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

Psychiatric symptoms and quality of life in older adults with schizophrenia spectrum disorder: results from a multicenter study

The severity of psychopathology has a strong negative impact on quality of life (QoL) among older adults with schizophrenia spectrum disorder. However, because these subjects generally experience multiple psychiatric symptoms, it remains unclear whether decreased QoL in this population is due to specific symptoms (e.g., hallucinations), specific dimensions of psychopathology (e.g., negative symptoms), a general psychopathology dimension representing the shared effect across all psychiatric symptoms, or a combination of these explanations. Data were derived from the Cohort of individuals with Schizophrenia Aged 55 years or more (CSA) study, a large (N = 353) multicenter sample of older adults with schizophrenia spectrum disorder recruited from French public-sector psychiatric departments. We used structural equation modeling to examine the shared and specific effects of psychiatric symptoms on QoL, while adjusting for sociodemographic characteristics, general medical conditions, global cognitive functioning and psychotropic medications. Psychiatric symptoms and QoL were assessed face-to-face by psychiatrists using the Brief Psychiatric Rating Scale (BPRS) and the Quality of Life Scale (QLS). Among older adults with schizophrenia spectrum disorder, effects of psychiatric symptoms on QoL were exerted mostly through a general psychopathology dimension (β = - 0.43, p < 0.01). Negative symptom dimension had an additional negative effect on QoL beyond the effect of that factor (β = - 0.28, p < 0.01). Because psychiatric symptoms affect QoL mainly through two dimensions of psychopathology, i.e., a general psychopathology dimension and a negative symptom dimension, mechanisms underlying those dimensions should be considered as promising targets for therapeutic interventions to substantially improve quality of life of this vulnerable population.

Effects of depression and cognitive impairment on quality of life in older adults with schizophrenia spectrum disorder: Results from a multicenter study

BACKGROUND

Little is known about the respective effects of depression and cognitive impairment on quality of life among older adults with schizophrenia spectrum disorder.

METHODS

We used data from the Cohort of individuals with Schizophrenia Aged 55-years or more (CSA) study, a large multicenter sample of older adults with schizophrenia or schizoaffective disorder (N = 353). Quality of life (QoL), depression and cognitive impairment were assessed using the Quality of Life Scale (QLS), the Center of Epidemiologic Studies Depression scale and the Mini-Mental State Examination, respectively. We used structural equation modeling to examine the shared and specific effects of depression and cognitive impairment on QoL, while adjusting for sociodemographic characteristics, general medical conditions, psychotropic medications and the duration of the disorder.

RESULTS

Depression and cognitive impairment were positively associated (r = 0.24, p < 0.01) and both independently and negatively impacted on QoL (standardized β = -0.41 and β = -0.32, both p < 0.01) and on each QLS quality-of-life domains, except for depression on instrumental role and cognitive impairment on interpersonal relations in the sensitivity analyses excluding respondents with any missing data. Effects of depression and cognitive impairment on QoL were not due to specific depressive symptoms or specific cognitive domains, but rather mediated through two broad dimensions representing the shared effects across all depressive symptoms and all cognitive deficits, respectively.

LIMITATIONS

Because of the cross-sectional design of this study, measures of association do not imply causal associations.

CONCLUSIONS

Mechanisms underlying these two broad dimensions should be considered as important potential targets to improve quality of life of this vulnerable population.

Subsyndromal and syndromal depressive symptoms among older adults with schizophrenia spectrum disorder: Prevalence and associated factors in a multicenter study

BACKGROUND

Few studies have examined the prevalence and correlates of subsyndromal and syndromal depressive symptoms (SSSD) among older adults with schizophrenia spectrum disorder. In this report, we examined the prevalence of SSSD and their associations with sociodemographic characteristics, clinical characteristics of schizophrenia, comorbidity, psychotropic medications, quality of life, functioning and mental health care utilization in a large, multicenter sample of older adults with schizophrenia spectrum disorder.

METHODS

Data from the Cohort of individuals with Schizophrenia Aged 55 years or more (CSA) were used to examine the prevalence of SSSD, defined using the Center of Epidemiologic Studies Depression (CESD) scale. Clinical characteristics associated with SSSD were explored.

