Comparative evaluation of conventional and novel antipsychotic drugs with reference to their subjective tolerability, side-effect profile and impact on quality of life

Best clinical practice with ziprasidone IM: update after 2 years of experience

Acute agitation is a common psychiatric emergency often treated with intramuscular (i.m.) medication when rapid control is necessary or the patient refuses to take an oral agent. Conventional i.m. antipsychotics are associated with side effects, particularly movement disorders, that may alarm patients and render them unreceptive to taking these medications again. Ziprasidone (Geodon) is the first second-generation, or atypical, antipsychotic to become available in an i.m. formulation. Ziprasidone IM was approved by the Food and Drug Administration in 2002 for the treatment of agitation in patients with schizophrenia. In October 2004, a roundtable panel of physicians with extensive experience in the management of acutely agitated patients met to review the first 2 years of experience with this agent. This monograph, a product of that meeting, discusses clinical experience to date with ziprasidone IM and offers recommendations on its use in various settings. In clinical trials, patients treated with ziprasidone IM demonstrated significant and rapid (within 15-30 minutes) reduction in agitation and improvement in psychotic symptoms, agitation, and hostility to an extent greater than or equal to that attained with haloperidol i.m. Tolerability of ziprasidone IM was superior to that of haloperidol IM, with a lower burden of movement disorders. Clinical trials have also shown that ziprasidone IM can be administered with benzodiazepines without adverse consequences. Transition from i.m. to oral ziprasidone has been well tolerated, with maintenance of symptom control. The most common adverse events associated with ziprasidone IM were insomnia, headache, and dizziness in fixed-dose trials and insomnia and hypertension in flexible-dose trials. No consistent pattern of escalating incidence of adverse events with escalating ziprasidone doses has been observed. Changes in QTc interval associated with ziprasidone at peak serum concentrations are modest and comparable to those seen with haloperidol IM. Results of randomized clinical trials of ziprasidone IM have been corroborated in studies in real-world treatment settings involving patients with extreme agitation or a recent history of alcohol or substance abuse. In these circumstances, clinically significant improvement was seen within 30 minutes of ziprasidone IM administration, without regard to the suspected underlying etiology of agitation. Agents with a good safety/tolerability profile, such as ziprasidone IM, may be more cost effective long term than older agents, due to reduced incidence of acute adverse effects (eg, acute dystonia) that often require extended periods of observation. Additional trials of ziprasidone IM in agitated patients in a variety of clinical setting are warranted to generate comparative risk/benefit data with conventional agents and other second-generation antipsychotics.

Acute Akathisia Associated With Quetiapine Use

Because of their better side-effect profile, atypical antipsychotic agents have replaced conventional antipsychotic agents as the first-line treatment for schizophrenia. Although atypical agents are less likely to be associated with extrapyramidal symptoms, such symptoms sometimes do occur in patients treated with atypical agents. The authors report the cases of two patients who developed akathisia after treatment with quetiapine for insomnia, consider previously reported cases of akathisia induced by atypical antipsychotic agents, discuss other medications that can induce similar symptoms, discuss treatments for akathisia, and examine issues in the use of quetiapine as a soporific agent.

Subjective experiences on antipsychotic medications: synthesis and conclusions

OBJECTIVE

This report synthesizes the literature describing the phenomenology, clinical importance and biology of subjective responses to antipsychotic medications in schizophrenia. A patient's experience of an antipsychotic is important because unpleasant or dysphoric responses can impair therapeutic relationships, lead to medication non-adherence, and have direct negative effects on a patient's quality of life.

METHOD

The author selectively reviewed early studies of subjective responses to antipsychotics and integrated this literature with the work of the other investigators in this special section.

RESULTS

There is substantial evidence that second-generation antipsychotics have advantages in causing fewer dysphoric responses when compared with first-generation agents. Clinical and neuroimaging studies suggest that dopamine blockade is an important determinant of many of these dysphorias. At this point in time it is unclear whether dysphoria results from extrapyramidal symptoms--particularly akathisia and akinesia--or whether they are a direct result of decreased dopamine activity.

CONCLUSION

Clinicians and researchers should continue to monitor dysphorias in schizophrenia. Contributions by the authors in this supplement provide new and more refined methods for measuring subjective responses in future studies.

Subjective well-being under the neuroleptic treatment and its relevance for compliance

OBJECTIVE

To review the concept of 'subjective well-being under neuroleptic treatment', its development and clinical relevance,particularly regarding compliance.

METHOD

The manuscript includes a review of the limited literature and recent open and controlled clinical trials.

RESULTS

The patients' perspective of antipsychotic treatment was largely neglected for a long time. Scientific interest in this field of strong clinical relevance started mainly with the development of atypical antipsychotics. Recent research indicates that subjective well-being (SW) is a major determinant of medication compliance in schizophrenia. There are several self-report instruments with sufficient internal consistency and good construct validity. Effects of antipsychotic treatment on psychopathology and SW are only partly related. Most patients strongly prefer the atypical over typical antipsychotics. The assessment of SW is helpful for selecting the optimal drug for the individual patient.

CONCLUSION

SW, under antipsychotic treatment, is a valid construct; its assessment provides an independent outcome variable, which is relevant to compliance.

Impact of present and past antipsychotic side effects on attitude toward typical antipsychotic treatment and adherence

OBJECTIVE

(1) determine which antipsychotic side effects (SE) schizophrenic patients consider the most distressing during treatment with typical antipsychotics, (2) measure the impact of actual and past SE on patients' attitude toward antipsychotics and (3) assess the influence of both on adherence.

METHODS

The 213 schizophrenics, treated with conventional antipsychotics, were recruited in two psychiatric hospitals in Hamburg. Subjects were assessed about type and severity of present and past side effects and their attitude and adherence to antipsychotic treatment.

RESULTS

The 82 (39%) patients presented present SE while 131 (61%) did not. Sexual dysfunctions (P < 0.001), extrapyramidal (P < 0.05) and psychic side effects (P < 0.05) were rated as significantly subjectively more distressing than sedation or vegetative side effects. Patients presenting with present SE compared with patients without present SE had a significantly more negative general attitude toward antipsychotics (P < 0.05), were more doubtful about their efficacy (P < 0.01) and were less likely to encourage a relative to take such a medication in case of need (P < 0.001). A regression analysis indicated that nonadherence was mainly influenced by negative general and efficacy attitudes toward antipsychotics and the experience of past or present antipsychotic side effects.

CONCLUSIONS

All antipsychotic side effects, present or past, can have a durable negative impact on patient's attitude toward antipsychotic treatment and adherence. Non-adherence is mainly determined, among other factors, by these negative attitudes, which are partly influenced by the experience of past or present antipsychotic-induced side effects.

