysfunction and a particular set of NSS shows specificity for schizophrenia.

Direct association between orbitofrontal atrophy and the response of psychotic symptoms to olanzapine in schizophrenia

The study of cerebral variables associated with response to neuroleptics holds interest from both theoretical and clinical points of view. To date, no studies have aimed to identify predictors of response to olanzapine based on cerebral measurements. Here, we used magnetic resonance to assess the relationship between volumes of the prefrontal (dorsolateral and orbitofrontal) and temporal (temporal lobe and hippocampus) cortical regions and ventricles and, on the other hand, the response to olanzapine in 16 schizophrenic patients. Data from 42 healthy controls were used to calculate volume residuals in the patients, defined as deviations from the expected values, given individual age and intracranial volume. Residuals thus represent the effect of illness on regional measurements. The association between clinical change and those residuals was calculated separately for the positive, negative and total scores from the Positive and Negative Syndrome Scale (PANSS). There was a significant direct association between the degree of orbitofrontal atrophy and the improvement of positive symptoms with olanzapine. No predictors were found for change in the negative dimension. A trend was found for patients with larger ventricles to show a greater global decrease in total PANSS scores. Neither age nor duration of illness explained a significant proportion of the symptom improvement. This result, together with others from the literature, supports the idea that atypical antipsychotics may offer some benefit to patients with significant regional atrophy, and this may have implications for the choice of antipsychotic in clinical practice.

Correlates of coping styles in psychotic illness

BACKGROUND

Both integration and sealing over have been identified as global, clinically distinct coping styles with the psychotic illness and integration was found to be associated with a better outcome. We studied a series of potential correlates of these coping styles.

SAMPLING AND METHODS

A total of 75 psychiatric patients in a recovery phase after a psychotic episode were studied. All patients filled out the Frankfurt Self-Concept Inventory and the Parental Bonding Instrument; the Integration/Sealing over Scale and the Positive and Negative Syndrome Scale were completed by an investigator for all patients during a semistructured interview. Besides, some sociodemographic and clinical data were collected.

RESULTS

A relationship was found between the integrative coping style and absence of negative symptoms, housing with partner or alone indicating more social competence and a diagnosis of psychotic illness other than (paranoid) schizophrenia.

CONCLUSIONS

As only 25% of the variance were explained, other--still unknown--factors are also of importance.

Linkage of eye movement dysfunction to chromosome 6p in schizophrenia: additional evidence

Establishing the genetics of physiological traits associated with schizophrenia may be an important first step in building a neurobiological bridge between the disease phenotype and its genetic underpinnings. One of the best known of the traits associated with schizophrenia is a disorder of smooth pursuit eye tracking (ETD), which is present in 50-80% of schizophrenia patients. ETD is more than three times more prevalent in the families of a schizophrenia patient than is schizophrenia itself. Arolt et al. [1999] estimated LOD scores for ETD of 2.85 for D6S282 and 3.70 for D6S271, two markers on 6p21.1, as well as obtaining an indication of possible linkage for schizophrenia. Our sample comprised two large families in Denmark. Markers in the region that was implicated by the study of Arolt et al. [1996, 1999] were analyzed as part of a genome scan using the "latent trait (L.T.) model" for the co-transmission of schizophrenia and ETD that we had previously fitted to segregation analysis data from Norway. We obtained a LOD score of 2.05 for D6S1017, a marker within 3 cM of the positive markers obtained by Arolt et al. [1996, 1999]. We regard our results as independent evidence supporting the findings of Arolt et al. [1996, 1999] and also as support for the L.T. model as a way of combining the traits ETD and schizophrenia.

Functional connectivity as revealed by spatial independent component analysis of fMRI measurements during rest

Cortical functional connectivity, as indicated by the concurrent spontaneous activity of spatially segregated regions, is being studied increasingly because it may determine the reaction of the brain to external stimuli and task requirements and it is reportedly altered in many neurological and psychiatric disorders. In functional magnetic resonance imaging (fMRI), such functional connectivity is investigated commonly by correlating the time course of a chosen "seed voxel" with the remaining voxel time courses in a voxel-by-voxel manner. This approach is biased by the actual choice of the seed voxel, however, because it only shows functional connectivity for the chosen brain region while ignoring other potentially interesting patterns of coactivation. We used spatial independent component analysis (sICA) to assess cortical functional connectivity maps from resting state data. SICA does not depend on any chosen temporal profile of local brain activity. We hypothesized that sICA would be able to find functionally connected brain regions within sensory and motor regions in the absence of task-related brain activity. We also investigated functional connectivity patterns of several parietal regions including the superior parietal cortex and the posterior cingulate gyrus. The components of interest were selected in an automated fashion using predefined anatomical volumes of interest. SICA yielded connectivity maps of bilateral auditory, motor and visual cortices. Moreover, it showed that prefrontal and parietal areas are also functionally connected within and between hemispheres during the resting state. These connectivity maps showed an extremely high degree of consistency in spatial, temporal, and frequency parameters within and between subjects. These results are discussed in the context of the recent debate on the functional relevance of fluctuations of neural activity in the resting state.

Pituitary volume in psychosis

BACKGROUND

Patients with psychosis have activation of the hypothalamic-pituitary-adrenal (HPA) axis during the acute phase of the psychosis. Whether this has any morphological consequences for the pituitary gland is currently unknown.

AIMS

To examine pituitary volume variation in people at different stages of psychotic disorder.

METHOD

Pituitary volume was measured using 1.5 mm, coronal magnetic resonance images in 24 people with first-episode psychosis, 51 with established schizophrenia and 59 healthy controls.

RESULTS

Compared with the control group, the people with first-episode psychosis had pituitary volumes that were 10% larger, whereas those with established schizophrenia had pituitary volumes that were 17% smaller. In both of the groups with psychosis, there was no difference in pituitary volume between those receiving typical antipsychotic drugs and those receiving atypical antipsychotics.

CONCLUSIONS

The first episode of a psychosis is associated with a larger pituitary volume, which we suggest is due to activation of the HPA axis. The smaller pituitary volume in the group with established schizophrenia could be the consequence of repeated episodes of HPA axis hyperactivity.

Insight into current symptoms of schizophrenia. Association with frontal cortical function and affect

OBJECTIVE

Examine whether frontal lobe dysfunction or affective experiences correlates with lack of symptom awareness in schizophrenia.

