Suicide and schizophrenia

Ethnicity and suicide attempt: analysis in bipolar disorder and schizophrenia

BACKGROUND

Evidence is mixed as to whether White Europeans are at a higher risk for suicide attempts or completions compared to other ethnic groups. The present analysis assessed whether risk for suicide attempt was associated with White European ethnicity in 907 subjects with schizophrenia or bipolar disorder.

METHODS

Subjects were diagnosed using the Structured Clinical Interview for DSM-IV, and ethnicity was determined by self-report. Subjects were recruited from psychiatric care centers in Toronto, Canada. Logistic regression correcting for clinical covariates like age, gender and diagnosis, was used in this study.

RESULTS

We found no difference in suicide attempter status in white and non-white subjects who were diagnosed with schizophrenia and bipolar disorder.

CONCLUSION

Our study does not support the evidence that White-European patients in North America are at higher risk for suicide attempt compared to non-European descent subjects. However, this result has to be replicated in larger studies in patients with these disorders.

Suicide attempts in schizophrenic patients: clinical variables

INTRODUCTION

Schizophrenia is associated with a significant risk of suicide: 40-50% of schizophrenic patients report suicidal ideation at some point in their lives, and 4-13% eventually commit suicide. In order to be able to predict and prevent suicide in schizophrenic patients, it is necessary to investigate and characterise suicide victims who meet the criteria for psychotic disorders and risk factors.

METHODS

The aim of this retrospective study was to verify the associations between suicide attempts (SAs) and the demographic and clinical variables of 106 patients who met the DSM-IV-TR criteria for schizophrenia. The patients were divided into two groups on the basis of the presence/absence of lifetime suicide attempts, and their main demographic and clinical characteristics were analysed and compared.

RESULTS

The patients with a history of SAs frequently had a duration of untreated psychosis (DUP) of ≥1 year (chi-squared test=9.984, df=1, p=0.0016). They also showed significant associations with the presence of a depressive dimension (chi-squared test=4.439, df=1, p=0.0351), hospitalisations before SAs (chi-squared test=25.515, df=1, p <0.001), and a family history of psychiatric disorders (chi-squared test=12.668, df=2, p=0.0018) or suicidal behaviours (chi-squared test=18.241, df=2, p=0.0001). Finally, they were more frequently prescribed typical antipsychotic agents.

CONCLUSIONS

The severity of psychiatric symptoms indicates a high risk of suicide in schizophrenic patients. Further prospective studies of larger samples should investigate the role of early interventions and atypical antipsychotic treatment in reducing the risk.

Are structural brain abnormalities associated with suicidal behavior in patients with psychotic disorders?

Suicide represents a major health problem world-wide. Nevertheless, the understanding of the neurobiological underpinnings of suicidal behavior remains far from complete. We compared suicide attempters to non-attempters, and high vs. low lethality attempters, to identify brain regions associated with suicidal behavior in patients with psychotic disorders. 489 individuals with schizophrenia, schizoaffective disorder, or psychotic bipolar disorder I and 262 healthy controls enrolled in the B-SNIP study were studied. Groups were compared by attempt history and the highest medical lethality of previous suicide attempts. 97 patients had a history of a high lethality attempt, 51 of a low lethality attempt and 341 had no attempt history. Gray matter volumes were obtained from 3T structural MRI scans using FreeSurfer. ANCOVAs were used to examine differences between groups, followed by Hochberg multiple comparison correction. Compared to non-attempters, attempters had significantly less gray matter volume in bilateral inferior temporal and superior temporal cortices, left superior parietal, thalamus and supramarginal regions, right insula, superior frontal and rostral middle frontal regions. Among attempters, a history of high lethality attempts was associated with significantly smaller volumes in the left lingual gyrus and right cuneus. Compared to non-attempters, low lethality attempters had significant decreases in the left supramarginal gyrus, thalamus and the right insula. Structural brain abnormalities may distinguish suicide attempters from non-attempters and high from low lethality attempters among individuals with psychotic disorders. Regions in which differences were observed are part of neural circuitries that mediate inhibition, impulsivity and emotion, visceral, visual and auditory perception.

Prevalence, demographic and clinical correlates of suicide attempts in Chinese medicated chronic inpatients with schizophrenia

The high prevalence of suicide in schizophrenia may be related to its demographic and clinical characteristics. Because suicide prevalence and its associations with clinical variables are less well characterized in Chinese than European patients with schizophrenia, we assessed the suicide attempts in 520 Chinese inpatients with schizophrenia. The suicide attempt data were collected from medical case notes and interviews with the patients and their family members. Patients were rated on the Positive and Negative Syndrome Scale (PANSS), the Simpson and Angus Extrapyramidal Symptom Rating Scale (SAES), and the Abnormal Involuntary Movement Scale (AIMS). Smoking severity was evaluated using clinician-administered questionnaires and the Fagerstrom Test for Nicotine Dependence (FTND). We found a suicide attempt rate of 9.2% in these schizophrenic inpatients. The attempters were single, had a significantly younger age but more hospitalizations, had higher depressive symptoms, and began smoking at an earlier age, smoked more cigarettes each day and had higher FTND total scores than patients without suicide attempts. The logistic regression analysis also indicated that suicide attempts were associated with the number of hospitalizations, depressive symptoms and FTND total scores. These results suggest that Chinese inpatients with schizophrenia attempt suicide more often than the general population. Further, some demographic and clinical variables are risk factors for suicide attempts in schizophrenia.

Command hallucinations and clinical characteristics of suicidality in patients with psychotic spectrum disorders

BACKGROUND

Suicide is a leading cause of death among patients with psychotic illnesses. Several researchers have suggested that specific illness symptoms may better predict suicide risk. An ability to identify high-risk patients would aid clinicians in instituting risk-reduction measures to decrease suicidal behavior in this population.

METHODS

We examined the association between psychotic symptoms and suicidal behavior among 148 inpatients with psychosis using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), the Scale for the Assessment of Positive Symptoms, and the Positive and Negative Syndrome Scale. Measures of suicidality were obtained from risk assessment clinical data routinely collected during intake.

RESULTS

For individuals with a DSM-IV diagnosed psychotic spectrum disorder, 40% (n=57) endorsed suicidal ideation on admission and 23% (n=33) endorsed a recent suicide attempt. The presence of command auditory hallucinations was significantly associated with active suicidal ideation across diagnostic categories. Similarly, a greater percentage of patients endorsed a recent suicide attempt in the presence of command hallucinations. These correlations with CAH are noteworthy, as we found no significant difference in the prevalence of SI among those with and without general auditory hallucinations (42.5% and 37.7%).

CONCLUSIONS

The presence of command auditory hallucinations, in particular, but not auditory hallucinations, in general, was associated with suicidal behavior. These results indicate that command auditory hallucinations may identify or even place psychotic individuals at greater risk for acute, suicidal behavior--these symptoms should be the target of immediate and aggressive characterization and treatment.

The Stigma subscale of the Consumer Experiences of Stigma Questionnaire (CESQ): a psychometric evaluation in Polish psychiatric patients

OBJECTIVE

There is a scarcity of well validated measures of the subjective experience of the stigma of mental illness. The aim of this paper was to evaluate the psychometric properties of the Stigma subscale of the Consumer Experiences of Stigma Questionnaire (CESQ).