RESULTS

Among 343 older adults with schizophrenia spectrum disorder, 78.1% had either subsyndromal (30.6%) or syndromal (47.5%) depressive symptoms. SSSD were independently associated with positive and negative symptoms, lower quality of life, non-late-onset psychosis, benzodiazepine use and urbanicity. There were no significant associations of SSSD with other sociodemographic characteristics and psychotropic medications, or with general medical conditions. We found no significant differences in the proportion of participants who were treated with antidepressants between those with syndromal depressive symptoms and those without depression (22.1% vs. 20.0%, p = 0.89). SSSD were not associated with higher mental health care utilization.

LIMITATIONS

Data were cross-sectional and depression was not evaluated with a semi-structured interview.

CONCLUSION

SSSD may be highly prevalent and under-assessed and/or undertreated among older adults with schizophrenia spectrum disorder. Our findings should alert clinicians about the need to assess systematically and regularly depression in this vulnerable population.

Studying the neurobiology of human social interaction: Making the case for ecological validity

With this commentary we make the case for an increased focus on the ecological validity of the measures used to assess aspects of human social functioning. Impairments in social functioning are seen in many types of psychopathology, negatively affecting the lives of psychiatric patients and those around them. Yet the neurobiology underlying abnormal social interaction remains unclear. As an example of human social neuroscience research with relevance to biological psychiatry and clinical psychopharmacology, this commentary discusses published experimental studies involving manipulation of the human brain serotonin system that included assessments of social behavior. To date, these studies have mostly been laboratory-based and included computer tasks, observations by others, or single-administration self-report measures. Most laboratory measures used so far inform about the role of serotonin in aspects of social interaction, but the relevance for real-life interaction is often unclear. Few studies have used naturalistic assessments in real life. We suggest several laboratory methods with high ecological validity as well as ecological momentary assessment, which involves intensive repeated measures in naturalistic settings. In sum, this commentary intends to stimulate experimental research on the neurobiology of human social interaction as it occurs in real life.

Antidepressants for cognitive impairment in schizophrenia--a systematic review and meta-analysis

BACKGROUND

Cognitive impairment in schizophrenia is disabling, but current treatment options remain limited.

OBJECTIVE

To meta-analyze the efficacy and safety of adjunctive antidepressants for cognitive impairment in schizophrenia.

DATA SOURCES AND STUDY SELECTION

PubMed, MEDLINE, PsycINFO, and Cochrane Library databases were searched until 12/2013 for randomized controlled trials comparing antidepressant augmentation of antipsychotics with placebo regarding effects on cognitive functioning in schizophrenia.

DATA EXTRACTION

Two authors independently extracted data. Standardized mean differences (SMDs) were calculated for continuous outcomes and risk ratios for categorical outcomes. SMDs of individual cognitive tests were pooled on a study level within domains (primary outcome) and across domains. When results were heterogeneous, random instead of fixed effects models were used.

RESULTS

We meta-analyzed 11 studies (duration = 8.7 ± 3.7 weeks) including 568 patients (mean age = 39.5 ± 6.9 years, males = 67.2%, illness duration = 12.5 ± 8.0 years). Antidepressants included mirtazapine (4 studies; n = 126), citalopram (2 studies; n = 231), fluvoxamine (1 study; n = 47), duloxetine (1 study; n = 40), mianserin (1 study; n = 30), bupropion (1 study; n = 61), and reboxetine (1 study; n = 33). Statistically significant, but clinically negligible, advantages were found for pooled antidepressants compared to placebo in executive function (Hedges' g = 0.17, p = 0.02) and a composite cognition score (Hedges' g = 0.095, p = 0.012). Depression improved with serotonergic antidepressants (p = 0.0009) and selective serotonin reuptake inhibitors (p = 0.009), but not with pooled antidepressants (p = 0.39). Sedation was more common with pooled antidepressants (p = 0.04).

CONCLUSION

Adjunctive antidepressants do not demonstrate clinically significant effects on cognition in schizophrenia patients, however, larger studies, preferably in euthymic schizophrenia patients and using full neurocognitive batteries, are needed to confirm this finding.

Prevalence and correlates of depressive symptoms in a catchment-area based cohort of older community-living schizophrenia patients

BACKGROUND

Depressive symptoms frequently accompany schizophrenia. Older patients constitute the fastest growing segment of the schizophrenia population. With regard to the risk factors associated with depression, it is uncertain to which extent older schizophrenia patients differ from their age peers in the community.