METHOD

A total of 122 consecutive adult schizophrenia outpatients were assessed cross-sectionally with standard rating scales of psychopathology and of insight, and underwent neuropsychological assessment with a battery of tests sensitive to frontal lobe dysfunction. Correlational analyses were used to determine relationships between variables.

RESULTS

About 62% of patients had at least partial awareness of symptoms. Anxiety correlated modestly with insight into the abnormal nature of positive and negative symptoms. No cognitive variable was significantly correlated with symptom awareness.

CONCLUSION

The pathological nature of symptoms is better recognized by patients who experience dysphoric affect. Neither severity of psychotic symptoms nor frontal lobe cognitive deficits correlates to symptom awareness. Lack of insight, which can be partial for symptoms of the illness, might be a non-reducible symptom of schizophrenia.

Correlation between P300 and EEG rhythm in schizophrenia

We hypothesized that cognitive deficits reflected by P300 abnormality and distorted EEG rhythm in schizophrenia, which might share the subcortical generation system, could be closely associated with each other. Our goal is to assess the relationship between P300 and EEG rhythm generation in schizophrenics. Quantitative EEG (QEEG) in resting condition and P300 during auditory oddball paradigm were recorded with 25 unmedicated patients. Additionally, lateral ventricular-brain ratio (LV-BR), which partially reflects thalamic volume, was measured using CT scan. Brief Psychotic Rating Scale (BPRS) and Scale for Assessment of Negative Symptoms (SANS) were also rated. P300 amplitudes at Pz positively correlated with theta and slow alpha power before pharmacotherapy, however, the correlation tended to be confined to fast alpha after pharmacotherapy. BPRS and SANS showed no significant correlation with QEEG. High frequency bands such as fast alpha and beta showed trends to correlate negatively to LV-BR. The lack of correlation between P300 amplitudes and fast alpha power before pharmacotherapy, which was restored after pharmacotherapy, might indicate thalamocortical dysfunction in schizophrenia.

The interface between publicly funded and industry-funded research in pediatric psychopharmacology: opportunities for integration and collaboration

Pediatric psychopharmacology research is undergoing a major expansion consequent to increasing use of psychotropic medications in children and recent legislative incentives to industry. In this rapidly changing context, the interface between publicly and privately funded research needs to be reconsidered to integrate activities and avoid unnecessary duplication of efforts. Once, by default, the almost exclusive domain of public research, child research is now increasingly funded by industry. There are, however, important issues unlikely to be addressed through private funding for which public support is needed, such as direct comparisons between active medications, between pharmacological and psychosocial interventions, or between combined and single treatment modalities; development of effective treatment strategies for patients unresponsive to first-line treatments; development of better research methods to assess efficacy and safety; identification of moderators and mechanisms of treatment response; and impact of treatment on illness course and prognosis. Industry-sponsored research is limited by the restricted access to proprietary databases, which impedes independent analyses and meta-analyses. Translation of basic neuroscience discoveries into treatment applications for children with mental illness is a critical area of inquiry that can benefit from integration of efforts and collaborations among academia, government, and industry.

QUALITY-CONSTANT "PRICES" FOR THE ONGOING TREATMENT OF SCHIZOPHRENIA: AN EXPLORATORY STUDY*

Health care expenditures have been increasing sharply in the last ten years, with spending on mental health disorders being particularly prominent. Over the same time period, a number of new antipsychotic medications have been added to the armamentarium for treatment of persons diagnosed with schizophrenia. Due in part to the sharply increased expenditures by Medicaid on mental health disorders such as schizophrenia, controversies have arisen as to the use of these more costly innovative medications, particularly their impact on the annualized cost of treating patients.Using Medicaid data on 12,864 person years from two counties in Florida over the 1994-95 to 1999-2000 time period, in this study we address three issues: (i) On a per person year basis, what is happening over time to the mental health-related costs of treating schizophrenia? (ii) How is the composition and quality of care changing over time? and (iii) Holding quality of care constant, on a per person year basis, by how much are the costs for the ongoing treatment of schizophrenia changing?We find that unadjusted for changes in quality of care over time, the annualized costs for the ongoing treatment of schizophrenia per person have increased about 0.5% per year. The composition of treatments for schizophrenia has changed substantially over this six-year time period, toward more intensive use of atypical antipsychotics, and away from psychosocial treatments. Holding treatment quality type and patient characteristics constant over time, mean treatment costs have fallen about 5.5% per year between 1994-1995 and 1999-2000.

Memory and attention performance in psychiatric patients: lack of correspondence between clinician-rated and patient-rated functioning with neuropsychological test results

In the present study, the correspondence between clinician-assessed and self-reported neurocognitive performance was contrasted with scores obtained from psychometric neuropsychological tests in 148 psychiatric in-patients. Results revealed that self-reported cognitive functioning was strongly associated with depressive symptomatology but was only poorly related to psychometric neurocognitive performance, particularly in schizophrenia. After illness denial was controlled for, the overall association between subjective and objective test performance was slightly increased but still failed to reach significance in six out of eight analyses. In approximately 20% to 40% of all cases, clinicians judged memory performance to be normal despite substantial impairment revealed by neuropsychological test results (attention parameters: 7-51%). Since (ecological) validity and reliability have been demonstrated for many neurocognitive paradigms, the present results question the validity of non-psychometric neurocognitive assessment and call for a complementation of clinical judgment with neurocognitive assessment. Reasons for decreased sensitivity of self-reported and clinician-assessed neurocognitive functioning are discussed.

A randomized comparison of group cognitive-behavioural therapy and group psychoeducation in patients with schizophrenia

OBJECTIVE

Although the efficacy of cognitive-behavioural therapy (CBT) in schizophrenia has been established in a number of studies, no information is available on the differential efficacy of CBT in comparison with patient psychoeducation (PE).

METHOD

Eighty-eight in-patients with schizophrenia were randomized to receive a therapy envelope of 8 weeks including either 16 sessions group CBT or eight [correction] sessions group PE treatment. Assessments took place at baseline, post-treatment and 6 month follow-up.

RESULTS

Patients, who received CBT were significantly less rehospitalized than patients in the PE group during the follow-up period. On a descriptive level, CBT resulted in lower relapse rates and higher compliance ratings at post-treatment and at follow-up than PE. Both forms of therapy led to significant psychopathological improvement at post-treatment and at follow-up.