METHODS

A secondary analysis of the data from two cross-sectional studies using the CESQ was conducted in order to assess the factor structure, internal consistency and concurrent validity of the Stigma subscale. Sample 1 included 373 diagnostically heterogeneous patients (65% had psychotic disorders) and Sample 2 included 136 patients with schizophrenia.

RESULTS

Since none of the factor models of the original 9-item scale was satisfactory, it was shortened by removing two psychometrically weakest items. The abbreviated 7-item scale proved to be a one-dimensional instrument, with good estimates of internal consistency. Its concurrent validity was partly confirmed by demonstrating negative correlation with quality of life and positive correlations with self-rated psychopathological symptoms. However, contrary to theoretical expectations, the stigma score was not associated with global functioning and clinician-rated symptoms.

CONCLUSIONS

The psychometric properties of the Stigma subscale of the CESQ may be improved by shortening the instrument. Although the reliability and validity of the abbreviated version were partly established, further research is needed to explore in particular its test-retest reliability and concurrent validity.

Onset Pattern and Long-Term Prognosis in Schizophrenia: 10-Year Longitudinal Follow-Up Study

BACKGROUND

Although the duration of untreated psychosis (DUP) plays an important role in the short-term prognosis of patients with schizophrenia, their long-term prognosis generally is not determined by DUP alone. It is important to explore how other clinical factors in the early stage are related to DUP and consequent disease courses.

METHODS

A total of 664 patients with untreated psychosis were surveyed for this study. At the first examination, we divided them into the severe positive symptoms cases (SC) or the less severe cases (NonSC) and compared the prognosis among the two groups after a 10-year follow-up. In all, 113 patients in the SC group and 43 patients in the NonSC group were follow-up completers.

RESULTS

Whereas DUP was not different between the two groups, patients with nonacute onset in both groups had significantly longer DUP than those in patients with acute onset. For all clinical measures, there was no difference in prognosis between the two groups or among the four groups classified by mode of onset (MoO) and initial severity of positive symptoms. However, the degree of improvement of global assessment of functioning (GAF) was significantly smaller in the NonSC-nonacute group than in the SC-acute and SC-nonacute groups.

CONCLUSIONS

These results suggest that neither DUP nor MoO alone necessarily affects the initial severity of positive symptoms. Moreover, it is possible that patients with low impetus of positive symptoms onset within long DUP experience profound pathologic processes. Therefore, the current study results indicated that long DUP and nonacute onset were related to poor long-term prognosis, regardless of initial positive symptoms.

Atypical antipsychotics in the treatment of depressive and psychotic symptoms in patients with chronic schizophrenia: a naturalistic study

Objectives. The aim of this naturalistic study was to investigate whether treatment with clozapine and other atypical antipsychotics for at least 2 years was associated with a reduction in psychotic and depressive symptoms and an improvement in chronic schizophrenia patients' awareness of their illness. Methods. Twenty-three adult outpatients (15 men and 8 women) treated with clozapine and 23 patients (16 men and 7 women) treated with other atypical antipsychotics were included in the study. Psychotic symptoms were evaluated using the Positive and Negative Syndrome Scale (PANSS), depressive symptoms were assessed with the Calgary Depression Scale for Schizophrenia (CDSS), and insight was assessed with the Scale to Assess Unawareness of Mental Disorder (SUMD). Results. The sample as a whole had a significant reduction in positive, negative, and general symptoms, whereas the reduction in depression was significant only for patients with CDSS scores of 5 and higher at the baseline. At the follow-up, patients treated with other atypical antipsychotics reported a greater reduction in depression than patients treated with clozapine, but not when limiting the analyses to those with clinically relevant depression. Conclusions. Atypical antipsychotics may be effective in reducing psychotic and depressive symptoms and in improving insight in patients with chronic schizophrenia, with no differences in the profiles of efficacy between compounds.

Akathisia and suicidal ideation in first-episode schizophrenia

Patients with first-episode schizophrenia (FES) are known to be notably sensitive for developing extrapyramidal adverse effects, but the relation of akathisia and suicidal ideation has rarely been studied. The current report is an ongoing analysis of an 8-week double-blind randomized controlled multicenter trial in 289 FES, comparing risperidone and haloperidol. Assessments were conducted weekly and included the Hillside Akathisia Scale and 21-item Hamilton Depression Rating Scale ratings. Suicidal ideation was significantly associated with clinician observed akathisia, depressed mood, younger age, and use of propranolol. The allocated treatment, anxiety, and nervousness had no influence. The present findings suggest a promoting effect of akathisia on suicidal ideation can not be ruled out in patients with FES.

Functional status and all-cause mortality in serious mental illness

Background

Serious mental illness can affect many aspects of an individual’s ability to function in daily life. The aim of this investigation was to determine if the environmental and functional status of people with serious mental illness contribute to the high mortality risk observed in this patient group.

Methods

We identified cases of schizophrenia, schizoaffective and bipolar disorder aged ≥15 years in a large secondary mental healthcare case register linked to national mortality tracing. We modelled the effect of activities of daily living (ADLs), living conditions, occupational and recreational activities and relationship factors (Health of the Nation Outcome Scale [HoNOS] subscales) on all-cause mortality over a 4-year observation period (2007–10) using Cox regression.

Results

We identified 6,880 SMI cases (242 deaths) in the observation period. ADL impairment was associated with an increased risk of all-cause mortality (adjusted HR 1.9; 95% CI 1.3–2.8; p = 0.001, p for trend across ADL categories = 0.001) after controlling for a broad range of covariates (including demographic factors, physical health, mental health symptoms and behaviours, socio-economic status and mental health service contact). No associations were found for the other three exposures. Stratification by age indicated that ADLs were most strongly associated with mortality in the youngest (15 to <35 years) and oldest (≥55 years) groups.

Conclusions

Functional impairment in people with serious mental illness diagnoses is a marker of increased mortality risk, possibly in younger age groups as a marker of negative symptomatology.

A cross-sectional study of the relationships between illness insight, internalized stigma, and suicide risk in individuals with schizophrenia

BACKGROUND

Suicide is the major cause of premature death among individuals with schizophrenia. Ironically, one factor that heightens suicide risk is insight into mental illness. Little is known, however, about how insight contributes to suicidality. Recent evidence suggests that negative outcomes related to insight might depend on whether or not the individual accepts the stigmatizing beliefs about the mental illness.

OBJECTIVE

The present study examined the interactive effects of insight and internalized stigma on suicide risk in individuals with schizophrenia. We hypothesized that insight into mental illness and internalized stigma would increase suicide risk and that internalized stigma would moderate the effect of insight on suicide risk.

DESIGN AND PARTICIPANTS

A cross-sectional design was used in this study. A convenience sample of 200 individuals with schizophrenia was recruited from an outpatient clinic in the Eastern catchment area in Alexandria, Egypt.

METHODS

Eligible study participants were individuals with an illness duration not exceeding ten years, currently in outpatient treatment and follow-up, and post-acute or in a stable phase of their disorder. Individuals provided signed consent to participate and were interviewed to assess suicide risk, insight, internalized stigma of mental illness and depression.