Impact of atypical antipsychotics on quality of life in patients with schizophrenia

Schizophrenia is a long-term disabling illness that affects approximately 1% of the population. Its course is generally chronic with acute psychotic exacerbations that may require frequent hospitalisations. The clinical picture includes a range of symptoms such as delusions, hallucinations, agitation, suspiciousness, hostility, conceptual disorganisation, blunted affect, emotional and social withdrawal, lack of spontaneity, poverty of speech and a wide range of neurocognitive deficits. Over the past 50 years, antipsychotic medications have emerged as the cornerstone of management in concert with other important interventions, such as psychosocial and economic support and rehabilitation efforts. However, the unrivalled role of conventional antipsychotic medications has been continuously challenged by the wide range of adverse effects of these medications and their lack of usefulness in the treatment of neurocognitive deficits as well as deficit and negative symptoms. In addition, the lack of subjective tolerability of these agents and their negative impact on quality of life have complicated management for a large number of patients. Over the last 15 years, several new atypical antipsychotic medications have been introduced, including amisulpride, remoxipride, risperidone, sertindole, olanzapine, zotepine, quetiapine, ziprasidone and aripiprazole. In general, the new antipsychotics have shown themselves to be at least comparable in efficacy to conventional antipsychotics but with superior subjective tolerability and a more favourable adverse effect profile. The majority of quality of life studies involving new antipsychotic agents have evaluated the benefits of risperidone, olanzapine and clozapine; only a few studies have examined the effects of other new antipsychotics. While most of these studies have methodological and design limitations, the weight of evidence from them nevertheless points to a trend towards a more positive impact on quality of life with atypical agents. A number of recommendations can be made. First, more independent well designed and controlled studies are urgently needed to evaluate the effects of antipsychotic therapy on quality of life in patients with schizophrenia. New comparative studies should explore not only the differences between new and old antipsychotics but also identify any potential differences between individual new agents. The role of cost-effectiveness studies such as cost utility approaches in schizophrenia needs to be revisited, notwithstanding the fact that these types of studies have been reported to be feasible in schizophrenia. Finally, quality-of-life-based pharmacoeconomic studies of antipsychotic agents should not concentrate solely on cost reduction or containment, as it is likely that in order to maximise the benefits of new antipsychotic medications, greater expenditure on rehabilitation programmes and other support services will be necessary in the short-term at least.

Randomized double blind comparison of olanzapine vs. clozapine on subjective well-being and clinical outcome in patients with schizophrenia

OBJECTIVE

This randomized double-blind multicenter trial evaluated the effects of olanzapine vs. clozapine on subjective well-being, quality of life (QOL) and clinical outcome.

METHOD

The primary objective was to demonstrate non-inferiority of olanzapine, mean dosage 16.2 +/- 4.8 (5-25 mg/day) vs. clozapine, mean dosage 209 +/- 91 (100-400 mg/day) regarding improvement on the 'Subjective Well-Being under Neuroleptic Treatment' (SWN) Scale after 26 treatment weeks in 114 patients with schizophrenia. Secondary outcome parameters included: Munich QOL Dimension List (MLDL), Positive and Negative Symptom Scale (PANSS), Clinical Global Impression (CGI).

RESULTS

SWN scores improved significantly in both groups, olanzapine was non-inferior to clozapine (group difference 3.2 points in favor of olanzapine; 95% CI: 4.2;10.5). MLDL-satisfaction, PANSS and CGI-S improved similarly, olanzapine yielded a higher CGI Therapeutic Index. Individual SWN and PANSS changes correlated only moderately (r = -0.45).

CONCLUSION

Olanzapine was non-inferior to clozapine. The lack of a marked correlation between PANSS and SWN improvements indicates that patients and psychiatrists perceive treatment differently.

Is quality of life associated with cognitive impairment in schizophrenia?

BACKGROUND

The subjectively assessed quality of life of schizophrenia patients is mostly lower than healthy subjects, and cognitive impairment is an integral feature of schizophrenia. The aims of the present study were to compare the quality of life and neurocognitive functioning between the patients with schizophrenia and the healthy subjects, and to examine the relationships between quality of life and neurocognitive functions among the patients with schizophrenia.

METHODS

Thirty-eight patients with schizophrenia (15 women and 23 men) and 31 healthy individuals (18 women and 13 men) were included in the study. All participants were administered World Health Organization Quality of Life-Brief Form (WHOQOL-BREF) to assess their quality of life, and Digit Span Test (DST) and Controlled Oral Word Association Test (COWAT) for cognitive functions.

RESULTS

The patients with schizophrenia demonstrated lower scores in physical (F=25.6, p=0.0001), psychological (F=15.85, p=0.0001) and social (F=37.7, p=0.0001) domains compared to control group. The patients with schizophrenia showed significantly lower scores on COWAT compared to healthy subjects (F=4.22, p=0.04). The social domain scores of WHOQOL correlated to DST total scores (r=0.45, p=0.007), DST forwards scores (r=0.54, p=0.001) and COWAT total scores (r=0.40, p=0.04) in patients with schizophrenia but not in the control group. The patients with lower level of cognitive functioning had lower scores on social domain of WHOQOL-BREF (z=-2.01, p=0.04).

CONCLUSION

Our results confirm that the cognitive deficits in executive function and working memory appear to have direct impact on the patients' perceived quality of life especially in social domain which can either be a cause or a consequence of social isolation of patients with schizophrenia.

Adverse cardiac effects associated with clozapine

OBJECTIVE

To review the published literature on serious adverse cardiac events associated with the atypical antipsychotic agent, clozapine, and to make recommendations for cardiac assessment of candidates for clozapine treatment and for monitoring of cardiac status after treatment is initiated.

DATA SOURCES

We searched the PubMed and MEDLINE databases for articles published from 1970 to 2004 that contain the keywords "clozapine and myocarditis," "clozapine and cardiomyopathy," "clozapine and cardiotoxicity," "clozapine and sudden death" or "clozapine and mortality." We also manually searched the bibliographies of these articles for related sources.

STUDY SELECTION

We reviewed the 30 case reports, case series, laboratory and clinical trials, data mining studies, and previous reviews identified by this search.

DATA SYNTHESIS

Recent evidence suggests that clozapine is associated with a low (0.015% to 0.188%) risk of potentially fatal myocarditis or cardiomyopathy. The drug is not known to be independently associated with pathologic prolongation of the QTc interval, but it may contribute to pathologic QTc prolongation in patients with other risk factors for this condition.

CONCLUSIONS

The low risk of a serious adverse cardiac event should be outweighed by a reduction in suicide risk for most patients taking clozapine. We provide recommendations for assessing and monitoring cardiac status in patients prior to and after initiation of treatment with clozapine.

Assessing cost-effectiveness of drug interventions for schizophrenia

OBJECTIVE

To assess from a health sector perspective the incremental cost-effectiveness of eight drug treatment scenarios for established schizophrenia.

METHOD

Using a standardized methodology, costs and outcomes are modelled over the lifetime of prevalent cases of schizophrenia in Australia in 2000. A two-stage approach to assessment of health benefit is used. The first stage involves a quantitative analysis based on disability-adjusted life years (DALYs) averted, using best available evidence. The robustness of results is tested using probabilistic uncertainty analysis. The second stage involves application of 'second filter' criteria (equity, strength of evidence, feasibility and acceptability) to allow broader concepts of benefit to be considered.

RESULTS

Replacing oral typicals with risperidone or olanzapine has an incremental cost-effectiveness ratio (ICER) of 48,000 Australian dollars and 92,000 Australian dollars/DALY respectively. Switching from low-dose typicals to risperidone has an ICER of 80,000 Australian dollars. Giving risperidone to people experiencing side-effects on typicals is more cost-effective at 20,000 Australian dollars. Giving clozapine to people taking typicals, with the worst course of the disorder and either little or clear deterioration, is cost-effective at 42,000 Australian dollars or 23,000 Australian dollars/DALY respectively. The least cost-effective intervention is to replace risperidone with olanzapine at 160,000 Australian dollars/DALY.