CONCLUSION

The brief group CBT intervention showed some superiority to the PE programme, which could be of considerable clinical and economical importance.

Can patients at risk for persistent negative symptoms be identified during their first episode of psychosis?

Patients with schizophrenia who show persistent negative symptoms are an important subgroup, but they are difficult to identify early in the course of illness. The objective of this study was to examine characteristics that discriminate between first-episode psychosis (FEP) patients in whom primary negative symptoms did or did not persist after 1 year of treatment. Patients with a DSM-IV diagnosis of FEP whose primary negative symptoms did (N = 36) or did not (N = 35) persist at 1 year were contrasted on their baseline and 1-year characteristics. Results showed that patients with persistent primary negative symptoms (N = 36) had a significantly longer duration of untreated psychosis (p < .005), worse premorbid adjustment during early (p < .001) and late adolescence (p < .01), and a higher level of affective flattening (p < .01) at initial presentation compared with patients with transitory primary negative symptoms. The former group also showed significantly lower remission rates at 1 year (p < .001). Multiple regression analysis confirmed the independent contribution of duration of untreated psychosis, premorbid adjustment, and affective flattening at baseline to the patients' likelihood of developing persistent negative symptoms. It may therefore be possible to distinguish a subgroup of FEP patients whose primary negative symptoms are likely to persist on the basis of characteristics shown at initial presentation for treatment.

Perceived reasons for substance misuse among persons with a psychiatric disorder

The etiology of substance use among persons with severe mental illness remains unclear. This study investigates stated reasons for substance use among persons in recovery from co-occurring disorders of serious mental illness and substance abuse and dependence. The desire to fit in with peers played a key role in the initiation of substance use; boredom, loneliness, temptations to use, and stress were cited most as relapse triggers. The authors discuss the need for dually diagnosed persons to develop sobriety-supporting peer networks to help them learn adaptive strategies to deal with the stress of recovery; further, treatment programs should instill hope for recovery and provide opportunities for meaningful activities and relationships.

Nicotine blocks apomorphine-induced disruption of prepulse inhibition of the acoustic startle in rats: possible involvement of central nicotinic alpha7 receptors

Nicotine has been reported to normalize deficits in auditory sensory gating in the cases of schizophrenia, suggesting an involvement of nicotinic acetylcholine receptors in attentional abnormalities. However, the mechanism remains unclear. The present study investigated the effects of nicotine on the disruption of prepulse inhibition (PPI) of the acoustic startle response induced by apomorphine or phencyclidine in rats. Over the dose range tested, nicotine (0.05-1 mg kg(-1), s.c.) did not disrupt PPI. Neither methyllycaconitine (0.5-5 mg kg(-1), s.c.), an alpha(7) nicotinic receptor antagonist, nor dihydro-beta-erythroidine (0.5-2 mg kg(-1), s.c.), an alpha(4)beta(2) nicotinic receptor antagonist, had any effect on PPI. Nicotine (0.01-0.2 mg kg(-1), s.c.) dose-dependently reversed the disruption of PPI induced by apomorphine (1 mg kg(-1), s.c.), but had no effect on the disruption of PPI induced by phencyclidine (2 mg kg(-1), s.c.). The reversal of apomorphine-induced PPI disruption by nicotine (0.2 mg kg(-1)) was eliminated by mecamylamine (1 mg kg(-1), i.p.), but not by hexamethonium (10 mg kg(-1), i.p.), indicating the involvement of central nicotinic receptors. The antagonistic action of nicotine on apomorphine-induced PPI disruption was dose-dependently blocked by methyllycaconitine (1 and 2 mg kg(-1), s.c.). However, dihydro-beta-erythroidine (1 and 2 mg kg(-1), s.c.) had no effect. These results suggest that nicotine reverses the disruption of apomorphine-induced PPI through central alpha(7) nicotinic receptors.

Disease Models of Mental Illness and Aftercare Patient Education: Critical Observations from Meta-Analyses, Cross-Cultural Practice and Anthropological Study

This paper examines critically the idea of educating mental health service users in the frame of neurobiological psychiatry as a way of understanding their experience. This idea is compared with the findings in five broad areas of the literature on schizophrenia: psychopharmacological research, psychosocial rehabilitation, first person accounts, international epidemiology and familial expressed emotion research. This literature, which includes reports of five meta-analyses, is used to highlight ethnographic findings from the author's original research. The implications of the argument made about aftercare education for the practice of occupational therapists in hospital and community psychiatry conclude the article.

Well-being, appraisal, and coping in African-American and Caucasian dementia caregivers: findings from the REACH study

Although there has been considerable interest in racial differences in family caregiving for persons with dementia, most research to date has either ignored racial diversity or based conclusions on small numbers of caregivers drawn primarily from single site studies. The current study utilized participants from four sites of the REACH (Resources for Enhancing Alzheimer's Caregiver Health) multi-site study to compare well-being, appraisal, and religious coping by race. African-American (n = 295) and Caucasian (n = 425) dementia caregivers from four cities (Birmingham, Memphis, Boston, and Philadelphia) were compared in their demographics, care recipient characteristics, mental and physical health, and psychosocial coping resources including appraisal and religious coping. African-American caregivers reported lower anxiety, better well-being, less use of psychotropic medications, more benign appraisals of stress and perceived benefits of caregiving, and greater religious coping and participation, than Caucasian caregivers. Self-rated health did not differ by race, but African-American caregivers reported more unhealthy behaviors than Caucasian caregivers. Some results were specific to site, possibly due to differences in recruitment strategies, inclusion/exclusion criteria, and regional differences. Adjustment for covariates, including caregiver relationship to the care recipient, gender, age, socioeconomic status, and care recipient behavioral problems, altered few of these differences. Results are discussed in terms of their relevance to psychosocial intervention programs for ethnically diverse caregivers.

Nicotinic receptors and schizophrenia

The incidence of smoking is very high in non-schizophrenic subjects presenting various psychiatric disorders (35 to 54%). However, the incidence of smoking is extremely high in schizophrenic patients: 80% to 90%, versus 25% to 30% of the general population. Various studies have demonstrated that the use of tobacco transiently restores the schizophrenic patient's cognitive and sensory deficits. Smoking cessation also appears to exacerbate the symptoms of the disease. Post-mortem binding studies have revealed a disturbance of nicotinic receptor expression, affecting the alpha(7) and alpha(4)beta(2) subunits, in various cerebral areas. Genetic linkage studies have also shown that the alpha(7) subunit is involved in schizophrenia. This review assesses the involvement of the nicotinic system in schizophrenia and suggests ways in which this system may participate in the pathophysiology of this disease.