RESULTS

Slightly more than 38% of the study participants were classified as having a severe suicide risk. As predicted, suicide risk was positively associated with insight (r=.55, p<.001), internalized stigma (r=.79, p<.001), and depression (r=.78, p<.001). However, the influence of insight was not significant after controlling for covariates in the regression model (β=-.02, ns). Internalized stigma and depression independently predicted suicide risk, explaining 74% of variance in suicide risk, F(change) (6, 191)=11.54, p<.001. Greater insight was significantly linked to increased levels of internalized stigma (r=.59, p<.001) and depression (r=.61, p<.001). Internalized stigma did not moderate the influence of insight on suicide risk.

CONCLUSION

The present study draws attention to the robust influence of internalized stigma in increasing suicide risk and suggests clinical approaches for managing internalized stigma and suicide risk among individuals with schizophrenia.

Contributors to suicidality in rural communities: beyond the effects of depression

BACKGROUND

Rural populations experience a higher suicide rate than urban areas despite their comparable prevalence of depression. This suggests the identification of additional contributors is necessary to improve our understanding of suicide risk in rural regions. Investigating the independent contribution of depression, and the impact of co-existing psychiatric disorders, to suicidal ideation and suicide attempts in a rural community sample may provide clarification of the role of depression in rural suicidality.

METHODS

618 participants in the Australian Rural Mental Health Study completed the Composite International Diagnostic Interview, providing assessment of lifetime suicidal ideation and attempts, affective disorders, anxiety disorders and substance-use disorders. Logistic regression analyses explored the independent contribution of depression and additional diagnoses to suicidality. A receiver operating characteristic (ROC) analysis was performed to illustrate the benefit of assessing secondary psychiatric diagnoses when determining suicide risk.

RESULTS

Diagnostic criteria for lifetime depressive disorder were met by 28% (174) of the sample; 25% (154) had a history of suicidal ideation. Overall, 41% (63) of participants with lifetime suicidal ideation and 34% (16) of participants with a lifetime suicide attempt had no history of depression. When lifetime depression was controlled for, suicidal ideation was predicted by younger age, being currently unmarried, and lifetime anxiety or post-traumatic stress disorder. In addition to depression, suicide attempts were predicted by lifetime anxiety and drug use disorders, as well as younger age; being currently married and employed were significant protective factors. The presence of comorbid depression and PTSD significantly increased the odds of reporting a suicide attempt above either of these conditions independently.

CONCLUSIONS

While depression contributes significantly to suicidal ideation, and is a key risk factor for suicide attempts, other clinical and demographic factors played an important role in this rural sample. Consideration of the contribution of factors such as substance use and anxiety disorders to suicidal ideation and behaviours may improve our ability to identify individuals at risk of suicide. Acknowledging the contribution of these factors to rural suicide may also result in more effective approaches for the identification and treatment of at-risk individuals.

Relationships between stereotyped beliefs about mental illness, discrimination experiences, and distressed mood over 1 year among persons with schizophrenia enrolled in rehabilitation

PURPOSE

Research suggests stereotype endorsement or self-stigma serves as a barrier to functioning and well-being among persons with schizophrenia. Little is known about how stable self-stigma is and whether it is linked over time with related constructs such as discrimination experiences and psychological distress.

METHODS

Stereotype endorsement and discrimination experiences were assessed using the Internalized Stigma of Mental Illness Scale and psychological distress was assessed using the Emotional Discomfort component of the Positive and Negative Syndrome Scale, at three points in time across 1 year.

RESULTS

Path analyses indicated that the constructs of stereotype endorsement and discrimination experiences are stable over periods of 5-7 months and may fluctuate over 12 months. Further, the constructs of stereotype endorsement and discrimination experiences were related to one another concurrently, but analyses failed to detect a relationship over time. Neither construct was related to psychological distress over time.

CONCLUSIONS

Self-stigma is a stable construct in the short term, and is distinct from related constructs such as discrimination experiences and psychological distress.

Insight in schizophrenia and risk of suicide: a systematic update

BACKGROUND

Suicide has been shown to represent the major single cause of premature death among patients with schizophrenia spectrum disorders. Insight has been proposed to increase such risk. However, this subject has not been sufficiently investigated, and inconclusive results have been reported.

OBJECTIVE

The objective of this study is to systematically examine the role of insight in the risk of suicide attempts and completed suicide among patients with schizophrenia and related disorders.

METHOD

Articles assessing insight and suicidality in patients with schizophrenia spectrum disorders published between 1977 and 2010 were reviewed. A MEDLINE search strategy was used to identify studies using keywords. Application of meta-analytic techniques to selected studies was not possible because of important methodological differences between them.

RESULTS

Fifteen studies met predetermined selection criteria. Ten failed to demonstrate a positive association between insight and risk for suicide.

DISCUSSION

There is little evidence to support the suggestion that insight may represent a risk factor for suicide in patients with schizophrenia. If there is an association between such risk and insight, it appears to be mediated by other variables such as depression and, above all, hopelessness. Further studies with larger samples and longer follow-up periods in naturalistic conditions, in which insight should be evaluated from a multidimensional approach, are required to analyze this issue in depth, given the crucial implications that it may have on the development of a model for suicide prevention in schizophrenia.

Associations between symptoms and all-cause mortality in individuals with serious mental illness

OBJECTIVE

To determine if aggression, hallucinations or delusions, and depression contribute to excess mortality risk observed in individuals with serious mental illness (SMI).

METHODS

We identified SMI cases (schizophrenia, schizoaffective and bipolar disorder) aged≥15years in a large secondary mental healthcare case register linked to national mortality tracing. We modelled the effect of specific symptoms (HoNOS subscales) on all-cause mortality using Cox regression.

RESULTS

We identified 6880 SMI cases (242 deaths) occurring 2007-2010. Bipolar disorder was associated with reduced mortality risk compared to schizophrenia (HR 0.7; 95% CI 0.4-0.96; p=0.028). Mortality was not significantly associated with hallucinations and delusions or overactive-aggressive behaviour, but was associated with physical illness/disability. There was a positive association between mortality and subclinical depression among individuals with schizophrenia (HR 1.5; 1.1-2.2; p=0.019) but a negative association with subclinical and more severe depression among those with schizoaffective disorder (HR 0.1; 0.02-0.4; p=0.001 and 0.3; 0.1-0.8; p=0.021, respectively).

CONCLUSIONS

The recognised increased risk of mortality in SMI did not appear to be influenced by severity of hallucinations, delusions, or overactive-aggressive behaviour. Physical illness and lifestyle may need to be addressed and the relationship between depression and mortality requires further investigation.

Suicides during 7 years among a catchment area cohort of patients with psychoses

OBJECTIVE

To investigate a series of consecutive suicides at a psychosis clinic by using a psychological autopsy technique.

METHOD

The clinic serves an adult population of 225,000 individuals, of whom 0.5% have regular contact with the clinic. During a 7½-year period, 23 men and nine women committed suicide, which corresponds to an odds ratio of 14.