CONCLUSIONS

Based on an 50,000 Australian dollars/DALY threshold, low-dose typical neuroleptics are indicated as the treatment of choice for established schizophrenia, with risperidone being reserved for those experiencing moderate to severe side-effects on typicals. The more expensive olanzapine should only be prescribed when risperidone is not clinically indicated. The high cost of risperidone and olanzapine relative to modest health gains underlie this conclusion. Earlier introduction of clozapine however, would be cost-effective. This work is limited by weaknesses in trials (lack of long-term efficacy data, quality of life and consumer satisfaction evidence) and the translation of effect size into a DALY change. Some stakeholders, including SANE Australia, argue the modest health gains reported in the literature do not adequately reflect perceptions by patients, clinicians and carers, of improved quality of life with these atypicals.

Effectiveness of quetiapine for the management of aggressive psychosis in the emergency psychiatric setting: a naturalistic uncontrolled trial

Objective Traditionally, conventional antipsychotics, often administered intramuscularly, are used to reduce hostility and aggression in the emergency setting. This study investigated the efficacy of quetiapine, an oral atypical antipsychotic, in managing aggressive psychosis. Methods Adult hospitalized patients (n=36) with an Overt Aggression Scale (OAS) total score ≥1 and a Brief Psychiatric Rating Scale-derived Psychosis Index score ≥6 received 100-800 mg/day flexibly dosed quetiapine and were monitored daily for a maximum of 5 days. The OAS total score and Physical Aggression Against Others subscale score were primary efficacy assessments. Tolerability was assessed with the Udvalg for Kliniske Undersogelser Side Effects Rating Scale. Results An 83% decrease in the OAS Physical Aggression Against Others subscale score occurred from Day 1 (baseline) to Day 2, which was generally maintained to Day 5; a 39% reduction in OAS total score was observed by Day 2. The OAS total score decreased from a mean baseline of 3.3 to 1.5 at Day 5, a significant decrease for Days 2-4 (P < 0.01) and of borderline significance on Day 5 (P=0.059). Adverse events were mostly mild to moderate with concentration difficulties and somnolence the most common. Conclusion These results from an uncontrolled trial suggest that quetiapine may be helpful for some aggressive patients in the emergency setting.

Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of schizophrenia and related disorders

BACKGROUND

The Royal Australian and New Zealand College of Psychiatrists is co-ordinating the development of clinical practice guidelines (CPGs) in psychiatry, funded under the National Mental Health Strategy (Australia) and the New Zealand Health Funding Authority. This paper presents CPGs for schizophrenia and related disorders. Over the past decade schizophrenia has become more treatable than ever before. A new generation of drug therapies, a renaissance of psychological and psychosocial interventions and a first generation of reform within the specialist mental health system have combined to create an evidence-based climate of realistic optimism. Progressive neuroscientific advances hold out the strong possibility of more definitive biological treatments in the near future. However, this improved potential for better outcomes and quality of life for people with schizophrenia has not been translated into reality in Australia. The efficacy-effectiveness gap is wider for schizophrenia than any other serious medical disorder. Therapeutic nihilism, under-resourcing of services and a stalling of the service reform process, poor morale within specialist mental health services, a lack of broad-based recovery and life support programs, and a climate of tenacious stigma and consequent lack of concern for people with schizophrenia are the contributory causes for this failure to effectively treat. These guidelines therefore tackle only one element in the endeavour to reduce the impact of schizophrenia. They distil the current evidence-base and make recommendations based on the best available knowledge.

METHOD

A comprehensive literature review (1990-2003) was conducted, including all Cochrane schizophrenia reviews and all relevant meta-analyses, and a number of recent international clinical practice guidelines were consulted. A series of drafts were refined by the expert committee and enhanced through a bi-national consultation process.

TREATMENT RECOMMENDATIONS

This guideline provides evidence-based recommendations for the management of schizophrenia by treatment type and by phase of illness. The essential features of the guidelines are: (i) Early detection and comprehensive treatment of first episode cases is a priority since the psychosocial and possibly the biological impact of illness can be minimized and outcome improved. An optimistic attitude on the part of health professionals is an essential ingredient from the outset and across all phases of illness. (ii) Comprehensive and sustained intervention should be assured during the initial 3-5 years following diagnosis since course of illness is strongly influenced by what occurs in this 'critical period'. Patients should not have to 'prove chronicity' before they gain consistent access and tenure to specialist mental health services. (iii) Antipsychotic medication is the cornerstone of treatment. These medicines have improved in quality and tolerability, yet should be used cautiously and in a more targeted manner than in the past. The treatment of choice for most patients is now the novel antipsychotic medications because of their superior tolerability and, in particular, the reduced risk of tardive dyskinesia. This is particularly so for the first episode patient where, due to superior tolerability, novel agents are the first, second and third line choice. These novel agents are nevertheless associated with potentially serious medium to long-term side-effects of their own for which patients must be carefully monitored. Conventional antipsychotic medications in low dosage may still have a role in a small proportion of patients, where there has been full remission and good tolerability; however, the indications are shrinking progressively. These principles are now accepted in most developed countries. (vi) Clozapine should be used early in the course, as soon as treatment resistance to at least two antipsychotics has been demonstrated. This usually means incomplete remission of positive symptomatology, but clozapine may also be considered where there are pervasive negative symptoms or significant or persistent suicidal risk is present. (v) Comprehensive psychosocial interventions should be routinely available to all patients and their families, and provided by appropriately trained mental health professionals with time to devote to the task. This includes family interventions, cognitive-behaviour therapy, vocational rehabilitation and other forms of therapy, especially for comorbid conditions, such as substance abuse, depression and anxiety. (vi) The social and cultural environment of people with schizophrenia is an essential arena for intervention. Adequate shelter, financial security, access to meaningful social roles and availability of social support are essential components of recovery and quality of life. (vii) Interventions should be carefully tailored to phase and stage of illness, and to gender and cultural background. (viii) Genuine involvement of consumers and relatives in service development and provision should be standard. (ix) Maintenance of good physical health and prevention and early treatment of serious medical illness has been seriously neglected in the management of schizophrenia, and results in premature death and widespread morbidity. Quality of medical care for people with schizophrenia should be equivalent to the general community standard. (x) General practitioners (GPs)s should always be closely involved in the care of people with schizophrenia. However, this should be truly shared care, and sole care by a GP with minimal or no specialist involvement, while very common, is not regarded as an acceptable standard of care. Optimal treatment of schizophrenia requires a multidisciplinary team approach with a consultant psychiatrist centrally involved.