A Cognitive Model of Schizophrenia

The poor reality testing and the thinking disorder in schizophrenia may be attributed to a deficiency in cognitive resources related to the neurobiological deficiencies. Recent therapy and research have demonstrated that, far from being a bizarre psychologically incomprehensible phenomenon, schizophrenia can be understood within our conventional conception of human nature. This humanizing trend is especially evident in the cognitive approaches to this disorder. Research has established that there is a continuum from normal experiences of paranormal beliefs, hallucinations, thinking problems, and withdrawal to their counterpart in schizophrenia. The kinds of biases in schizophrenia are also evident in common social problems such as prejudices and ethnocentrism as well as in interpersonal strife. Dysfunctional attitudes about attachment and performance in schizophrenia form the infrastructure for persecutory delusions and negative symptoms, respectively. Grandiose delusions, on the other hand, are shown to be an overcompensation for a sense of loneliness, inferiority, and vulnerability.

Emotional effects of startling background music during reading news reports: The moderating influence of dispositional BIS and BAS sensitivities

We examined the moderating influence of dispositional behavioral inhibition system (BIS) and behavioral activation system (BAS) sensitivities on the relationship of startling background music with emotion-related subjective and physiological responses elicited during reading news reports, and with memory performance among 26 adult men and women. Physiological parameters measured were respiratory sinus arrhythmia (RSA), electrodermal activity (EDA), and facial electromyography (EMG). The results showed that, among high BAS individuals, news stories with startling background music were rated as more interesting and elicited higher zygomatic EMG activity and RSA than news stories with non-startling music. Among low BAS individuals, news stories with startling background music were rated as less pleasant and more arousing and prompted higher EDA. No BIS-related effects or effects on memory were found. Startling background music may have adverse (e.g., negative arousal) or beneficial effects (e.g., a positive emotional state and stronger positive engagement) depending on dispositional BAS sensitivity of an individual. Actual or potential applications of this research include the personalization of media presentations when using modern media and communications technologies.

Assessing cost-effectiveness in mental health: family interventions for schizophrenia and related conditions

OBJECTIVE

Existing evidence suggests that family interventions can be effective in reducing relapse rates in schizophrenia and related conditions. Despite this, such interventions are not routinely delivered in Australian mental health services. The objective of the current study is to investigate the incremental cost-effectiveness ratios (ICERs) of introducing three types of family interventions, namely: behavioural family management (BFM); behavioural intervention for families (BIF); and multiple family groups (MFG) into current mental health services in Australia.

METHOD

The ICER of each of the family interventions is assessed from a health sector perspective, including the government, persons with schizophrenia and their families/carers using a standardized methodology. A two-stage approach is taken to the assessment of benefit. The first stage involves a quantitative analysis based on disability-adjusted life years (DALYs) averted. The second stage involves application of 'second filter' criteria (including equity, strength of evidence, feasibility and acceptability to stakeholders) to results. The robustness of results is tested using multivariate probabilistic sensitivity analysis.

RESULTS

The most cost-effective intervention, in order of magnitude, is BIF (8000 Australian dollars per DALY averted), followed by MFG (21,000 Australian dollars per DALY averted) and lastly BFM (28,000 Australian dollars per DALY averted). The inclusion of time costs makes BFM more cost-effective than MFG. Variation of discount rate has no effect on conclusions.

CONCLUSIONS

All three interventions are considered 'value-for-money' within an Australian context. This conclusion needs to be tempered against the methodological challenge of converting clinical outcomes into a generic economic outcome measure (DALY). Issues surrounding the feasibility of routinely implementing such interventions need to be addressed.

Nicotine improves delayed recognition in schizophrenic patients

RATIONALE

Nicotine has been shown to enhance some aspects of memory, attention and cognition in normal subjects and in some patient populations such as Alzheimer's and Parkinson's disease groups.

OBJECTIVES

Memory disorders are consistently observed in schizophrenic patients, so it is of interest to determine whether nicotine might improve memory performance in these patients.

METHODS

Delayed recognition was assessed using yes/no recognition of visuospatial designs. Working memory was assessed in a delayed match-to-sample paradigm using unfamiliar faces. Nicotine (1.0 mg delivered via nasal spray) was administered to schizophrenic patients and normal volunteers prior to testing in the nicotine condition. Results were compared to a baseline condition in which no nicotine was given.

RESULTS

On both tasks, normal volunteers performed better overall than schizophrenic patients. Significant improvement following nicotine administration was obtained only on the delayed recognition task and only for the subset of schizophrenic patients who were smokers. This improvement reflected a reduction in false alarm rates in the nicotine condition; hit rates were unaffected by nicotine.

CONCLUSIONS

These results suggest that nicotine enhances delayed recognition memory in schizophrenic patients who smoke, but that similar performance enhancement is not observed for working memory.

Essential elements of an early intervention service for psychosis: the opinions of expert clinicians

BACKGROUND

Early intervention teams attempt to improve outcome in schizophrenia through earlier detection and the provision of phase-specific treatments. Whilst the number of early intervention teams is growing, there is a lack of clarity over their essential structural and functional elements.

METHODS

A 'Delphi' exercise was carried out to identify how far there was consensus on the essential elements of early intervention teams in a group of 21 UK expert clinicians. Using published guidelines, an initial list was constructed containing 151 elements from ten categories of team structure and function.

RESULTS

Overall there was expert consensus on the importance of 136 (90%) of these elements. Of the items on which there was consensus, 106 (70.2%) were rated essential, meaning that in their absence the functioning of the team would be severely impaired.

CONCLUSION

This degree of consensus over essential elements suggests that it is reasonable to define a model for UK early intervention teams, from which a measure of fidelity could be derived.