RESULTS

Most patients were schizophrenic, and 24 were outpatients. Suicide methods were violent in all but two cases. Nineteen had a history of at least one suicide attempt, and 24 were known to have had suicidal ideation. More than half had no social contacts over the last year except with psychiatric staff. The median time between the last contact with the psychiatric services and the suicide was 4 days. No warning signs were noted. At the time of death, 3 of the 24 who were prescribed antipsychotics, and none of the 10 who were prescribed antidepressants had plasma levels of the corresponding drug.

CONCLUSION

Findings of special interest are the lack of forewarnings and the poor drug compliance. Patients appear to have played "business as usual" with the care-givers, and did it well. Is it a sign of health and despair, or illness?

Significant relationship between lifetime alcohol use disorders and suicide attempts in an Australian schizophrenia sample

OBJECTIVE

Suicide and attempted suicide are common in individuals with schizophrenia, and evidence exists for a link between substance use disorders and suicidality in this disorder. However, alcohol has not been consistently implicated. We examined the relationship between substance use disorders and suicide attempts in schizophrenia.

METHODS

We recruited a schizophrenia sample in Australia (n = 821) for genetic analyses. We analysed demographic and clinical variables, including substance use disorders, and their relationship to suicide attempts using generalised equation modelling.

RESULTS

A significant association was identified between lifetime alcohol abuse/dependence and suicide attempts (OR = 1.66; 95% CI, 1.23 to 2.24; p = 0.001) after adjustment for potential confounders, but not between cannabis abuse/dependence and suicide attempts, nor between other illicit drug abuse/dependence and suicide attempts. Polysubstance abuse/dependence was also not implicated.

CONCLUSIONS

These results suggest that the presence of alcohol abuse/dependence may be a risk factor for suicide attempts in individuals with schizophrenia, independent of comorbid substance abuse/dependence.

Mindfulness in the Treatment of Suicidal Individuals

Suicidal behavior is exhibited by a diverse population of individuals and spans many diagnostic categories. In order to develop effective prevention and treatment programs, it is important to identify transdiagnostic processes that impact the many pathways to suicidality, are amenable to intervention, and affect clinical outcomes when modified. A growing body of data suggests that experiential avoidance, or the tendency to escape or avoid unwanted psychological experiences, even when such efforts cause harm, may represent one such universal process. This article reviews theory and evidence that support mindfulness and psychological acceptance as a means to target experiential avoidance in suicidal clients and thereby reduce the risk of suicide. The article also provides two case examples of the application of mindfulness to suicidality and discusses how mindfulness may help clinicians in managing the stress associated with treating suicidal clients.

Cost-effectiveness of several atypical antipsychotics in orally disintegrating tablets compared with standard oral tablets in the treatment of schizophrenia in the United States

OBJECTIVE

Although the use of innovative drug delivery systems, like orally disintegrating antipsychotic tablets (ODT), may facilitate medication adherence and help reduce the risk of relapse and hospitalization, no information is available about the comparative cost-effectiveness of standard oral tablets (SOT) vs ODT formulations in the treatment of schizophrenia. This study compared the cost-effectiveness of olanzapine ODT and olanzapine SOT in the usual treatment of outpatients with schizophrenia from a US healthcare perspective. The study also compared olanzapine ODT with risperidone and aripiprazole, two other atypical antipsychotics available in both ODT and SOT formulations.

METHODS

Published medical literature and a clinical expert panel were used to populate a 1-year Monte Carlo Micro-simulation model. The model captures clinical and cost parameters including adherence levels, treatment discontinuation by reason, relapse with and without inpatient hospitalization, quality-adjusted life years (QALYs), treatment-emergent adverse events, healthcare resource utilization, and associated costs. Key outcomes were total annual direct cost per treatment, QALY, and incremental cost-effectiveness (ICER) per 1 QALY gained.

RESULTS

Based on model projections, olanzapine ODT therapy was more costly ($9808 vs $9533), but more effective in terms of a lower hospitalization rate (15% vs 16%) and better QALYs (0.747 vs 0.733) than olanzapine SOT therapy. Olanzapine ODT was more cost-effective than olanzapine SOT (ICER: $19,643), more cost-effective than risperidone SOT therapy (ICER: $39,966), and dominant (meaning less costly and more effective) than risperidone ODT and aripiprazole in ODT or SOT formulations.

LIMITATIONS

Lack of head-to-head randomized studies comparing the three studied atypical antipsychotics required making input assumptions that need further study.

CONCLUSIONS

This micro-simulation found that the utilization of olanzapine ODT for the treatment of schizophrenia is predicted to be more cost-effective than any other ODT or SOT formulations of the studied atypical antipsychotic medications.

In patients with schizophrenia, symptoms improvement can be uncorrelated with quality of life improvement

OBJECTIVES

Quality of life has been found to be associated with symptoms in patients with schizophrenia. Nevertheless, the mechanism that underlies this association is still unclear. The objective of this paper is to prospectively evaluate the quality of life of patients with schizophrenia in relation to the concurrent evolution of their symptoms, their expectations and their perceived position in life.

METHODS

Participants included 306 outpatients with schizophrenia who were interviewed at baseline, 6 and 12 months, about their quality of life (Outcome revealed by Preference in Schizophrenia, OPS) and symptoms (Positive and Negative Syndrome Scale, PANSS).

RESULTS

Quality of life relative to subject expectations remained stable over time. A decrease in symptoms was correlated to an increase in both expectations and perceived position in life but did not correlate to quality of life.

CONCLUSION

The level of expectations seems to play a major role in the subjective assessment of quality of life in patients with schizophrenia. Symptom improvement is not necessarily associated with quality of life improvement relative to subject expectations. Caregivers should be aware of this result so as to deal with possible disappointments in patients receiving a new efficient treatment.

Influencing factors and predictors of early improvement in the acute treatment of schizophrenia and schizophrenia spectrum disorder

BACKGROUND

To examine the influencing factors and predictors of early improvement in schizophrenia patients.

METHODS

370 patients suffering from a schizophrenia spectrum disorder were examined within a naturalistic multicenter study. Early improvement was defined as a ≥30% PANSS total score reduction within the first two treatment weeks, response as a ≥50% improvement of the PANSS total score from admission to discharge and remission according to the consensus remission criteria. Baseline and course-related variables such as positive, negative and depressive symptoms, side effects, functioning and subjective well-being were examined regarding their explanatory value for early improvement.

RESULTS

46% of the patients were identified to be early improvers. Of these, 77% became treatment responder at discharge and 74% achieved the consensus remission criteria. Amongst others, early improvers were significantly more often first-episode patients (p = 0.009), with a significantly shorter duration of current episode (p = 0.024) and a shorter duration of the illness (p = 0.0094). A higher PANSS positive subscore (p = 0.0089), a higher score in the Strauss-Carpenter-Prognostic Scale (SCPS) (p < 0.0001), less extrapyramidal side effects (p = 0.0004) at admission and the development of less extrapyramidal side effects within the first two treatment weeks (p = 0.0013) as well as a duration of current episode of ≤6 months (p = 0.0373) were identified to be significant predictors of early improvement.

CONCLUSION

Early improvement is associated with less illness chronicity and seems to be independent of the type of antipsychotic and the antipsychotic dosage applied. The SCPS was found to be a valuable tool to detect early improvers already at the initiation of antipsychotic treatment.