METHODS

We assessed self-reported depressive symptoms in an epidemiological sample of older Dutch community-living patients with schizophrenia or schizoaffective disorder (N=99; mean age 67years). Demographic, clinical and social variables were evaluated for their predictive value on the level of depressive symptoms. A comparison group, proportionally matched for age and gender, was recruited from a community study.

RESULTS

In the schizophrenia group, 47.5% reported depressive symptoms at a level indicating clinically relevant depression, in contrast to 12.1% in their age peers (odds ratio 6.55; 95% CI, 3.19-13.48; p<0.001). This difference could not be explained by differential exposure to the evaluated general risk factors. In both groups, functional limitations were the strongest predictor of depressive symptoms. In the patient group, chronic physical disorders and lack of a confidant were predictors, while a diagnosis of schizoaffective disorder (vs. schizophrenia) was the only disorder-related risk factor that contributed to depressive symptoms, with marginal significance.

CONCLUSION

The high rate of depressive symptoms in this epidemiological sample of older schizophrenia patients confirms that these symptoms frequently accompany this severe mental illness in late life. With physical and social factors as important predictors of depressive symptoms, risk factors for depression are more comparable between older schizophrenia patients and their age peers than is often assumed.

Empathy, depressive symptoms, and social functioning among individuals with schizophrenia

Empathy deficits have been associated with schizophrenia and depression. We compared whether individuals with schizophrenia with and without co-occurring depressive symptoms differed on self-reported and performance-based measures of empathy and social functioning. We also examined the relationships among depressive symptoms, empathy, clinical symptoms, and social functioning. Twenty-eight individuals with schizophrenia and depressive symptoms, 32 individuals with schizophrenia without depressive symptoms, and 44 control subjects were compared on assessments of depressive symptoms, empathy, global neurocognition, clinical symptoms, and social functioning. Both groups of individuals with schizophrenia scored higher than controls on the Interpersonal Reactivity Index personal distress subscale. Individuals with schizophrenia and co-occurring depressive symptoms scored significantly higher than individuals with schizophrenia without depressive symptoms on the personal distress subscale. Personal distress and depressive symptoms were significantly correlated among individuals with schizophrenia and co-occurring depressive symptoms, while both measures negatively correlated with social functioning. Emotional empathy was related to clinical symptoms in both groups of individuals with schizophrenia. Personal distress partially mediated the relationship between co-occurring depressive symptoms and social functioning. Personal distress may be an important implication for social functioning among individuals with schizophrenia and co-occurring depressive symptoms, and should be examined further as a potential treatment target.

Subjective quality of life and its determinants in a catchment area based population of elderly schizophrenia patients

BACKGROUND

Subjective quality of life (SQOL) is an established outcome measure in schizophrenia. In spite of the substantial proportion of elderly in the total schizophrenia population, evaluation of their SQOL and its determinants has been scarce and findings from epidemiological samples are lacking.

METHODS

We assessed SQOL in elderly Dutch patients with schizophrenia or schizoaffective disorder (n=107; mean age 68 years), treated within a psychiatric catchment area. Demographic, clinical and social variables were evaluated for their impact on SQOL.

RESULTS

The mean SQOL score was 4.83, moderately surpassing the midpoint of the SQOL scale. Nearly half of all patients (47.7%) reported an overall favorable SQOL. Of the total variance in SQOL, clinical variables explained 50%, and social variables explained 16%, while demographic factors did not contribute. In multivariable analysis, less self-reported depressive symptoms, worse global neurocognition, and higher observer-based level of social functioning significantly predicted a higher SQOL, explaining 53% of the total variance.

CONCLUSION

The relatively high level of SQOL in this epidemiological sample of elderly patients is in line with what has been reported for both older and younger schizophrenia populations. Depressive symptoms are a robust predictor of SQOL in late life schizophrenia, clearly outweighing psychotic symptoms. This finding has major clinical relevance, as depression is amenable to therapeutic intervention.