Social Perception Deficits After Traumatic Brain Injury: Interaction Between Emotion Recognition, Mentalizing Ability, and Social Communication

Thirty-four adults with severe traumatic brain injuries (TBI) and 34 matched control participants were asked to interpret videotaped conversational exchanges. Study participants were asked to judge the speakers' emotions, the speakers' beliefs (first-order theory of mind), what the speakers intended their conversational partners to believe (second-order theory of mind), and what they meant by remarks that were sincere or literally untrue (i.e., a lie or sarcastic retort). The TBI group had marked difficulty judging most facets of social information. They could recognize speaker beliefs only when this information was explicitly provided. In general, emotion recognition and first-order theory of mind judgments were not related to the ability to understand social (conversational) inference, whereas second-order theory of mind judgments were related to that ability.

Effect of switching to atypical antipsychotics on memory in patients with chronic schizophrenia

While the usefulness of atypical antipsychotics for improving cognitive function has been proven, the specific effects of these drugs are still unknown. The objective of this study was to investigate changes of the immediate memory and verbal working memory in patients with chronic schizophrenia after switching to one of four atypical antipsychotic agents and cessation of anticholinergic therapy. The subjects included 77 schizophrenic patients who were treated primarily with typical antipsychotics. Treatment was randomly switched to one of four atypical antipsychotics (olanzapine, perospirone, quetiapine, or risperidone) over a 4-week period, and then the drug was continued for another 4 weeks while the patient was taken off anticholinergics. The immediate memory, verbal working memory, and symptoms were evaluated. Significant improvement of immediate memory was only seen with olanzapine and risperidone. Improvement was also seen after switching to perospirone, but immediate memory worsened after treatment with this anticholinergic drug was discontinued. Deterioration was seen after switching to quetiapine, but immediate memory improved and reached the previous level after treatment with anticholinergic drugs was discontinued. Significant improvement of the verbal working memory was only seen during risperidone administration. The findings suggested that switching chronic schizophrenic patients to atypical antipsychotics can improve both the immediate memory and the verbal working memory when risperidone is used, while improvement of immediate memory can be expected with olanzapine. From the viewpoint of improving the memory, quetiapine should not be administered concomitantly with anticholinergic drugs, and caution should be exercised when discontinuing anticholinergic drugs during treatment with perospirone.

Cumulative incidence of mental disorders among offspring of mothers with psychotic disorder. Results from the Helsinki High-Risk Study

BACKGROUND

The Helsinki High-Risk Study follows up all women born between 1916 and 1948 and treated for schizophrenia-spectrum disorders in psychiatric hospitals in Helsinki, their offspring born between 1960 and 1964, and controls.

AIMS

To determine the cumulative incidence of adulthood Axis I disorders among offspring.

METHOD

Using all hospital and out-patient treatment records we rediagnosed parents and offspring according to DSM-IV-TR criteria. Offspring were grouped by mother's diagnosis (schizophrenia n=104, schizoaffective disorder n=20, other schizophrenia-spectrum disorder n=30, and affective disorder n=25) and compared with a control group (n=176). The cumulative incidences of Axis I disorders among offspring were calculated.

RESULTS

The cumulative incidences of any psychotic disorder were 13.5%, 10.0%, 10.0%, 4.0% and 1.1% among offspring of mothers with schizophrenia, schizo-affective disorder, other schizophrenia-spectrum disorders, affective disorders and controls, respectively. The corresponding figures for schizophrenia were 6.7%, 5.0%, 6.7%, 0% and 0.6%, and for any mental disorder 23.1%, 20.0%, 20.0%, 12.0% and 6.9%.

CONCLUSIONS

Offspring of mothers with a psychotic disorder have heightened risk of developing a wide range of severe mental disorders.

Neurocognitive correlates of therapeutic alliance in schizophrenia

Although therapeutic alliance in schizophrenia has been linked with treatment adherence and outcome, less is known about its clinical correlates. This study explored neurocognition as a possible predictor of perceived therapeutic alliance among people with schizophrenia in cognitive behavior therapy. Twenty-four participants with schizophrenia spectrum disorders and their therapists were administered the Working Alliance Inventory, Short Form after 3 months of therapy. Totals for clients and therapists were correlated with measures of verbal memory, premorbid intelligence, visual spatial reasoning, executive function, and attention, all obtained before beginning therapy. Poorer performance on verbal memory was significantly related to client report of stronger alliance, whereas better performance on visual spatial reasoning was significantly related to therapist report of stronger alliance. Client and therapist ratings of therapeutic alliance were significantly and positively related. Clients' abilities may differentially affect therapist and client perception of therapeutic alliance in schizophrenia.

Abnormalities of the NMDA Receptor and Associated Intracellular Molecules in the Thalamus in Schizophrenia and Bipolar Disorder

Several lines of investigation support a hypothesis of glutamatergic dysfunction in schizophrenia, including our recent reports of altered NMDA receptor subunit and associated intracellular protein transcripts in the thalamus of elderly patients with schizophrenia. In the present study, we used in situ hybridization to measure the expression of NMDA subunits (NR1, NR2A-D), and associated intracellular proteins (NF-L, PSD95, and SAP102) in a second, younger cohort from the Stanley Foundation Neuropathology Consortium, which included patients with both schizophrenia and affective disorders. We wanted to determine whether glutamatergic abnormalities in the thalamus in schizophrenia are present at younger ages, and whether these abnormalities occur in other psychiatric illnesses. In the present work, we observed increased expression of NMDA NR2B subunit transcripts, and decreased expression of all three associated postsynaptic density protein transcripts in schizophrenia. We also found evidence of glutamatergic dysfunction in the thalamus in affective disorders, particularly in bipolar disorder. In particular, we found decreased NF-L, PSD95, and SAP102 transcripts in bipolar disorder, and decreased SAP102 levels in major depression. Interestingly, one of the most consistent findings across diagnostic groups was an abnormality of intracellular signaling molecules that are linked to the NMDA receptor, rather than changes in the receptor subunits themselves. PSD95 and similar scaffolding molecules link the NMDA receptor with intracellular enzymes that mediate signaling, and also provide a physical link between different neurotransmitter systems to coordinate and integrate information from multiple effector systems. Abnormalities of PSD95-like molecules and other intracellular signaling machinery may contribute to dysregulated communication between multiple neurotransmitter systems (such as glutamatergic and dopaminergic systems) that are potentially involved in the neurobiology of schizophrenia and affective disorders.