An epidemiologic and clinical overview of medical and psychopathological comorbidities in major psychoses

The presence of comorbidity in major psychoses (e.g., schizophrenia and psychotic subtypes of bipolar disorder and major depressive disorder) seems to be the rule rather than the exception in both DSM-IV and ICD-10. Examining comorbidity in major psychoses, however, requires an investigation into the different levels of comorbidity (either full-blown and subsyndromal) which should be analyzed in both psychopathological and medical fields. On one hand, the high prevalence of psychiatric comorbidity in major psychoses may be the result of the current nosographic systems. On the other hand, it may stem from a common neurobiological substrate. In fact, comorbid psychopathological conditions may share a biological vulnerability, given that dysfunction in specific brain areas may be responsible for different symptoms and syndromes. The high rates of comorbidity in major psychoses require targeted pharmacological treatments in order to effectively act on both the primary diagnosis and comorbid conditions. Nevertheless, few controlled trials in comorbid major psychoses had been carried out and treatment recommendations in this field have mostly an empirical basis. The aim of the present article is to provide a comprehensive and updated overview in relation to epidemiological and clinical issues of comorbidity in major psychoses.

A comparative study on quality of life of patients of schizophrenia with and without depression

Depression in schizophrenia has been recognized as one of the important factors influencing the Quality of Life (QOL). For this study 60 patients with a clinical diagnosis of schizophrenia as per ICD-10 (DCR version) were divided into two groups (with and without depression) on the basis of their score on Calgary Depression Rating Scale for Schizophrenia (CDSS). Thereafter, all patients were assessed on Positive and Negative Syndrome Scale for Schizophrenia (PANSS) for psychopathology, on Lehman Quality of Life Interview (QOLI)-brief version for QOL, on World Health Organization Disability Assessment Schedule-II (WHODAS-II) for disability, on UKU Side Effect Rating Scale for side effects of drugs and on Social Support Questionnaire (SSQ) for perceived social support. The two (depressed and non-depressed schizophrenia) groups differed significantly on symptoms of general psychopathology of PANSS and disability as per WHODAS-II, with the depressed group scoring higher. In the total sample, positive symptoms and the symptoms of general psychopathology of PANSS had a strong negative correlation with all three (subjective, objective and combined) domains of QOL, whereas, disability and medication side effects had a negative correlation with subjective and combined domains of QOL. CDSS total score did not significantly correlate with QOL. General psychopathology symptoms of PANSS emerged as the sole significant predictor of subjective and combined QOL, while positive symptoms of PANSS emerged as the sole predictor of objective QOL. Hence, it can be concluded that general psychopathology on PANSS had significant effect whereas depression as rated on CDSS had no significant effect on QOL in patients with schizophrenia. Treatments to improve QOL in schizophrenia should focus on symptoms of general psychopathology of PANSS.

Carbon dioxide induction of panic anxiety in schizophrenia with auditory hallucinations

Panic is commonly co-morbid with schizophrenia. Panic may emerge prodromally, contribute to specific psychotic symptoms, and predict medication response. Panic is often missed due to agitation, impaired cognition, psychotic symptom overlap and limited clinician awareness. Carbon dioxide exposure has been used reliably to induce panic in non-psychotic panic subjects, but has not been systematically studied in schizophrenia. Eight inpatients with schizophrenia, recent auditory hallucinations, none preselected for panic, all on antipsychotic medication, received a structured Panic and Schizophrenia Interview (PaSI), assessing DSM-IV panic symptoms concurrent with paroxysmal auditory hallucinations. On that interview, all eight subjects reported panic concurrent with auditory hallucinations. At one sitting, subjects were exposed, in random order, to 35% carbon dioxide and to placebo room air, blinded to condition. All subjects experienced panic to carbon dioxide, one with limited symptoms. Only one subject panicked to placebo. One subject (one of only two without antipanic medication) had paroxysmal voices concurrent with induced panic. With added adjunctive clonazepam, that patient had marked clinical improvement and no response to carbon dioxide re-challenge. This first systematic examination offers preliminary evidence that carbon dioxide safely induces panic symptoms in schizophrenia. Panic may be prevalent and pathophysiologically significant in schizophrenia with auditory hallucinations.

Evidence-based psychotherapy for schizophrenia: 2011 update

Many patients with schizophrenia have psychological distress and receive some form of psychotherapy. Several different psychotherapeutic approaches for schizophrenia have been developed and studied. Of these approaches, cognitive behavior therapy (CBT) has the strongest evidence base and has shown benefit for symptom reduction in outpatients with residual symptoms. In addition to CBT, other approaches include compliance therapy, personal therapy, acceptance and commitment therapy, and supportive therapy. Although usually studied as distinct approaches, these therapies overlap with each other in their therapeutic elements. Psychotherapy for schizophrenia continues to evolve with the recent advent of such approaches as metacognitive therapy, narrative therapies, and mindfulness therapy. Future research may also consider three different goals of psychotherapy in this patient population: to provide emotional support, to enhance functional recovery, and to alter the underlying illness process.

Elucidating biological risk factors in suicide: role of protein kinase A

Suicide is a major public health concern. Although there have been several studies of suicidal behavior that focused on the roles of psychosocial and sociocultural factors, these factors are of too little predictive value to be clinically useful. Therefore, research on the biological perspective of suicide has gained a stronghold and appears to provide a promising approach to identify biological risk factors associated with suicidal behavior. Recent studies demonstrate that an alteration in synaptic and structural plasticity is key to affective illnesses and suicide. Signal transduction molecules play an important role in such plastic events. Protein kinase A (PKA) is a crucial enzyme in the adenylyl cyclase signal transduction pathway and is involved in regulating gene transcription, cell survival, and plasticity. In this review, we critically and comprehensively discuss the role of PKA in suicidal behavior. Because stress is an important component of suicide, we also discuss whether stress affects PKA and how this may be associated with suicidal behavior. In addition, we also discuss the functional significance of the findings regarding PKA by describing the role of important PKA substrates (i.e., Rap1, cyclic adenosine monophosphate response element binding protein, and target gene brain-derived neurotrophic factor). These studies suggest the interesting possibility that PKA and related signaling molecules may serve as important neurobiological factors in suicide and may be relevant in target-specific therapeutic interventions for these disorders.

Suicide risk in first episode psychosis: a selective review of the current literature

Many studies have confirmed that the risk of suicide in patients with first-episode psychosis (FEP) is high, and high rates of premature mortality, particularly from suicide, may occur in the early phases of schizophrenia. However, suicide rates are difficult to measure in FEP patients, even in carefully defined samples, and there is relatively little specific information about the risk of suicide at illness onset or retrospectively concerning the untreated psychotic period. This selected review of the literature investigates suicidal behaviour with particular regard to severe suicidality (plans and attempts) and risk factors associated with suicide in FEP patients. A search was performed to identify all papers and book chapters during the period 1965-2010, and approximately 100 studies met the inclusion criteria. Most of evidence suggests that risk of suicidal behaviour is relatively high in FEP patients. The research reports highlight the need for universal, comprehensive, public mental health interventions aimed, not only toward early detection, but also toward the rapid engagement in treatment of people with psychoses. These interventions should include an adequate assessment of suicidal behaviour in patients with FEP, and an examination of the efficacy of specific components of the interventions.