Management of schizophrenia in late life with antipsychotic medications: a qualitative review

Although patients with schizophrenia are reported to have excess mortality compared with the general population, many affected patients will nonetheless survive and continue to have the disorder in later life. Consequently, geriatric schizophrenia will be a significant public health concern in the years to come, and evidence-based treatment of schizophrenia in older patients is becoming an urgent issue. However, there has been a paucity of comparative data to guide selection of antipsychotics for schizophrenia in late life. The primary aim of this review was to synthesize the available evidence on management of late-life schizophrenia with antipsychotic medications; a secondary aim was to evaluate treatment resistance in this population. Accordingly, PubMed and EMBASE were searched using the keywords 'antipsychotics', 'age' and 'schizophrenia' to identify psychopharmacological studies of antipsychotics in late-life schizophrenia (last search 30 April 2011). The literature search identified 23 prospective studies of use of antipsychotics for schizophrenia in older patients (generally age ≥65 years), including eight double-blind trials. The sample size was smaller than 40 patients for 52% of the studies. Two of the double-blind studies were post hoc analyses and one was a placebo-controlled trial. In the largest double-blind study, olanzapine (n = 88, median dose 10 mg/day) and risperidone (n = 87, median dose 2 mg/day) were compared in patients not resistant to these therapies, with similar effects. There have also been several open-label trials of these two agents that have shown efficacy and tolerability in non-resistant patients. Evidence on other antipsychotics has been scarce and less robust. The gold standard for treatment-resistant schizophrenia is clozapine. However, almost all of the studies of clozapine to date have effectively excluded older patients with schizophrenia. Only one small study has evaluated clozapine (n = 24, mean dose 300 mg/day) in comparison with chlorpromazine (n = 18, mean dose 600 mg/day) in a difficult-to-treat older population; the investigators reported that both treatments were similarly efficacious. Furthermore, there has been little compelling evidence in favour of or against augmentation of antipsychotics with other psychotropic medications in the older age group. Treatment of non-resistant, late-life schizophrenia with olanzapine and risperidone appears to be supported by the available evidence. However, data on geriatric patients with schizophrenia are generally scarce, particularly for treatment-resistant subpopulations, underscoring the need for more research in this important area.

Menstrual exacerbation of schizophrenia symptoms

OBJECTIVE

To better understand premenstrual exacerbations of schizophrenia in women and weigh treatment options.

METHOD

A PubMed literature search was conducted, using the search terms 'schizophrenia', 'psychosis', 'menstrual exacerbation', 'hormones' and assessing relevance to premenstrual exacerbation of schizophrenia symptoms.

RESULTS

Exacerbations are usually distinguishable from periodic or menstrual psychosis, a relatively rare condition. Controversy continues about whether low estrogen periods of the month lead to an increase in schizophrenia symptoms among women of reproductive age or whether some women suffer from both schizophrenia and premenstrual dysphoric disorder (PMDD). No treatment trials of specific interventions have been conducted so that physicians must decide on a case-by-case basis whether to raise antipsychotic doses premenstrually, try estrogens or estrogen/progesterone combinations or selective estrogen receptor modulators, or target PMDD symptoms.

CONCLUSION

Clinicians need to be aware of premenstrual symptom aggravation in a large minority of women with schizophrenia. Treatment strategies will depend on the nature of the symptoms that are exacerbated. Optimal treatment needs to be adjusted to the individual woman.

Forms of antipsychotic therapy: improved individual outcomes under personalised treatment of schizophrenia focused on depression

Depressive symptoms are common in schizophrenia and they can occur during any phase of the disorder. Early diagnosis, adequate differential diagnosis and promptly initiated interventions have been shown to reduce further deterioration of illness and to improve patients' quality of life. Common psychiatric rating scales for early detection of depressive symptoms in schizophrenia are Calgary Depression Scale for Schizophrenia and Hamilton Depression Rating Scale, but the most appropriate assessment instrument today regarding this topic is Calgary Depression Scale for Schizophrenia. Treatment of depression in schizophrenia consists of a combination of pharmacologic and psychosocial approach. Atypical antipsychotics have advantages over typical in reducing depressive symptoms in the context of schizophrenia. Most of the studies referred that clozapine, olanzapine, quetiapine and risperidone have an antidepressant spectrum of activity in patients with schizophrenia. Antidepressant augmentation of antipsychotic treatment in schizophrenic patients with depressive symptoms improves depressive symptomatology, particularly SSRI and SNRI augmentation.

Elderly patients with schizophrenia and depression: diagnosis and treatment

BACKGROUND

The treatment of older patients with schizophrenia and depressive symptoms poses many challenges for clinicians. Current classifications of depressive symptoms in patients with schizophrenia include: Major Depressive Episodes that occur in patients with schizophrenia and are not classified as schizoaffective disorder, Schizoaffective Disorder, and Schizophrenia with subsyndromal depression in which depressive symptoms do not meet criteria for Major Depression. Research indicates that the presence of any of these depressive symptoms negatively impacts the lives of patients suffering from schizophrenia-spectrum disorders.