Predictors of antipsychotic treatment response in patients with first-episode schizophrenia, schizoaffective and schizophreniform disorders

BACKGROUND

Duration of untreated psychosis (DUP) may contribute to the observed heterogeneity of the treatment response in first-episode schizophrenia.

AIMS

To examine the relationship of DUP and premorbid function with clinical outcomes following up to 2 years of antipsychotic treatment.

METHOD

For a subsample (n=191) of subjects participating in a clinical trial, DUP and premorbid function were prospectively compared with clinical response to olanzapine or haloperidol.

RESULTS

Shorter DUP and good premorbid function each independently are associated with better clinical response, including improvement in overall psychopathology and negative symptoms. Premorbid function also is associated with positive symptom, social and vocational outcomes.

CONCLUSIONS

Earlier antipsychotic treatment is associated with better outcomes in first-episode schizophrenia. Poor premorbid function could indicate an illness subtype less likely to respond to antipsychotic treatment regardless of when it is instituted.

Patientenzufriedenheit mit Psychopharmakotherapie

Zusammenfassung. Theoretischer Hintergrund: In den letzten Jahren gewann die Zufriedenheit von Patienten auf Grund gesundheitspolitischer und ökonomischer Gründe, aber auch aus klinischen und wissenschaftlichen Fragestellungen heraus an Bedeutung. Dabei werden multivariate Modelle propagiert. Fragestellung: In der vorliegenden Untersuchung wird der Zusammenhang der globalen Zufriedenheit mit der medikamentösen Behandlung mit unterschiedlichen Komponenten (Information, Mitgestaltung, Behandler/Patient-Beziehung, Wirkung der medikamentösen Behandlung) untersucht. In einem weiteren Schritt wird das Konzept auf die Zufriedenheit mit der stationären Behandlung erweitert. Schließlich werden zusätzlich Merkmale der Patienten zu einem Modell der Zufriedenheitsbildung verknüpft. Methode: 135 erwachsene stationäre psychiatrische Patienten wurden kurz vor Austritt ihres mindestens 14-tägigen Klinikaufenthalts zu Merkmalen der Patienten, der medikamentösen Behandlung, sowie zu unterschiedlichen Komponenten der Zufriedenheit befragt. Die Auswertung erfolgt mittels linearer Strukturgleichungsmodelle in Pfadanalysen. Ergebnisse: Die globale Zufriedenheit mit der medikamentösen Behandlung wird insbesondere durch die Aspekte Information und Wirkung der medikamentösen Behandlung beeinflusst. Bezogen auf die Zufriedenheit mit der stationären Behandlung erweist sich die Zufriedenheit mit der medikamentösen Behandlung bedeutsamer als die Zufriedenheit mit anderen Aspekten der stationären Behandlung. Weiters zeigt sich, daß Merkmale der Behandlung und Merkmale der Patienten ähnlich starke Zusammenhänge mit der Zufriedenheit der Patienten bezüglich medikamentöser Behandlung aufweisen. Schlussfolgerung: Anhand der Ergebnisse werden Vorschläge zur Steigerung der Zufriedenheit diskutiert.

Cognitive Therapy for Delusions in Schizophrenia: Models, Benefits, and New Approaches

The main purpose of the review is to demonstrate how cognitive models of psychosis translate into cognitive-behavioral approaches for intervening with psychotic symptoms in schizophrenia. Several cognitive-behavioral factors which play a role in the maintenance and possibly formation of delusional beliefs are discussed, including attentional bias to threat, “data gathering” deficits, dysfunctional metacognition, and safety behaviors. Strategies for engagement, problem formulation, and psychoeducation with deluded patients are described. Cognitive-behavioral interventions are presented, specifically, cognitive restructuring, behavioral experiments, and coping skills training. Challenges to conducting cognitive-behavioral therapy (CBT) with delusions in schizophrenia are reviewed. Novel cognitive therapies, which address these challenges, are presented.

Comparison of neurocognition between drug-free patients with schizophrenia and bipolar disorder

It is often difficult to make a differential diagnosis between schizophrenia and bipolar disorder because of the overlapping symptoms. The patients of both disorders have been shown to have neurocognitive deficits. In this study, a computerized battery of neurocognitive tasks, COGLAB, was administered to four participant groups: 30 patients with positive schizophrenia, 22 patients with negative schizophrenia, 27 patients with bipolar disorder, and 28 normal controls. All the patients were drug-free for at least 1 month. The tasks included Mueller-Lyer illusion, reaction time, size estimation, a variant of the Wisconsin Card Sorting Test, backward masking, and Asarnow continuous performance. Discriminant analyses were used to investigate the differences among the four groups. Results indicated that COGLAB correctly classified 73.5% of the cases of negative schizophrenia and bipolar disorder. The best discriminative tasks were card sort, Asarnow continuous performance, and backward masking. The results of this study were also compared with results of a previous study with medicated patients. Neurocognitive tasks had better discriminative power for medicated patients with schizophrenia and bipolar disorder than for drug-free patients. Moreover, medication effects did not seem to significantly change the pattern of the neurocognitive task responses of patients with schizophrenia.

Meta-analysis and the science of schizophrenia: variant evidence or evidence of variants?

Quantification (meta-analysis) of the neuroscience evidence on schizophrenia shows very modest average differences between patient and control distributions across a great variety of measures and literatures. The strongest findings involve cognitive and psychophysiological measures. Several possible explanations for this situation are reviewed including technical immaturity, methodological variability, dimensional and multiple illness models and the nature of cognitive measurement. An argument is developed that biological subtypes and endophenotypes within the broad diagnostic category of schizophrenia underpin the meta-analytic evidence. Considerations in the use of this evidence to identify illness variants are described and four candidate subtypes are proposed. Schizophrenia is a disease that will resist biological definition until its variants are isolated and extracted from the generic patient population.

Suicidal ideation in inpatients with acute schizophrenia

OBJECTIVE

Schizophrenia has been associated with a high rate of suicide. This study investigates the prevalence of suicidal ideation in a population of inpatients with acute schizophrenia, together with the clinical parameters associated with suicidal thoughts.

METHOD

We assessed 93 schizophrenia patients. We matched subjects for age and sex and compared subjects with and without suicidal thoughts. We performed stepwise multiple regression analysis to assess the association between specific clinical symptoms and suicidal ideation.