Suicidal behavior in the older patient with schizophrenia

Little is known about treating elderly suicidal patients with schizophrenia. The purpose of this article is to review the literature dealing with this population and to discuss what is required to advance this field. Most available studies from middle-aged and older individuals suggest that risk factors include hopelessness, lower quality of life, past traumatic events, depressive symptoms, lifetime suicidal ideation and past attempts; it is not clear whether these findings are generalizable to geriatric populations. Although little treatment research has been performed in older suicidal patients with schizophrenia, an integrated psychosocial and pharmacologic approach is recommended. In addition, one recent study augmented antipsychotic treatment with an SSRI (i.e., citalopram) in a sample of middle-aged and older individuals with schizophrenia with subsyndromal depression; in that study, serotonin selective reuptake inhibitor augmentation reduced depressive symptoms and suicidal ideation. More research is required to better understand suicidal behavior in older patients with schizophrenia.

Stress and protective factors in individuals at ultra-high risk for psychosis, first episode psychosis and healthy controls

Stress-vulnerability models of schizophrenia regard psychosocial stress as an important factor in the onset and aggravation of psychotic symptoms, but such research in the early phases of psychosis is limited. Protective factors against the effects of stress might be the key to understanding some inconclusive findings and to the development of optimal psychosocial interventions. The present study compared self-reported levels of stress, self-esteem, social support and active coping in 32 patients with a first episode of psychosis (FEP), 30 individuals at ultra-high risk for psychosis (UHR) and 30 healthy controls. Associations with symptoms of psychosis were assessed in both patient groups. Individuals at UHR reported significantly higher stress levels compared to FEP patients. Both patient groups showed lower self-esteem compared to controls, and the UHR group reported lower social support and active coping than controls. These group differences could not be explained by age and dose of antipsychotic medication in the FEP group. In the UHR group, higher stress levels and lower self-esteem were associated with more severe positive and depressive symptoms on the Brief Psychiatric Rating Scale. Multiple regression analyses revealed that stress was the only significant predictor for both symptom measures and that the relationship was not moderated by self-esteem. Our findings show that individuals at UHR for psychosis experience high levels of psychosocial stress and marked deficits in protective factors. The results suggest that psychosocial interventions targeted at reducing stress levels and improving resilience in this population may be beneficial in improving outcomes.

Cost-effectiveness of olanzapine long-acting injection in the treatment of patients with schizophrenia in the United States: a micro-simulation economic decision model

OBJECTIVE

To compare, from the perspective of third-party payers in the United States health care system, the cost-effectiveness of olanzapine long-acting injection (LAI, depot) with alternative antipsychotic agents including risperidone-LAI, paliperidone-LAI, haloperidol-LAI, and oral olanzapine, in the treatment of patients with schizophrenia who have been non-adherent or partially adherent with oral antipsychotics.

RESEARCH DESIGN AND METHODS

A 1-year micro-simulation economic decision model was developed to simulate the dynamics of usual care of patients with schizophrenia who continue, discontinue, switch, or restart their medication. The model uses a range of clinical and cost parameters including adherence levels, relapse with and without hospitalization, quality-adjusted life years (QALYs), treatment discontinuation rates by reason, treatment-emergent adverse events, suicide, health care resource utilization, and direct health care costs. Published medical literature and a clinical expert panel were used to develop baseline model assumptions.

OUTCOME MEASURES

Key model outputs include annual total direct cost (US$) per treatment and incremental cost-effectiveness values per additional QALY gained.

RESULTS

Model results found that the olanzapine-LAI treatment strategy was more effective (greater QALYs) and less costly than risperidone-LAI, paliperidone-LAI, and haloperidol-LAI. In addition, olanzapine-LAI was both more effective and more costly, with an estimated incremental cost/QALY of $26,824 compared to oral olanzapine. The base-case and multiple sensitivity analyses found olanzapine-LAI to remain within acceptable cost-effective ranges (<$50,000) in terms of incremental cost/QALY gained.

CONCLUSIONS

This micro-simulation model finds the olanzapine-LAI treatment strategy to result in better effectiveness and to be a cost-effective alternative compared to oral olanzapine and the LAI formulations of risperidone, paliperidone, and haloperidol in the treatment of non-adherent and partially adherent patients with schizophrenia in the United States. A key limitation is the assumption how LAI therapies compare to oral counterparts due to sparse head-to-head data. Further research is needed to verify baseline assumptions.

Managing suicide risk in patients with schizophrenia

The management of suicide risk in patients with schizophrenia poses many challenges for clinicians. Compared with the general population, these patients have an 8.5-fold greater risk of suicide. This article reviews the literature dealing with the treatment of at-risk patients with schizophrenia. An integrated psychosocial and pharmacological approach to managing this population of patients is recommended. Although there is at least modest evidence suggesting that antipsychotic medications protect against suicidal risk, the evidence appears to be most favourable for second-generation antipsychotics, particularly clozapine, which is the only medication approved by the US FDA for preventing suicide in patients with schizophrenia. In addition, treating depressive symptoms in patients with schizophrenia is an important component of suicide risk reduction. While selective serotonin receptor inhibitors (SSRIs) ameliorate depressive symptoms in patients with schizophrenia, they also appear to attenuate suicidal thoughts. Further research is needed to more effectively personalize the treatment of suicidal thoughts and behaviours and the prevention of suicide in patients with schizophrenia.

Suicide attempts in a prospective cohort of patients with schizophrenia treated with sertindole or risperidone

The incidence of suicide attempts (fatal and non-fatal) was analysed in a prospective cohort of patients with schizophrenia randomly assigned to sertindole (4905 patients) or risperidone (4904 patients) in a parallel-group open-label study with blinded classification of outcomes (the sertindole cohort prospective study--SCoP). The total exposure was 6978 and 7975 patient-years in the sertindole and risperidone groups, respectively. Suicide mortality in the study was low (0.21 and 0.28 per 100 patients per year with sertindole and risperidone, respectively). The majority (84%) of suicide attempts occurred within the first year of treatment. Cox's proportional hazards model analysis of the time to the first suicide attempt, reported by treating psychiatrists and blindly reviewed by an independent expert group according to the Columbia Classification Algorithm of Suicide Assessment (both defining suicide attempts by association of suicidal act and intent to die), showed a lower risk of suicide attempt for sertindole-treated patients than for risperidone-treated patients. The effect was statistically significant with both evaluation methods during the first year of randomized treatment (hazard ratios [95% CI]: 0.5 [0.31-0.82], p=0.006; and 0.57 [0.35-0.92], p=0.02, respectively). With classification by an independent safety committee using a broader definition including all incidences of intentional self-harm, also those without clear suicidal intent, the results were not significant. A history of previous suicide attempts was significantly associated with attempted suicides in both treatment groups.