Liverpool University Neuroleptic Side-Effect Rating Scale (LUNSERS) as a subjective measure of drug-induced parkinsonism and akathisia

The Liverpool University Neuroleptic Side-Effect Rating Scale (LUNSERS) was examined for its usefulness as a subjective measure of drug-induced parkinsonism and akathisia. Eighty-three subjects were assessed using the LUNSERS, the Simpson-Angus Scale (SAS) and the Barnes Akathisia Rating Scale (BARS), before and after a 6-week treatment with olanzapine. Significant correlations were found between the changes in scores of parkinsonism items of LUNSERS and SAS. The changes in scores of akathisia item (restlessness), extrapyramidal side effects (EPS) subscale and psychic side-effects subscale of LUNSERS were significantly correlated with those of the BARS. 'Shakiness', one item of the EPS subscale of LUNSERS, correctly classified between parkinsonism and non-parkinsonism groups with 81.0% accuracy. A combination of four items included in EPS and psychic side-effect subscales of LUNSERS identified akathisia and non-akathisia groups with 76.2% accuracy. These results suggest that the EPS and psychic side-effect subscales of LUNSERS may be useful in screening for drug-induced parkinsonism and akathisia.

Sustained drug delivery optimizes long-term treatment of patients with schizophrenia

Chronic disorders such as schizophrenia require long-term treatment programs in order to maintain patients at the lowest level of symptomatology, reduce the likelihood of psychotic relapse, and support achievement of remission and recovery. Evidence suggests that treatment with long-acting injectable antipsychotics reduces the impact of partial compliance and provides predictable release of medication, assuring continuous therapeutic coverage. Until recently, only conventional antipsychotic agents were available in long-acting formulations, thereby foregoing the advantages of the atypical class. Atypical agents which are given orally have been shown to provide long-term efficacy and tolerability benefits compared with conventional agents, but are limited by the need for daily administration. The most recent pharmacological strategy to achieve optimal maintenance treatment has been to combine the benefits of an atypical antipsychotic with delivery in a water-based long-acting formulation. The first antipsychotic to achieve this combination - long-acting risperidone - may thus represent an important advance in the optimization of long-term treatment outcomes in patients with schizophrenia.

Quality of life outcomes of risperidone, olanzapine, and typical antipsychotics among schizophrenia patients treated in routine clinical practice: a naturalistic comparative study

Findings in previous studies investigating the beneficial effect of risperidone and olanzapine versus typical antipsychotics on quality of life (QOL) are controversial since they did not adjust for various factors contributing to QOL. To test this assumption in a naturalistic cross-sectional design, we evaluated general and domain-specific QOL scores for baseline data of schizophrenia outpatients stabilized on atypical (N = 78, risperidone or olanzapine) and typical (N = 55) agents. Self-report and observer-rated QOL outcomes of both risperidone and olanzapine with typical antipsychotic therapy were compared across demographic, illness-related, and treatment-related factors using analysis of variance, multivariate analysis of variance, and correlation analysis. No significant differences were found in QOL outcomes of risperidone-treated and olanzapine-treated patients. Both self-report and rater-observed QOL measures indicated superiority of atypical over typical antipsychotic agents after adjusting for daily doses, duration of treatment, subjective tolerability, and adjuvant antidepressants. Lower daily doses and longer antipsychotic treatment were associated with better QOL. Self-report and observer-rated QOL scores correlated positively (r = 0.64, P < 0.001). Gender, marital status, age, education, living arrangement and employment status, age of onset, illness duration, symptom severity, emotional distress, subtypes of schizophrenia, and side effects did not affect QOL outcomes in either group. Risperidone and olanzapine revealed an advantage over typical agents in terms of QOL. Findings suggest that when calculating the beneficial effects of atypical antipsychotic therapy on QOL outcomes, daily doses, duration of treatment, and subjective tolerability may be intervening variables and should be adjusted accordingly to clearly appreciate benefits of atypical antipsychotics.

Current issues in schizophrenia: overview of patient acceptability, functioning capacity and quality of life

The increasing interest in the subjective wellbeing and quality of life (QoL) of patients with schizophrenia represents a conceptual extension of therapeutic outcome criteria. For a long time, the reduction of positive symptoms alone was the most important outcome parameter, but the development of atypical antipsychotic drugs in the early 1990s resulted in the adoption of more wide-reaching measures of therapeutic outcome. Patient satisfaction appears to be strongly related to their willingness to be or stay engaged in psychosocial and pharmacological treatment, and therefore to the symptomatic and functional outcome. Existing studies that deal with QoL and subjective wellbeing differ in their methodology and are difficult to compare because of varying underlying concepts of QoL or subjective wellbeing, different assessment scales or small sample sizes. Although QoL is a heterogeneous concept, it is clearly correlated with a number of factors, including illness, medication and stress process-related variables. Various protective factors have been identified; among these are personality traits, the degree of social support and treatment interventions. In clinical studies, atypical antipsychotic agents are associated with greater improvements in QoL and subjective wellbeing than are conventional agents. The reason for this is probably the ability of atypical agents to have a positive impact on factors most associated with QoL, such as negative and affective symptoms and drug tolerability. The most appropriate clinical approach to maximize QoL and subjective wellbeing for patients with schizophrenia is to use atypical antipsychotic drugs as a first-line treatment approach. Ideally, an atypical drug which is known not to have a negative effect on attention, affect or motivation should be chosen.

Intramuscular antipsychotics: Clinical experience review

Acute agitation is a therapeutic dilemma. Rapid control of agitation is necessary to minimize danger both to recipients of care and to caregivers. Although a comprehensive assessment may ultimately be necessary to determine the cause of agitation and to identify or exclude underlying medical illness, it is often imperative to treat agitation immediately. In this imperfect clinical world, it is essential to have treatments that are both safe and effective for patients with a wide variety of causes of agitation.

Clinical effectiveness of new generation antipsychotics in adolescent patients

In addition to management of symptoms of disease, pharmacological interventions in adolescents with psychotic disorders must be clinically effective to provide the best possible outcome in terms of well-being, functioning, and disease burden. Six outcome domains should be considered: symptoms of disease, tolerability, everyday functioning, subjective well-being, family/career burden, and treatment adherence. To date, few studies have compared the clinical effectiveness of the different new generation antipsychotics in adolescents. However, clear differences exist between available agents, particularly in terms of tolerability profile. This review will focus on the particular issues that clinicians need to consider in order to maximise the clinical effectiveness of the new generation antipsychotics in adolescent patients with psychosis. For example, adolescents are not only more susceptible to the side effects of antipsychotic medication than adults, but they are also more likely to be sensitive to the negative impact of side effects on appearance, body image, and self-esteem. Data available in children and adolescents will be reviewed, and the practical implications for patient management will be highlighted. The importance of dosing the new generation antipsychotics appropriately will also be discussed.

Tools for measuring clinical effectiveness

Efficacy studies fail to consider the multiple aspects of schizophrenia that determine the overall clinical effectiveness of treatment. We address this shortcoming by proposing definitions of six schizophrenia outcome domains which we believe contribute to clinical effectiveness: symptoms of disease, tolerability, everyday functioning, subjective well-being, family/career burden, and treatment adherence. Numerous specialised rating scales are in widespread use; however, these only assess specific aspects of schizophrenia within individual domains and are of limited use for measuring clinical effectiveness. New rating instruments that measure treatment outcomes across all six domains of schizophrenia need to be developed. One such scale is the revised Global Outcome Assessment of Life in Schizophrenia (GOALS) scale. We propose that further development of this scale should include validation in long-term studies, incorporation of the patient perspective of treatment within assessments, and education of clinicians on how to score this scale. If this approach to evaluating treatment outcomes is adopted, clinicians will be better placed to differentiate therapeutic interventions on the basis of clinical effectiveness.