RESULTS

Of the patients, 20.4% reported suicidal thoughts during the last 15 days. Severity of depressive symptoms, motor retardation, guilt feelings, pathological guilt, and self-depreciation predicted the patients' suicidal ideation.

CONCLUSIONS

Suicidal thoughts are frequent among inpatients with acute schizophrenia. Prevention of suicidal behaviour should include helping patients improve their self-esteem and reducing depression and guilt feelings.

Economic outcomes associated with olanzapine versus risperidone in the treatment of uncontrolled schizophrenia

OBJECTIVE

This study, based upon a database analysis, compares a one-year drug treatment course (duration of therapy, concomitant use of typical antipsychotics, anxiolytics/antidepressants or anti-Parkinsonians) and direct health care costs of uncontrolled schizophrenia patients initiated on olanzapine versus risperidone.

METHODS

The integrated medical and pharmacy claims of a large, geographically diverse, commercially insured population of 1.6 million employees, retirees and dependents were used to conduct this analysis. Patients who initiated outpatient treatment with either olanzapine or risperidone (no prescription for olanzapine or risperidone during a 1-year period prior to the initiation) and with uncontrolled schizophrenia were included. Drug treatment course and associated health care costs (calculated based on charges) during the subsequent 12-month period were examined using univariate and multivariate methods.

RESULTS

431 patients initiated on risperidone and 142 initiated on olanzapine met the inclusion criteria. The mean dose was 4.34 and 11.00 mg/day for risperidone and olanzapine, respectively. Olanzapine was associated with more favorable drug treatment course than risperidone. Although pharmaceutical costs were significantly higher, medical costs were significantly lower for patients on olanzapine compared to those on risperidone. Univariate and multivariate analyses (controlling for potential confounding factors including demographic and clinical characteristics) consistently demonstrated that olanzapine patients had significantly lower schizophrenia related costs (2839 US dollars less, p < 0.011), lower mental health care costs (3744 US dollars less, p < 0.004) and lower total health care costs (4674 US dollars less, p < 0.001) than those patients initiated on risperidone.

CONCLUSIONS

The findings revealed significant differences between olanzapine and risperidone in the treatment of uncontrolled schizophrenia patients in clinical practice. Olanzapine patients experienced a favorable drug treatment course and incurred lower overall costs. The lower costs were hospital-treatment driven. Further studies are needed to examine if these results hold for different patient populations.

The fountain of mental youth. Search for homeostatic and adaptational hormonal processes

Successful mental aging may be defined as maintenance of youthful attitudes, cognitive and adaptational processes despite advanced age. Maintenance of homeostasis and efficient adaptational processes are of utmost importance. It is suggested that multiple hormonal systems and processes are involved in the multidimensional, interdependent, interrelated successful aging process. Changes in their interactions over time probably occur. A complex integrated regulatory homeostatic and normalcy system is proposed. Disruption on this regulating normalization process may cause disorders, as well as accelerated mental aging. Currently not much is known about maintenance of mental normalcy, as well as homeostatic and adaptational underlying mechanisms. Their elucidation would substantially contribute to understanding of well-being, disorders, and successful as well as unsuccessful aging.

Long-acting injectable risperidone: safety and efficacy in stable patients switched from conventional depot antipsychotics

Long-acting injectable risperidone was assessed in schizophrenia patients who were symptomatically stable on conventional depot antipsychotics and who were then switched to long-acting risperidone. Participants in this open-label, multicentre, 12-week trial had received flupenthixol decanoate, fluphenazine decanoate, haloperidol decanoate, or zuclopenthixol decanoate for 4 months or longer. Each was considered symptomatically stable by investigators. After receiving two cycles of their conventional depot antipsychotic during the run-in period, patients were switched to receive long-acting risperidone every 2 weeks for 12 weeks at an initial dose of 25 mg. This dose could be increased in 12.5-mg increments at 4-week intervals. Ninety-two percent of the patients received all six injections; 62% received the 25-mg dose throughout the treatment period. Adverse events related to movement disorders were reported in 3%. Severity of movement disorders decreased during long-acting risperidone treatment. Positive and Negative Syndrome Scale (PANSS) total and factor scores and scores on the Clinical Global Impressions severity scale were significantly reduced during treatment; 48% of these stable patients showed further symptom improvement (> or =20% decrease in PANSS score at endpoint). The results indicate that patients with schizophrenia who are symptomatically stable during treatment with a conventional depot antipsychotic can be safely and effectively switched to long-acting injectable risperidone without a prior transition to oral risperidone.

Depression and bone mineral density in young adults: results from NHANES III

OBJECTIVE

The purpose of this cross-sectional population-based study was to assess the association of major depressive episode (MDE) and dysthymia with bone mineral density (BMD) in young adults.

METHODS

Data are from a nationally representative sample of 5,171 people aged 20 to 39 years from the Third National Health and Nutrition Examination Survey. Total proximal femoral BMD was measured using dual energy x-ray absorptiometry. MDE and dysthymia were measured using the Diagnostic Interview Schedule.

RESULTS

MDE was associated with lower BMD in multivariate models in men (mean BMD = 1.038 vs. 1.068 g/cm(2); odds ratio (OR) per 1 SD decline in BMD = 1.65, 95% confidence interval (CI) = 1.08-2.52; p = 0.02) but not in women (mean BMD = 0.982 vs. 0.979 g/cm(2); OR = 0.96, 95% CI = 0.71-1.30; p =.79). The same divergence by gender was seen for dysthymia.

CONCLUSION

The relationship between BMD and MDE or dysthymia in young adults varies by gender.

Effects of acute and chronic clozapine on D-amphetamine-induced disruption of auditory gating in the rat

RATIONALE

Auditory gating deficits observed in patients with schizophrenia have been modeled in animals administered the indirect-acting monoaminergic agonist, D-amphetamine (AMPH). The atypical antipsychotic drug clozapine (CLOZ) reverses the disruption of auditory gating in schizophrenic patients. However, its effects on psychostimulant-induced deficits in animals have yet to be assessed.

OBJECTIVES

In the present series of experiments, an auditory evoked potential paradigm was used to: (a) confirm the ability of AMPH to alter auditory gating in the anesthetized rat, (b) specify the nature of the accompanying change(s) in evoked potential waveforms and (c) determine the effects of CLOZ administration on AMPH-induced alterations in auditory gating.

