Double-blind comparison of half-dose and standard-dose flupenthixol decanoate in the maintenance treatment of stabilised out-patients with schizophrenia

Psychometric evaluation of a standardized and expanded Brief Psychiatric Rating Scale

The interrater reliability, factorial and discriminant validity of a standardized and expanded Brief Psychiatric Rating Scale (BPRS-E) were investigated in a heterogeneous short-stay group of psychiatric inpatients in the Netherlands (n = 162). Repeated separate interviews by single clinicians (psychiatrists, residents or clinical psychologists), best reflecting the way the BPRS is usually employed in clinical practice and psychopharmacological research, were used to determine interrater reliability (n = 79). Although the 5 subscales of the original 18-item BPRS (BPRS-18) were successfully cross-validated in this Dutch sample, 4 of these subscales (except for thought disturbance) were found to lack interrater reliability. The 10-item schizophrenia scale derived from the BPRS-18 by a Scandinavian group met the standard of acceptable interrater reliability; BPRS-18 and BPRS-E global scales approximated this standard. For the thought disturbance subscale, the schizophrenia scale and for BPRS-18 and BPRS-E global scales, findings supported discriminatory power.

Family interventions for schizophrenia

Studies that have attempted to reduce schizophrenic relapse by the use of family interventions are described. Results from studies that implemented behavioral family interventions with patients who were identified as high risk because of the expressed emotion status of their relatives have demonstrated that relapse rates can be significantly reduced over a 2-year postdischarge follow-up period. A number of ongoing studies, especially those that are investigating the interaction of family interventions and different medication regimes, are also discussed. Areas for further investigation are identified, for example: the use of multiple outcome measures, the use of single-case studies and the development of ideographic assessment measures, the interaction of biological and environmental influences, the alleviation of the burden of care, the involvement of the consumer in services, the development of behavioral formulations and analysis of family engagement and compliance, staff training in intervention methods, and the translation of research results into clinical practice.

Drug prescribing for schizophrenic out-patients on depot injections. Repeat surveys over 18 years

Serial surveys of the prescribing practices of psychiatrists for schizophrenic out-patients over 1970-88 showed important changes. During the interval 1970-83, polypharmacy and the use of multiple neuroleptics were reduced. The total dose of neuroleptics prescribed fell and the proportion administered by depot injection increased. Since 1983, however, some of these favourable trends have been reversed. Prescribing practices may also vary between teaching and non-teaching hospitals.

Brief intermittent neuroleptic prophylaxis for selected schizophrenic out-patients

“A study was conducted to investigate a novel approach to the prophylaxis of schizophrenic relapse. The treatment strategy comprised brief intermittent courses of neuroleptic agents begun as soon as non-psychotic symptoms believed to be early signs of relapse appeared. Fifty four stable, remitted outpatients meeting the American Psychiatric Association's DSM–III criteria for schizophrenia were randomised double blind to receive brief intermittent treatment with either active or placebo depot neuroleptic injections. Only three patients given placebo injections and two controls were admitted to hospital during one year of follow up. Eight (30%) of the patients given placebo injections and only 2 (7%) of the controls, however, had a recurrence of schizophrenic symptoms. Patients given placebo injections experienced fewer extrapyramidal side effects and showed a trend towards a reduction in tardive dyskinesia. Dysphoric and neurotic symptoms were identified before eight out of 11 relapses, and these symptoms were more frequent in patients given placebo depot injections. These results suggest a viable but not necessarily better alternative to continuous oral or depot treatment for less ill, chronic, stabilised schizophrenics based on the early treatment of putative prodromal symptoms of relapse.”

The significance of depression in the prediction of relapse in chronic schizophrenia

The prospective monitoring of two separate groups of chronically schizophrenic patients on regular depot maintenance therapy suggests that depression developing after an interval of 1 year from recovery from an acute relapse indicates a significant increase in the risk of a further relapse within 2 years, compared with depression within the first year, or no depression. Patients with such depression were more prone to relapses than other patients, despite regular medication within normal dose ranges. The results suggest that the aetiology of depression occurring in patients after 1 year in a stable mental state is different from that of depression within the first year, and in many patients, the former represents underlying schizophrenic activity prior to an early relapse.

Observations on the use of depot neuroleptics in schizophrenia

This paper reviews some of the advantages and disadvantages of long-term maintenance therapy with neuroleptics in schizophrenia. The need to separate first-illness schizophrenia from chronic schizophrenia is illustrated. The reduction in the risk of a further acute relapse with continued medication and the likely duration of maintenance therapy are discussed. The true meaning of a further relapse to the patient in terms of reduced social and work function is also discussed. The advantages of using long-acting depot injections for drug administration are stressed. The complex issue of the correct dosage for maintenance is reviewed, with no proven advantage for either very high doses or very low doses. The frequency of depressive symptoms in schizophrenia is reviewed and the possible aetiologies discussed. The decision to use short- or long-term drug therapy, and whether to use a particular method of drug administration (oral or long-acting depot injections) should be separate issues. Depot injections may, on occasions, be the appropriate method of drug administration for short-term therapies, just as oral drugs have a place in the longer-duration maintenance treatments.