Quality of life in persons with schizophrenia in out-patient treatment with first- or second-generation antipsychotics

OBJECTIVE

Effects of first in comparison with second-generation antipsychotics on the subjective quality of life (QoL) of patients with schizophrenia under routine treatment conditions were examined.

METHOD

In a prospective naturalistic trial the QoL, social, clinical, and treatment-related characteristics and type of antipsychotic medication of 307 patients with schizophrenia (ICD-10 F 20) were assessed five times with 6-month intervals over 2.5 years. Longitudinal and cross-sectional effects of antipsychotic medication were assessed by hierarchical regression models. Selection bias was controlled by propensity scores.

RESULTS

While positive effects of first-generation antipsychotics on subjective QoL in comparison with no antipsychotic treatment were found, second-generation antipsychotics caused no better QoL than first-generation antipsychotics.

CONCLUSION

The hypothesis that second-generation in comparison with first-generation antipsychotics have a better effect on the improvement of subjective QoL of people with schizophrenia in routine out-patient treatment was not supported.

Subjective response to antipsychotics of schizophrenia patients treated in routine clinical practice: a naturalistic comparative study

In routine practice, subjective response to antipsychotics is becoming a critical outcome measure among schizophrenia patients. This study sought to compare subjective response to atypical (risperidone and olanzapine) and typical antipsychotic drugs. Using a naturalistic cross-sectional design, we examined subjective response to antipsychotics (satisfaction with medication and subjective tolerability), psychopathology, side effects, emotional distress, and awareness in schizophrenia patients stabilized on atypical (n = 78) and typical (n = 55) drugs. Analysis of variance and multiple regression analysis were applied. We found that atypical drugs were superior to typical antipsychotics in both measures of subjective response, which were positively correlated (r = 0.52, P < 0.001). Poor subjective response was associated with severity of emotional distress, negative, and activation symptoms in the atypical group and with extrapyramidal side effects and positive symptoms in the typical group. Awareness of treatment is a positive factor that accounted for 20% and 34% of variation in the subjective responses to atypical and typical antipsychotic drugs, respectively. Demographic variables, age of onset, illness duration, and adjunctive drugs did not relate significantly to subjective response to antipsychotic drugs. Thus, atypical drugs are characterized by better subjective response compared with typical antipsychotics; their determinants differed considerably. Satisfaction with medication together with subjective tolerability needs to be considered in clinical trials.

Differences of satisfaction with medication between patients with schizophrenia treated with typical antipsychotics and atypical antipsychotics

Many studies have demonstrated that atypical antipsychotics are superior to typical antipsychotics in that they have fewer side-effects and produce better improvement of cognitive deficits and quality of life in patients with schizophrenia. However, most of these studies dealt with objective indices assessed by researchers rather than subjective indices that are indeed important to patients themselves. In 126 patients with schizophrenia, annoyance of side-effects and psychotic symptoms, satisfaction with medication, wish to change medication, and knowledge of atypical antipsychotics were assessed using questionnaires. Patients treated with typical antipsychotics complained less of annoyance of poor attention and concentration than those treated with atypical antipsychotics, which can be explained by increased awareness of these symptoms by the patients due to the improvement of cognitive function. There were no significant differences between the two groups in other variables. The present results that satisfaction and annoyance were similar between patients treated with typical antipsychotics and those with atypical antipsychotics, may partly explain why patients hesitated and rejected changing or shifting from typical to atypical antipsychotics. But because 98 of 126 patients did not know about atypical antipsychotics, it is important to educate the patients on the merits of atypical antipsychotics.

Is neuroleptic dysphoria a variant of drug-induced extrapyramidal side effects?

OBJECTIVES

Neuroleptic drugs induce psychological side effects such as dysphoria, cognitive impairment, and loss of motivation. These side effects were largely underrecognized and trivialized in the past as variants of extrapyramidal side effects (EPSEs). We review the recent literature on the subject and clarify the relation between neuroleptic-induced dysphoria and EPSEs.

METHODS

We critically examined clinical, interventional, neuroimaging, and basic science studies published in the past 10 years, delineating the temporal, phenomenological, biochemical, and neuroanatomical relation between dysphoria and EPSEs.

RESULTS

Subjective responses occur within 4 to 6 hours of neuroleptic use, whereas acute dystonia is often observed within 24 hours and parkinsonian syndrome after 5 to 7 days. Neuroleptic-induced dopaminergic blockade mediates both dysphoria and EPSEs. However, impaired dopamine function in the nucleus accumbens seems to give rise to dysphoria, whereas blockade of D2 receptors in the nigrostriatal system is responsible for EPSEs.

CONCLUSION

The earlier notion that neuroleptic dysphoria is a variant of EPSEs was simplistic and speculative. Exploring the differences rather than dwelling on the similarities will likely enhance our understanding of dopamine's role in the origin of varied side effects and in their distinctive characteristics.

New antipsychotics, compliance, quality of life, and subjective tolerability--are patients better off?

OBJECTIVES

This overview reviews the impact of second-generation antipsychotics on less frequently researched outcomes such as medication-adherence behaviour, quality of life, and subjective tolerability in patients with schizophrenia.

METHODS

We selectively reviewed recent literature and considered our own research and experiences in the field.

RESULTS

Most published studies about second-generation antipsychotics have dealt with issues related to efficacy and safety. So far, not many studies have focused on effectiveness in terms of such important outcomes as medication-adherence behaviour, quality of life, subjective tolerability, and overall satisfaction with treatment. Although most studies are inconclusive and their results are inconsistent--which has to do with several design and methodological limitations--there seems, on balance, to be a trend indicating superiority of second-generation, compared with first-generation, antipsychotics in improving medication-adherence behaviour and quality of life. The trend toward more favourable subjective tolerability and less frequent neuroleptic dysphoria seems to be relatively stronger.

CONCLUSIONS

At present, the state of the art can only indicate a more favourable trend for second-generation antipsychotics in regard to improving medication adherence behaviour, quality of life, and subjective tolerability. It is surprising that such important outcomes, which are likely the defining factors in the superiority of second-generation antipsychotics, have not received adequate research attention. Well-designed, controlled, and adequately powered studies are urgently needed before any firm conclusions can be reached.

Use of psychopharmacologic agents in the elderly

Most psychiatric disorders in elderly patients are amenable to treatment, provided that intervention is thorough and intensive. Appropriate and judicious use of psychopharmacologic agents has a potential for dramatically improving the quality of life and functional status of many elderly patients with psychiatric disorders. The decision to prescribe a psychopharmacologic agent in elderly patients is a serious and complex issue. Several basic principles need to be followed (Table 6). Although some strides have been made in the last decade regarding safety and efficacy of many psychopharmacologic agents in elderly [table: see text] patients, for many psychopharmacologic agents, large randomized controlled studies to evaluate efficacy and safety in elderly patients are lacking. Sparse data are available regarding the long-term effects of psychopharmacologic agents in elderly patients. Important gaps remain in our knowledge concerning the optimal duration of treatment for most psychiatric disorders in elderly patients. The treatment data deficiency is most striking among the oldest old (patients aged 85 and older), frail medically ill elderly patients (such as nursing home residents), and ethnic minority groups. Future research should focus on these and other relevant issues related to the use of psychopharmacologic agents in elderly patients.