Suicide schemas in non-affective psychosis: An empirical investigation

Suicide is the leading cause of premature death among individuals experiencing psychosis. The risk of suicide is proposed to increase with a greater potential for activation of suicide related schemas. Empirical representations of suicide schemas were compared between individuals experiencing non-affective psychosis, with and without a history of suicidal behaviour. Employing a cross-sectional between-groups comparison design, 84 participants, previously diagnosed with a non-affective psychotic disorder, were recruited from community mental health services. Participants completed a demographic questionnaire and clinical measures of psychopathology. To assess participants' suicide schemas, a series of direct and indirect cognitive tasks were designed and administered. Pathfinder analysis enabled the construction of empirically derived representations of the groups' suicide schemas based on responses to the cognitive tasks. The suicide group achieved significantly greater scores on measures of anxiety, depression, hopelessness and suicidality than the non-suicide group, but not on measures indicative of the severity of psychosis. The suicide schema for the suicide group was more elaborate and extensive than for the non-suicide group, even when clinical measures were taken into account. Clinical and theoretical implications are discussed.

Treatment of subsyndromal depressive symptoms in middle-age and older patients with schizophrenia: effect of age on response

OBJECTIVE

The authors hypothesized that age would moderate the response of patients with schizophrenia and subsyndromal depression (SSD) treated citalopram with depressive symptoms and other outcomes. Also, older patients would exhibit more side effects with citalopram.

METHODS

Participants of 40 years or older had schizophrenia or schizoaffective disorder with SSD. Patients randomly received flexible dosing of citalopram or placebo augmentation of their antipsychotic medication. Linear regression determined whether age had any moderating effect on depressive symptoms, global psychopathology, negative symptoms, mental functioning, and quality of life. Age-related side effects were examined.

RESULTS

There were no significant drug group by age interaction in depressive or psychotic symptoms, mental Short Form-12, or quality of life scores. Similarly, there were few age-related side effect differences.

CONCLUSION

Symptoms in younger and older patients with schizophrenia and SSD treated with citalopram seem to respond similarly. Adverse events do not seem to differ with age.

Antecedents and patterns of suicide behavior in first-admission psychosis

BACKGROUND

Persons with psychotic illnesses have an increased risk for suicide, especially early in the illness. Sufficient knowledge allowing for early recognition is lacking.

OBJECTIVES

To describe suicide behaviors before and during the 4 years following first psychiatric hospitalization, examine associations of demographic and psychiatric risk factors, and develop a suicide risk index.

METHOD

Data came from the Suffolk County Mental Health Project, a first-admission cohort (n = 529). Cox regression was used to study associations of risk factors to suicide behaviors; a summary suicide behavior risk index was also tested.

RESULTS

Prior to first admission, 28.0% (n = 148) of the cohort had attempted suicide. During the 4-year follow-up, 13.6% (n = 72) of the cohort attempted suicide (29.7% of those with previous attempts and 7.3% making their first attempt) and 3 respondents died of suicide. The significant predictors at index admission of subsequent attempts were prior attempts or ideation, severity of depressive symptoms and thought disorder, lifetime substance abuse, and younger age. Suicide ideation was predicted by the same variables with the addition of insight into illness and with the exception of age at admission. A 3-category risk index was created; 61.1% of those who made a suicide attempt were in the highest risk group (n = 44/72).

CONCLUSION

The current study confirms and extends previous research showing that risk factors early in the course of illness are predictive of subsequent ideation and attempts. The risk index may be a useful adjunct in identifying individuals likely to benefit from preventive interventions.

Professional service utilisation among patients with severe mental disorders

BACKGROUND

Generally, patients with serious mental disorders (SMD) are frequent users of services who generate high care-related costs. Current reforms aim to increase service integration and primary care for improved patient care and health-care efficiency. This article identifies and compares variables associated with the use by patients with SMD of services offered by psychiatrists, case managers, and general practitioners (GPs). It also compares frequent and infrequent service use.

METHOD

One hundred forty patients with SMD from five regions in Quebec, Canada, were interviewed on their use of services in the previous year. Patients were also required to complete a questionnaire on needs-assessment. In addition, data were collected from clinical records. Descriptive, bivariate, and multivariate analyses were conducted.

RESULTS

Most patients used services from psychiatrists and case managers, but no more than half consulted GPs. Most patients were followed at least by two professionals, chiefly psychiatrists and case managers. Care access, continuity of care, and total help received were the most important variables associated with the different types of professional consultation. These variables were also associated with frequent use of professional service, as compared with infrequent service use. In all, enabling factors rather than need factors were the core predictors of frequency of service utilisation by patients with SMD.

CONCLUSION

This study reveals that health care system organisation and professional practice--rather than patient need profiles--are the core predictors of professional consultation by patients with SMD. The homogeneity of our study population, i.e. mainly users with schizophrenia, recently discharged from hospital, may partly account for these results. Our findings also underscored the limited involvement of GPs in this patient population's care. As comorbidity is often associated with serious mental disorders, closer follow-up by GPs is needed. Globally, more effort should be directed at increasing shared-care initiatives, which would enhance coordination among psychiatrists, GPs, and psychosocial teams (including case managers). Finally, there is a need to increase awareness among health care providers, especially GPs, of the level of care required by patients with disabling and serious mental disorders.

Suicide attempts at the time of first admission and during early course schizophrenia: a population based study

This article examined suicide attempt rates at first psychiatric hospitalization and risk factors for subsequent suicide attempts over the early course of schizophrenia in national population-based data. Data were extracted from the National Psychiatric Hospitalization Case Registry of the State of Israel that contains all first psychiatric admissions with schizophrenia 1989-1992 and were followed up to 1996 (N=2293). Attempted suicide rates were: 8.5% (n=196) at the time of first psychiatric hospitalization and 6.6% (n=151) over the follow-up period of 4 to 7 years. Of those with a suicide attempt at first admission, 31.6% (n=62) made a subsequent suicide attempt during the follow-up period (OR=10.44, 95% CIs=7.22 to 15.09). Risk profiles were derived using recursive partitioning to predict sub-groups at risk of a subsequent suicide attempt. Those characterized by an attempt at the time of first admission were college educated, female and not married (45.9% (17/37), OR=13.46, 95% CIs=6.89 to 26.3). The risk profiles together correctly classified 90.7% (137/151) of subsequent suicide attempts. Suicide attempts at first admission and premorbid years of education have long-term prognostic utility and risk profiles are available.

Outcome of suicidal patients with schizophrenia: results from a naturalistic study

OBJECTIVE

Purpose was to assess suicidality before and at the time of admission in patients with schizophrenia and compare outcome differences.

METHOD

Biweekly PANSS (Positive and Negative Syndrome Scale), HAMD (Hamilton Depression Rating Scale) and UKU (Udvalg for Klinske Undersogelser Side Effect Rating Scale) ratings were evaluated in 339 in-patients with schizophrenic spectrum disorders. Response was defined as an initial 20% PANSS total score reduction at discharge, remission was defined according to the proposed consensus criteria by the Remission in Schizophrenia Working Group.

RESULTS

Suicidal patients (22%) scored significantly higher on the PANSS negative subscore, PANSS insight item and HAMD total score at admission and at discharge. They developed significantly more side effects. No differences were found concerning response and remission between the two patient subgroups.

CONCLUSION

Despite receiving significantly more antidepressants the suicidal patients suffered from significantly more depressive symptoms up to discharge, yet without differing regarding response and remission.