METHODS

We compared the effects of acute (5 mg/kg, i.p.) and chronic (28 days, 0.5 mg/ml in drinking water) CLOZ on AMPH-induced (1.8 mg/kg, i.p.) alterations in evoked potentials recorded in the hippocampus of anesthetized rats during presentation of a pair of identical tones. Gating was assessed by comparing the amplitude of conditioning and test responses in CLOZ and AMPH-treated rats.

RESULTS

The ratio of test to conditioning response amplitude (T/C ratio) was not altered by vehicle or CLOZ alone. However, T/C ratio was significantly increased following AMPH due to suppression of the conditioning response. Acute but not chronic CLOZ attenuated but did not prevent the increase in T/C ratio.

CONCLUSIONS

Qualitative differences between the idiopathic gating deficits observed in schizophrenic patients and AMPH-induced increases in T/C ratio in animals limit this models utility as a means of evaluating the ability of atypical antipsychotic drugs to restore normal sensory gating.

Cognitive Conceptualization of the Negative Symptoms of Schizophrenia

Cognitive therapy for the treatment of the negative symptoms of schizophrenia is in its infancy. Presented here is an outline of the conceptualization, assessment, and treatment of these disabling features of schizophrenia. Examination of possible secondary causes of the negative symptoms, including causes involving dysfunctional attitudes, is followed by a framing of primary negative symptoms in terms of the cognitive model of the influence of thoughts on emotion and behavior. Physiological models of the negative syndrome are incorporated into this cognitive framework. Unique features in the cognitive assessment and treatment of the negative symptoms are outlined. Clinical examples of clients with negative symptoms are provided.

Depressive syndrome in major psychoses: a study on 1351 subjects

The aim of this study was to investigate depressive symptomatology across distinct major psychiatric disorders. A total of 1351 subjects affected by major depressive disorder (MDD = 389), bipolar disorder (BP = 511), delusional disorder (DD = 93) and schizophrenia (SKZ = 358) were included in our study. Subjects were assessed using the Operational Criteria for Psychotic Illness checklist (OPCRIT). The most frequently represented depressive symptoms in MDD were Loss of energy/tiredness, Loss of pleasure, Poor concentration, and Sleep disorders. Compared with MDD, BP had higher occurrences of Agitated activity, Excessive sleep, and Increased appetite and/or Weight gain, as well as lower Loss of pleasure. In our sample, 32.3% and 26.8% of DD and SKZ, respectively, had quite consistent depressive symptomatology, with at least four or more depressive symptoms. The most common depressive symptoms were Sleep disorders, Poor concentration and Loss of energy/Tiredness, followed by Psychomotor symptoms in SKZ only. Excessive self-reproach, Suicidal ideation, and Appetite and/or Weight changes were more specific to mood disorders. Finally, compared with SKZ, DD suffered from more depressive symptoms and had more severe depressive symptomatology. A quite consistent level of depressive symptomatology is therefore present in subpopulations of delusional and schizophrenic subjects other than in affective subjects. We identified some symptoms that are common across all major psychoses and symptoms that are more specific to each group.

Dimensions of major psychoses: a confirmatory factor analysis of six competing models

The symptoms of major psychosis aggregate in factors. Models of one to eight dimensions have been reported. In the present study, we tested six competing factor models, based on the psychotic and affective items of the OPCRIT checklist, in a large sample (N = 1294) of patients diagnosed with DSM-IV schizophrenia (n = 460), bipolar disorder (n = 726) and delusional disorder (n = 108). Confirmatory factor analysis was used to test the following models: (1) unique psychotic dimension; (2) positive-manic items, negative-depressive items; (3) model 2 with the addition of a disorganized factor; (4A) positive, negative, depressive and manic dimensions; (4B) model 4A with loss of pleasure (Anhedonia) and loss of energy (Apathy) included among depressive instead of negative symptoms; and (5) same as model 4B except for the addition of a disorganized domain. The four- and five-factor models fit the data much better than simpler ones. Between the two four-factor models, M4B emerged as more appropriate than M4A. The five-factor solution (M5) displayed the best fit. In conclusion, our confirmatory factor analysis in a large sample of psychotic subjects indicated that the symptomatology of major psychoses is composed of the following five factors: mania, positive symptoms, disorganization, depression and negative symptoms.

Polymorphisms of dopamine degradation enzyme (COMT and MAO) genes and tardive dyskinesia in patients with schizophrenia

Several lines of evidence suggest that tardive dyskinesia (TD) may be associated with altered dopaminergic neurotransmission. We hypothesized that deranged dopamine degradation enzyme activities might be related to the susceptibility to TD through altered dopaminergic neurotransmission in the central nervous system. In the present study, we investigated the relationship between the gene polymorphisms of three dopamine degradation enzymes and TD. We genotyped the valine/methionine polymorphism of codon 108/158 in the catechol-O-methyltransferase (COMT) gene, the 30-bp repeat polymorphism in the promoter of the monoamine oxidase A (MAOA) gene, and the A/G polymorphism in intron 13 of the monoamine oxidase B (MAOB) gene in 206 Japanese patients with schizophrenia. No significant difference was found in total scores on the Abnormal Involuntary Movement Scale (AIMS) among the subject groups, sorted according to the COMT, MAOA and MAOB genotypes. Moreover, no significant difference was found in allele frequencies between patients with TD and patients without TD for any of the polymorphisms. As both COMT and MAO genes are involved in degrading catecholamines, we also sought evidence for additive and epistatic effects, but none was observed. Our data, therefore, do not support the hypothesis that polymorphisms in COMT, MAOA, and MAOB genes are involved individually or in combination in the predisposition to TD.

Symptomatological and cognitive predictors of insight in chronic schizophrenia

Studies of schizophrenia show lack of agreement about the relationship of symptomatological and cognitive factors to insight. In this study, positive and negative symptomatology and cognitive function were assessed by the Positive and Negative Syndrome Scale (PANSS), the Wisconsin Card Sorting Test (WCST), and the Wechsler Adult Intelligence Scale Revised (WAIS-R) in male chronic schizophrenic patients in relation to level of insight measured with the Japanese version of the Schedule for the Assessment of Insight (SAI-J). Negative symptoms were significantly and negatively associated with overall insight, particularly with treatment compliance and recognition of mental illness. The present findings suggest that aspects of insight such as treatment compliance and recognition of mental illness are negatively associated with negative symptoms.