Efficacy and tolerability of quetiapine in poorly responsive, chronic schizophrenia

With the notable exception of clozapine, there is at present insufficient information on the efficacy of atypical antipsychotic medications in patients with poorly responsive schizophrenia. The present study reports on the efficacy and tolerability of quetiapine and haloperidol in patients with schizophrenia who showed no response to treatment with fluphenazine. This study is a post hoc subanalysis of an 8-week, double-blind study of patients receiving quetiapine 600 mg/day or haloperidol 20 mg/day. The proportion of patients classified as "Clinical Global Impression responders" (defined as Clinical Global Impression Severity of Illness score of < or = 3 at study end) was greater in the quetiapine group compared with the haloperidol group (51% vs. 25%; P = 0.023). Overall, quetiapine was well tolerated with less extrapyramidal side-effects and reduction in prolactin when compared to haloperidol. Weight gain was modest but more apparent in quetiapine-treated patients. Quetiapine is an appropriate treatment choice in patients who do not respond to prior antipsychotic treatment.

Assessing and monitoring antipsychotic-induced movement disorders in hospitalized patients: a cautionary study

OBJECTIVE

To assess the amount of documentation and level of assessment provided by attending physicians and nursing staff in regard to extrapyramidal symptoms (EPS) experienced by hospitalized patients with varied DSM-IV diagnoses regularly treated with antipsychotic medication.

METHOD

We examined the medical records of 204 hospitalized patients. All medical records were examined retrospectively from consecutive admissions beginning in January 1996. We identified demographics, length of hospitalization, diagnosis, and antipsychotic and adjunct medication. EPS were classified into dystonia, parkinsonism, akathisia, and tardive dyskinesia (TD). For each type of EPS, 2 independent raters rated the quality of assessment based on dimensions of severity, location, and laterality.

RESULTS

The extent of interrater agreement was found to be 91.1%. Parkinsonism and akathisia were more frequently assessed, compared with TD and dystonia. However, the medical records examined showed generally poor assessment and documentation of EPS. The percentage of medical records with "no description" for each EPS classification was as follows: dystonia (89%), parkinsonism (71%), akathisia (67%), and TD (94%).

CONCLUSIONS

The major finding of this study was a high rate of failure to document the assessment and course of EPS. This finding suggests that clinicians do not recognize the importance of documenting these significant adverse events. This shortcoming can be corrected with increased awareness of EPS and increased training in their physical examination.

Neuroleptic dysphoria: towards a new synthesis

RATIONALE

Neuroleptic dysphoria (ND) is a subtle and under-recognized side effect of antipsychotic drugs. It is an all-inclusive descriptive phrase that encompasses a variety of unpleasant subjective changes in arousal, mood, thinking and motivation induced by neuroleptic drugs. Understanding this phenomenon has wide ranging clinical and research implications.

OBJECTIVE

The present review examined the themes identified in the original studies from the neuroleptic era in the light of recent findings from neuroimaging research, cumulative experience with second generation antipsychotic drugs, and new concepts such as pleasure responsivity, hedonic regulation and subjective tolerability.

METHODS

Empirical studies on neuroleptic drugs involving clinical populations treated for schizophrenia, Tourette's disorder and stuttering, studies performed on normal healthy volunteers and selected experimental studies in animals, are reviewed.

RESULTS

Dysphoric responses occur early during treatment and typically manifest as a dislike towards medication (drug aversiveness). Dysphoria persisting over time, may lead to adverse clinical consequences such as treatment non-adherence, substance abuse, poor clinical outcome, increased suicidality and compromised quality of life. Interference with the physiological processes of hedonic capacity by the neuroleptics due to their dopaminergic blocking action in the prefrontal cortex and the shell of nucleus accumbens is the putative mediating mechanism underlying the occurrence of dysphoric responses. Second generation antipsychotic drugs with an atypical receptor blocking profile are less likely to elicit dysphoric responses.

CONCLUSION

Viewing neuroleptic dysphoria within a broader spectrum of disorders of subjective tolerability and exploring its neurobiological mechanisms is relevant to addressing the nuances of antipsychotic therapy, and could help unravel the questions surrounding the pathophysiology of depression, substance abuse and other dysphoric clinical states.

Exploring cognitive complaints in schizophrenia: the subjective scale to investigate cognition in schizophrenia

While it has become commonplace to test the various components of memory in schizophrenia with paper-and-pencil or in-lab tasks, very little data exist on the subjective complaints of patients regarding their memory. Few instruments have been designed to collect systematically the complaints of patients with schizophrenia. We present a work in progress on the Subjective Scale to Investigate Cognition in Schizophrenia (SSTICS), a 21-item, Likert-type scale that is simple and easy to use. It allows a quantitative approach to the subjective and cognitive dimensions of schizophrenia. Stip constructed the scale based on a questionnaire covering several cognitive domains: memory (working memory, explicit long-term memory), attention (divided, distractibility, alertness, sustained), language, and praxia. We evaluated the psychometric properties of the SSTICS in a population of 114 French-speaking patients in Montreal. Patients were recruited in the community and assessed with the Structured Clinical Interview for DSM-III-R (SCID), the Positive and Negative Syndrome Scale (PANSS), and the Extrapyramidal Symptoms Rating Scale (ESRS). Cognition was measured using the Rey Auditory Verbal Learning Test (RAVLT) (long-term memory), Controlled Oral Word Association Test (verbal fluency), and Trails A and B. Preliminary analyses showed very good internal consistency for the global score (alpha=0.88), and alphas varying from 0.57 to 0.72 for the subscales. Stability over time was very good. The principal components analysis accounted for a multiple structure. Correlations between subjective scores and objective cognitive assessment were significant for several domains. Validation of the SSTICS needs to be completed through further exploration of the factorial structure and testing of the English version.

Safety, effectiveness, and quality of life of olanzapine in first-episode schizophrenia: a naturalistic study

OBJECTIVE

This study evaluated the effectiveness, safety, and quality of life (Qol) offered by olanzapine in first-episode schizophrenia.

METHOD

One hundred and eighty-two patients with first-episode schizophrenia (ICD-10) drawn from a larger, naturalistic, study were evaluated after 6 months of treatment with olanzapine, risperidone, or conventional antipsychotics (CA). Clinical status was assessed using the Clinical Global Impression-Severity (CGI-S) and Global Assessment of Function (GAF). AWAD and EuroQol scales were used to evaluate patients' attitude towards medication and Qol, respectively.

RESULTS

Subjects treated with olanzapine, risperidone, and CA showed similar improvements on CGI-S and GAF. Treatment-emergent, extrapyramidal symptoms were significantly lower in olanzapine-treated patients (17.8%) than in the risperidone (46.4%) and CA (62.2%) groups. Compared to CA, olanzapine and risperidone showed significantly greater improvement on the visual analog scale of EuroQol. Olanzapine-treated patients also showed significantly improved AWAD scores.