PURPOSE

The purpose of this paper is to review the literature related to older patients with schizophrenia-spectrum disorders and co-occurring depressive symptoms, and to guide mental health professionals to better understand the diagnosis and treatment of depressive symptoms in patients with schizophrenia.

CONCLUSIONS

The treatment of elderly patients with schizophrenia and depressive symptoms includes first reassessing the diagnosis to make sure symptoms are not due to a comorbid condition, metabolic problems or medications. If these are ruled out, pharmacological agents in combination with psychosocial interventions are important treatments for older patients with schizophrenia and depressive symptoms. A careful assessment of each patient is needed in order to determine which antipsychotic would be optimal for their care; second-generation antipsychotics are the most commonly used antipsychotics. Augmentation with an antidepressant medication can be helpful for the elderly patient with schizophrenia and depressive symptoms. More research with pharmacologic and psychosocial interventions is needed, however, to better understand how to treat this population of elderly patients.

Antidepressants for people with both schizophrenia and depression

BACKGROUND

Depressive symptoms, often of substantial severity, are found in 50% of newly diagnosed suffers of schizophrenia and 33% of people with chronic schizophrenia who have relapsed. Depression is associated with dysphoria, disability, reduction of motivation to accomplish tasks and the activities of daily living, an increased duration of illness and more frequent relapses.

OBJECTIVES

To determine the clinical effects of antidepressant medication for the treatment of depression in people who also suffer with schizophrenia.

SEARCH STRATEGY

We undertook electronic searches of the Cochrane Schizophrenia Group's Register (October 2000), ClinPsych (1988-2000), The Cochrane Library (Issue 3, 2000), EMBASE (1980-2000) and MEDLINE (1966-2000). This was supplemented by citation searching, personal contact with authors and pharmaceutical companies.

SELECTION CRITERIA

All randomised clinical trials that compared antidepressant medication with placebo for people with schizophrenia or schizoaffective disorder who were also suffering from depression.

DATA COLLECTION AND ANALYSIS

Data were independently selected and extracted. For homogeneous dichotomous data the fixed effects risk difference (RD), the 95% confidence intervals (CI) and, where appropriate, the number needed to treat (NNT) were calculated on an intention-to-treat basis. For continuous data, reviewers calculated weighted mean differences. Statistical tests for heterogeneity were also undertaken.

MAIN RESULTS

Eleven studies met the inclusion criteria. All were small, and randomised fewer than 30 people to each group. Most included people after the most acute phase of psychosis and investigated a wide range of antidepressants. The quality of reporting varied a great deal. For the outcome of 'no important clinical response' antidepressants were significantly better than placebo (n=209, 5 RCTs, summary risk difference fixed effects -0.26, 95% CI -0.39 to -0.13, NNT 4 95% CI 3 to 8). The depression score at the end of the trial, as assessed by the Hamilton Rating Scale (HAM-D), seemed to suggest that using antidepressants was beneficial, but this was only statistically significant when a fixed effects model was used (n=261, 6 RCTs, WMD fixed effects -2.2 95% CI -3.8 to -0.6; WMD random effects -2.1 95% CI -5.04 to 0.84). There was no evidence that antidepressant treatment led to a deterioration of psychotic symptoms in the included trials. Heterogeneous data on 'any adverse effect' are equivocal (n=110, 2 RCTs, RD fixed 0.11 CI -0.03 to 0.25, Chi square 7.5, df=1, p=0.0062). In one small study extrapyramidal adverse effects were reported less often by those allocated to antidepressant (n=52, 1 RCT, RD fixed -0.28 CI -0.5 to -0.04). Only about 10% of people left these studies by 12 weeks. There was no apparent difference between those allocated placebo and those given an antidepressant (n=426, 10 RCTs, RD fixed 0.04 CI -0.02 to 0.1).

REVIEWER'S CONCLUSIONS

Overall, the literature was of poor quality, and only a small number of trials made useful contributions. Though our results provide some evidence to indicate that antidepressants may be beneficial for people with depression and schizophrenia, the results, at best, are likely to overestimate the treatment effect, and, at worst, could merely reflect selective reporting of statistically significant results and publication bias. At present, there is no convincing evidence to support or refute the use of antidepressants in treating depression in people with schizophrenia. We need further well-designed, conducted and reported research to determine the best approach towards treating depression in people with schizophrenia.