Treatment of subsyndromal depressive symptoms in middle-aged and older adults with schizophrenia: effect on functioning

BACKGROUND

Subsyndromal symptoms of depression (SSD) in patients with schizophrenia are common and clinically important. SSRI's appear to be helpful in alleviating depressive symptoms in patients with schizophrenia who have SSD in patients age 40 and greater. It is not known whether SSRI's help improve functioning in this population. We hypothesized that treating this population with the SSRI citalopram would lead to improvements in social, mental and physical functioning as well as improvements in medication management and quality of life.

METHODS

Participants were 198 adults > or = 40 years old with schizophrenia or schizoaffective disorder who met study criteria for subsyndromal depression based on having two or more of the nine DSM-IV symptoms of a major depressive episode, for at least 2 weeks, and a Hamilton depression rating scale (HAM-D 17) score > or = 8. Patients were randomly assigned to flexible-dose treatment with citalopram or placebo augmentation of their current antipsychotic medication(s) which was stable for 1 month. Subjects were assessed with the following functional scales at baseline and at the end of the 12-week trial: (1) social skills performance assessment (SSPA), (2) medication management ability assessment (MMAA), (3) mental and physical components of the medical outcomes study SF-12 Scale, and (4) the Heinrichs quality of life scale (QOLS). Analysis of covariance (ANCOVA) was used to compare differences between endpoint scores of the citalopram and placebo treated groups, controlling for site and baseline scores. ANCOVAs were also used to compare differences in the above endpoint scores in responders versus non-responders (responders = those with > 50% reduction in depressive symptoms).

RESULTS

Overall, the citalopram group had significantly higher SSPA, mental functioning SF-12, and quality of life scale (QOLS) scores compared to the placebo group. There was no effect on MMAA or physical functioning SF-12 scores. Responders had significantly better endpoint mental SF-12 and QOLS scores compared to non-responders. Response to citalopram in terms of depressive symptoms mediated the effect of citalopram on mental functioning, but not on the quality of life.

CONCLUSIONS

Citalopram augmentation of antipsychotic treatment in middle aged and older patients with schizophrenia and subsyndromal depression appears to improve social and mental health functioning as well as quality of life. Thus it is important for clinicians to monitor these aspects of functioning when treating this population of patients with schizophrenia with SSRI agents.

The burden of depressive symptoms in people with schizophrenia

People with schizophrenia and concurrent depressive symptoms have poorer long-term functional outcomes compared with the nondepressed. Their poorer quality of life, greater use of mental health services, and higher risk of involvement with law enforcement agencies underscore a need for special treatment interventions. Treatment of the nonpsychotic dimensions of schizophrenia is a critical part of recovery. In a 3-year study, the depressed cohort was significantly more likely than the nondepressed to use relapse-related mental health services (emergency psychiatric services, sessions with psychiatrists); to be a safety concern (violent, arrested, victimized, or suicidal); to have greater substance-related problems; and to report poorer life satisfaction, quality of life, mental functioning, family relationships, and medication adherence. Furthermore, changes in depressed status were associated with changes in functional outcomes.

Management of schizophrenia with suicide risk

Suicidal behavior remains a major source of morbidity and mortality among schizophrenics. The National Institute of Mental Health Longitudinal Study of Chronic Schizophrenia found that over a mean of 6 years, 38% of the patients had at least one suicide attempt and 57% admitted to substantial suicidal ideation. Suicide is also a major issue among inpatients, with serious implications for clinical practice and patient-doctor relationships. The management of schizophrenic patients with suicide risk remains a difficult area for clinicians despite attempts to better understand it by gathering experts in the field. This article discusses the frequency of suicidal behavior in schizophrenia, offers a model for understanding it, and discusses various aspects of the management of the at-risk schizophrenic patient.

Suicide among women with schizophrenia spectrum disorders

This paper presents five cases of suicide in women attending a schizophrenia clinic and demonstrates that, in the presence of psychosis, women can act impulsively and aggressively and can use lethal means to end their lives. If generalizations can be made from the stories of these five women, then multiple prior admissions, comorbid psychiatric and substance abuse diagnoses, lack of negative symptoms, full awareness of illness, and current crisis appear to constitute important risk variables. Female-specific factors associated with suicide in this sample were childhood sexual abuse, intimate partner abuse, and child loss. The author, who knew these five women very well over a long period of time, concludes that the deaths might have been prevented by critical interventions such as timely hospital admission, suicide screening prior to hospital discharge, safety check of the immediate environment, in-depth explanation of therapeutic decisions, and complete assessment of the personal meaning attached to recent events.

Cost-effectiveness model comparing olanzapine and other oral atypical antipsychotics in the treatment of schizophrenia in the United States

BACKGROUND

Schizophrenia is often a persistent and costly illness that requires continued treatment with antipsychotics. Differences among antipsychotics on efficacy, safety, tolerability, adherence, and cost have cost-effectiveness implications for treating schizophrenia. This study compares the cost-effectiveness of oral olanzapine, oral risperidone (at generic cost, primary comparator), quetiapine, ziprasidone, and aripiprazole in the treatment of patients with schizophrenia from the perspective of third-party payers in the U.S. health care system.

METHODS

A 1-year microsimulation economic decision model, with quarterly cycles, was developed to simulate the dynamic nature of usual care of schizophrenia patients who switch, continue, discontinue, and restart their medications. The model captures clinical and cost parameters including adherence levels, relapse with and without hospitalization, quality-adjusted life years (QALYs), treatment discontinuation by reason, treatment-emergent adverse events, suicide, health care resource utilization, and direct medical care costs. Published medical literature and a clinical expert panel were used to develop baseline model assumptions. Key model outcomes included mean annual total direct cost per treatment, cost per stable patient, and incremental cost-effectiveness values per QALY gained.

RESULTS

The results of the microsimulation model indicated that olanzapine had the lowest mean annual direct health care cost ($8,544) followed by generic risperidone ($9,080). In addition, olanzapine resulted in more QALYs than risperidone (0.733 vs. 0.719). The base case and multiple sensitivity analyses found olanzapine to be the dominant choice in terms of incremental cost-effectiveness per QALY gained.

CONCLUSION

The utilization of olanzapine is predicted in this model to result in better clinical outcomes and lower total direct health care costs compared to generic risperidone, quetiapine, ziprasidone, and aripiprazole. Olanzapine may, therefore, be a cost-effective therapeutic option for patients with schizophrenia.

Suicidal behavior in schizophrenia: a test of the demoralization hypothesis

This study examined Drake's model that individuals with schizophrenia with good premorbid adjustment and insight into their illness are more vulnerable to becoming demoralized and therefore suicidal. One hundred sixty-four patients with schizophrenia (N = 115) or schizoaffective disorder (N = 49) were assessed for depressive symptoms and DSM-III-R depression, premorbid functioning, insight and suicidal behavior using The Diagnostic Interview for Genetic Studies and the Premorbid Adjustment Scale. Premorbid adjustment, insight and past MDE did not discriminate attempters from nonattempters, contrary to the model. However, consistent with the model, the interaction between good premorbid adjustment and insight predicted severity of depressive symptoms, and the psychological symptoms of depression significantly differentiated attempters from nonattempters, whereas the somatic symptoms did not. This study provides support for some aspects of the demoralization model.