CONCLUSIONS

In first-episode schizophrenia, atypical antipsychotics were effective, and improved Qol. Olanzapine had a lower incidence of extrapyramidal symptoms and better subjective acceptance of medication.

Clozapine-induced akathisia in children with schizophrenia

Akathisia is a relatively rare side effect with the newer atypical antipsychotic agents, particularly clozapine, and is easily misdiagnosed in children. As children are often unable to describe their symptoms verbally, their akathisia can be misdiagnosed as worsening of their psychosis, prompting an unnecessary increase in their neuroleptic dose. Two cases of childhood-onset schizophrenia associated with clozapine-induced akathisia responsive to beta-blocker treatment are described. Akathisia should be considered in all cases of apparent nonresponse to atypical antipsychotics.

Perception of depot antipsychotics by mental health professionals

OBJECTIVE

This study examines attitudes of mental health professionals about the use and usefulness of depot antipsychotic medications and determines similarities and differences in attitudes between professional groups.

METHODS

Mental health professionals working with patients with severe mental illness completed a questionnaire designed to evaluate their opinions concerning rate of depot use, indications for use of depots, problems with use of depots, common side effects of depots, barriers to switching from depot to oral atypical antipsychotics, impact of staffing levels on drug choice, and relative confidence in various antipsychotics for the management of chronic psychosis.

RESULTS

Overall, all professional groups perceived depot antipsychotics as a requirement for the treatment of those with serious mental illness who were poorly adherent. However, there were a number of professional differences in responses to certain items in the survey that probably reflected the degree of direct contact with patients. Medical staff were remarkably uniform in their opinions on the use and usefulness of depots. Mental health staff from all the professional groups surveyed considered extrapyramidal side effects (EPS) a major concern, while few rated cognitive side effects, sexual side effects, and weight gain as significant concerns, even though these problems are reported to be a principal concern of patients. Although all professional groups indicated an awareness of the potential toxicity of depot antipsychotics and there was an overall consensus that atypical antipsychotics are likely to be beneficial in chronic psychosis, limitations in resources were seen as a barrier to switching.

CONCLUSIONS

Attitudes concerning the usefulness and rationale for use of depot antipsychotics differ by medical profession. Nursing and allied health workers are more likely than medical staff to note patient specific variables such as weight gain, injection site reactions, and patient preferences as problems with depots. The results also suggest that, in a community-based psychiatric care system, the use of newer and potentially better agents for the management of psychosis is impaired by resource limitations in service delivery as well as by educational disparities between the professions.

Clozapine, quetiapine and olanzapine among addicted schizophrenic patients: towards testable hypotheses

Although life prevalence of substance use disorders among patients with schizophrenia is close to 50%, few studies have been carried out to date to identify an integrated pharmacological treatment for this comorbidity. So far, the most promising results, that we report here, have been obtained with clozapine. To a lesser extent, quetiapine and olanzapine, both clozapine analogues, have also shown promising results. Further to these observations, the present paper critically reviews the advantages associated with clozapine, quetiapine and olanzapine, and their relevance to the treatment of addiction among schizophrenic patients. Six characteristics seem to distinguish clozapine, quetiapine and olanzapine from the first-generation antipsychotics: (1) acting preferentially on the reward system, these second-generation antipsychotics (mainly clozapine and quetiapine) induce almost no extrapyramidal symptoms; (2) quickly dissociating from D(2), theses drugs (mainly clozapine and quetiapine) seem not to induce dysphoria, unlike conventional antipsychotics like haloperidol;(3) these drugs (mainly clozapine) seem more effective in the treatment of negative symptoms than conventional antipsychotics; (4) because of a diversified activity on several serotoninergic and noradrenergic receptors, these drugs positively alter mood, which does not seem to be the case with conventional antipsychotics, except for flupenthixol; (5) these drugs have a positive impact on cognition, which is not the case with the first-generation antipsychotics; (6) unlike conventional antipsychotics, these drugs seem to have a moderate affinity for 5-HT(3), the receptor on which ondansetron, an anti-craving medication, acts.

Switching from conventional to novel antipsychotic drugs: results of a prospective naturalistic study

OBJECTIVE

We examined the long-term consequences of switching patients from conventional to novel antipsychotic drugs, from a patient's perspective.

METHODS

In a prospective, single-blinded, naturalistic study, a cohort of subjects (n=150) with schizophrenia or schizo-affective disorder (DSM-IV) were switched from conventional neuroleptic drugs to either risperidone (n=50), olanzepine (n=50) or quetiapine (n=50), and monitored for a period of 2 to 6 years. The ensuing natural history of transitions in treatments was charted, and the outcomes including symptoms, side effects, subjective tolerability of drugs and their impact on quality of life were documented with standardized rating scales.

RESULTS

Majority (85%) of the subjects benefited from a switch to the novel antipsychotic drugs, though some preferred to return to their original neuroleptic (8%), and others eventually required clozapine (7%) therapy. Novel antipsychotic drugs were significantly tolerated better, and had a positive impact on treatment-adherence, psychosocial functioning and quality of life. Among the novel drugs, risperidone was significantly better in improving negative symptoms, while olanzepine was particularly well tolerated and effective against comorbid anxiety and depressive symptoms. Patients treated with quetiapine reported fewer side effects, and showed a significantly greater improvement in neurocognitive deficits.

CONCLUSION

Novel antipsychotics emerged as the drug of choice in view of their overall effectiveness, though conventional neuroleptics and clozapine will continue to have a limited but distinct role in the management of schizophrenia. The challenge for clinicians lies in matching a patient's clinical and biochemical profile with that of a drug's pharmacological actions, in order to achieve optimum outcomes.

Patients' subjective experiences of antipsychotics: clinical relevance

The subjective experience of patients with schizophrenia who are receiving antipsychotic medication has been a neglected research area, as has the satisfaction of patients with their drug treatments. This is unfortunate, as satisfaction with treatment appears to be related strongly to the readiness of patients to take their medication as prescribed, and thereby to outcome. Patients' perceptions of their treatment do not appear to be related strongly to severity of illness or symptom ratings, although there are associations between perceptions of treatment and adverse effects. Surveys of patient experience with typical antipsychotics have tended to indicate high levels of dissatisfaction and perceived adverse effects. There have been a number of surveys of patients' perceptions of treatment with the atypical antipsychotics. These tend to accord with the expectation that a relative freedom from adverse effects with the atypical antipsychotics will be reflected in enhanced levels of satisfaction and perceived well-being. In general, these studies share a number of weaknesses, including small sample sizes, bias in selection of respondents, open treatment and lack of suitable comparator groups. In addition, many have adopted a cross-sectional, rather than longitudinal, approach and have relied on nonvalidated and perhaps idiosyncratic rating measures. Recently, there have been studies of better methodological quality. These, too, have indicated that patients regard the newer treatments more positively than the older regimens. In addition, there is now evidence that the various new-generation antipsychotics may be evaluated differently by patients.

Personal evaluation of transitions in treatment (PETiT):a scale to measure subjective aspects of antipsychotic drug therapy in schizophrenia

The paper describes the development and preliminary testing of a scale designed to capture aspects of subjective responses to, and tolerability of antipsychotic drugs, treatment adherence, and impact of antipsychotic drug therapy on the quality of life of individuals treated for schizophrenia. Using empirical study approaches and qualitative methods of data analysis, twelve themes were initially identified as relevant to the quality of life of individuals during antipsychotic drug therapy. Based on these dimensions, in the second phase, a 30 item self report questionnaire was constructed and field tested in a community based, heterogeneous sample of schizophrenic patients (n=335). The scale was easy to self-administer (in 2-5 min) and perceived as user-friendly by patients. Correlational analysis revealed a high internal consistency (Cronbach's alpha=0.92) and split half reliability (Spearman-Brown coefficient of 0.85). The scale scores were able to distinguish subjects with lower and higher rates of treatment adherence, and factor analysis confirmed the robustness of the original construct. Repeated administration of the scale in a sub-sample of clinically stable schizophrenic population (n=71) revealed a test-retest reliability coefficient of 0.97 (P<0.001); and repeat administration at quarterly intervals in a sample of patients receiving active treatment (n=54) indicated a significant increases in mean scores (t=6.2, df=53, P<0.005), suggesting that the scale was sensitive to changes in patients' clinical status. Based on these preliminary data, PETiT could be considered as a potentially useful tool for measuring client-centred outcomes in clinical practice, drug trials, quality assurance programs and interventional research involving schizophrenic patients.

Quality of life in schizophrenia: a review of the literature from 1995 to 2000

The measurement of the quality of life of patients diagnosed with psychiatric disorders has become central to evaluating the effectiveness of treatments offered by Australian mental health services. The importance of quality of life as an indicator of the outcomes of interventions has been reflected by a large body of research seeking to measure the impact of variables such as gender, ethnicity and duration of illness on the measurable quality of life of an individual diagnosed with schizophrenia. This study aims to review and synthesize the recent literature in which quality of life has been measured by the use of at least one quality of life instrument. It is concludes that while the measurement of quality of life is valuable as a measure of outcomes, it should be treated as only one means of doing so.

The impact of side-effects of antipsychotic agents on life satisfaction of schizophrenia patients: a naturalistic study

This study compared the impact of side-effects of antipsychotic treatment, clinical and psychosocial factors on the subjective quality of life (QOL) of hospitalized patients. We surveyed 161 patients meeting DSM-IV criteria for schizophrenia stabilized on conventional and atypical antipsychotic drugs using standardized measures of adverse events, psychopathology, psychosocial variables, and perceived QOL. We found that patients with adverse events reported less satisfaction with life domains of subjective feelings and general activities than asymptomatic patients. Patients treated with conventional and novel antipsychotic agents had comparable QOL ratings. Multiple regression analysis showed total variance in QOL ratings as follows: psychosocial factors, 20.9%; clinical symptoms and associated distress, 10.1%; adverse effects, 3.2%. Thus, medication side-effects influence subjective quality of life of schizophrenia inpatients significantly less than other clinical and psychosocial factors. Patient's subjective response to these events rather than their number is more predictive of QOL.

Subjective response to antipsychotic treatment and compliance in schizophrenia. A naturalistic study comparing olanzapine, risperidone and haloperidol (EFESO Study)

BACKGROUND

In order to compare the effectiveness of different antipsychotic drugs in the treatment of schizophrenia it is very important to evaluate subjective response and compliance in patient cohorts treated according to routine clinical practice.

METHOD

Outpatients with schizophrenia entered this prospective, naturalistic study when they received a new prescription for an antipsychotic drug. Treatment assignment was based on purely clinical criteria, as the study did not include any experimental intervention. Patients treated with olanzapine, risperidone or haloperidol were included in the analysis. Subjective response was measured using the 10-item version of the Drug Attitude Inventory (DAI-10), and treatment compliance was measured using a physician-rated 4 point categorical scale.

RESULTS

A total of 2128 patients initiated treatment (as monotherapy) with olanzapine, 417 with risperidone, and 112 with haloperidol. Olanzapine-treated patients had significantly higher DAI-10 scores and significantly better treatment compliance compared to both risperidone- and haloperidol-treated patients. Risperidone-treated patients had a significantly higher DAI-10 score compared to haloperidol-treated patients.

CONCLUSION

Subjective response and compliance were superior in olanzapine-treated patients, compared to patients treated with risperidone and haloperidol, in routine clinical practice. Differences in subjective response were explained largely, but not completely, by differences in incidence of EPS.

Treatment-refractory schizophrenia

Treatment-refractory schizophrenia is common. Refinements in pharmacologic and psychosocial treatments of schizophrenia offer the expectation of superior outcomes for this disadvantaged patient group. This article critically reviews those articles that were published during the year 2000 that address this treatment-refractory population.

Risperidone olanzapine drug outcomes studies in schizophrenia (RODOS): efficacy and tolerability results of an international naturalistic study

The Risperidone Olanzapine Drug Outcomes studies in Schizophrenia (RODOS) programme was an international series of naturalistic studies designed to evaluate drug use patterns and outcomes. RODOS consisted of retrospective chart reviews performed in patients who had been admitted to hospital and treated in 61 centres in nine countries. The analysed population consisted of 1901 patients with diagnoses of schizophrenia or schizoaffective disorder. The mean (SD) daily doses of risperidone and olanzapine were 5.3 (2.6) mg/day and 14.5 (5.1) mg/day, respectively. Patients treated with risperidone stayed an average of 3.8 days less in hospital compared to those receiving olanzapine (time to discharge was 43.6 days versus 47.4 days, respectively; P = 0.004). Risperidone was rated as effective in significantly more patients than olanzapine (84% versus 79%; P = 0.01). The time to onset of efficacy was significantly shorter with risperidone than with olanzapine (P < 0.001). The numbers of adverse events in the two treatment groups were not significantly different (13% risperidone, 11% olanzapine; P = 0.1). Correcting for small but statistically significant baseline differences between the two treatment groups did not produce a substantive change in the magnitude or significance of any outcome parameter. In conclusion, the clinical outcomes reported by RODOS suggest that risperidone may be more effective as a first-line therapy drug for schizophrenia than olanzapine.

Asymptomatic QTc prolongation associated with quetiapine fumarate overdose in a patient being treated with risperidone

We report a patient who ingested a 2000-mg overdose of quetiapine fumarate (Seroquel). Her maintenance medications also included risperidone, venlafaxine, topiramate, and clonazepam. On presentation, she was drowsy, but had no other significant CNS signs and no cardiac symptoms or abnormal physical signs. Approximately 2 h after the quetiapine ingestion, an electrocardiogram (ECG) showed normal sinus rhythm at 95 beats/min with a corrected QT (QTc) interval of 537 ms (upper limit of normal = 440 ms). Plasma quetiapine concentration at that time was 1800 ng/ml. Continuous ECG monitoring for the subsequent 18 h did not reveal any episode of ventricular tachycardia. A 12-lead ECG 18 h post-overdose was normal with a QTc interval of 401 ms and the corresponding plasma quetiapine concentration was 160 ng/ml. She made an uneventful medical recovery from the toxic ingestion. This case suggests that when patients overdose on quetiapine while taking therapeutic doses of risperidone, such overdoses, even if not massive, can cause considerable QTc interval prolongation. We recommend that quetiapine overdose patients undergo continuous ECG monitoring for 12-18 h post-ingestion.