The European Schizophrenia Cohort (EuroSC): a naturalistic prognostic and economic study

Longitudinal symptomatic interactions in long-standing schizophrenia: a novel five-point analysis based on directed acyclic graphs

BACKGROUND

Recent network models propose that mutual interaction between symptoms has an important bearing on the onset of schizophrenic disorder. In particular, cross-sectional studies suggest that affective symptoms may influence the emergence of psychotic symptoms. However, longitudinal analysis offers a more compelling test for causation: the European Schizophrenia Cohort (EuroSC) provides data suitable for this purpose. We predicted that the persistence of psychotic symptoms would be driven by the continuing presence of affective disturbance.

METHODS

EuroSC included 1208 patients randomly sampled from outpatient services in France, Germany and the UK. Initial measures of psychotic and affective symptoms were repeated four times at 6-month intervals, thereby furnishing five time-points. To examine interactions between symptoms both within and between time-slices, we adopted a novel technique for modelling longitudinal data in psychiatry. This was a form of Bayesian network analysis that involved learning dynamic directed acyclic graphs (DAGs).

RESULTS

Our DAG analysis suggests that the main drivers of symptoms in this long-term sample were delusions and paranoid thinking. These led to affective disturbance, not vice versa as we initially predicted. The enduring relationship between symptoms was unaffected by whether patients were receiving first- or second-generation antipsychotic medication.

CONCLUSIONS

In this cohort of people with chronic schizophrenia treated with medication, symptoms were essentially stable over long periods. However, affective symptoms appeared driven by the persistence of delusions and persecutory thinking, a finding not previously reported. Although our findings as ever remain hostage to unmeasured confounders, these enduring psychotic symptoms might nevertheless be appropriate candidates for directly targeted psychological interventions.

Influence of positive and negative symptoms on hedonic and eudaemonic well-being in people with schizophrenia: A longitudinal analysis from the EuroSc study

BACKGROUND

Subjective well-being in people with schizophrenia is likely to be impaired by positive and negative psychotic symptoms. However, these may impact differentially on hedonic (satisfaction and interest in life) and eudaemonic (optimal psychological and social functioning) components.

AIMS

We hypothesized that positive symptoms would influence the hedonic component, while negative symptoms would be linked to eudaemonic well-being.

METHODS

We tested this using longitudinal data (N = 1208) from the EUROSC study. Measures were repeated after 6, 12, 18 and 24 months. Hedonic and eudaemonic features were identified using the Quality of Life Interview. Positive and negative symptoms were assessed with the Positive and Negative Syndrome Scale. We used latent variable structural equation modelling to investigate the impact of positive and negative symptoms at each of the four data points on well-being components 6 months later, controlling for depressed mood.

RESULTS

The measurement model yielded acceptable fit. People with higher scores on positive symptoms at a given time-point were more likely to report lower scores for hedonic components six months later (6-, 12-, and 24-month), whereas we found no significant paths from negative symptoms to hedonic or eudaemonic features.

CONCLUSIONS

Although we found a longitudinal influence of positive symptoms on hedonic well-being, negative symptoms had no effect on either hedonic or eudaemonic components. While symptom reduction strategies may be helpful for hedonic well-being, the amelioration of eudaemonic features may require targeted psychosocial programmes to help individuals attain more rewarding lives.

Healthcare costs and resource use associated with negative symptoms of schizophrenia: A systematic literature review

OBJECTIVE

To identify and describe the available literature quantifying the economic burden associated with the negative symptoms of schizophrenia.

METHODS

A search of five electronic databases (Medline, PsycINFO, EconLit, CINAHL, EMBASE) and hand searches of bibliographies was conducted to identify all relevant articles written in English and published from date of database inception to January 2021. Search strategies included terms for schizophrenia, negative symptoms, direct and indirect costs and health-care resource utilisation. Quality assessment of included articles was undertaken using a standardised checklist for the evaluation of cost of illness studies. Annual costs were converted to 2022 Australian dollars (A$).

RESULTS

Four hundred and thirty-six abstracts were identified for inclusion. Following screening, six unique studies utilizing data from 6293 participants with an average age of 40 were identified to inform the review. Study quality was high for four studies. All studies concluded there was a positive relationship between negative symptoms and costs or resource utilisation. Four studies providing cost data show an increase in direct costs per annum associated with negative symptoms (range A$ 4046 to 171,564). The wide range in costs was attributable to between study differences in patient characteristics and cohorts, included costs, and country of study.

CONCLUSION

Health care costs and resource utilisation are associated with negative symptoms in people with schizophrenia. Heterogeneity prevented calculation of an overall dollar value per point increase in negative symptoms. Future research is warranted to further quantify the relationship between negative symptoms and costs, including health sector and societal.

Magnetic resonance imaging of the dopamine system in schizophrenia - A scoping review

For decades, aberrant dopamine transmission has been proposed to play a central role in schizophrenia pathophysiology. These theories are supported by human in vivo molecular imaging studies of dopamine transmission, particularly positron emission tomography. However, there are several downsides to such approaches, for example limited spatial resolution or restriction of the measurement to synaptic processes of dopaminergic neurons. To overcome these limitations and to measure complementary aspects of dopamine transmission, magnetic resonance imaging (MRI)-based approaches investigating the macrostructure, metabolism, and connectivity of dopaminergic nuclei, i.e., substantia nigra pars compacta and ventral tegmental area, can be employed. In this scoping review, we focus on four dopamine MRI methods that have been employed in patients with schizophrenia so far: neuromelanin MRI, which is thought to measure long-term dopamine function in dopaminergic nuclei; morphometric MRI, which is assumed to measure the volume of dopaminergic nuclei; diffusion MRI, which is assumed to measure fiber-based structural connectivity of dopaminergic nuclei; and resting-state blood-oxygenation-level-dependent functional MRI, which is thought to measure functional connectivity of dopaminergic nuclei based on correlated blood oxygenation fluctuations. For each method, we describe the underlying signal, outcome measures, and downsides. We present the current state of research in schizophrenia and compare it to other disorders with either similar (psychotic) symptoms, i.e., bipolar disorder and major depressive disorder, or dopaminergic abnormalities, i.e., substance use disorder and Parkinson's disease. Finally, we discuss overarching issues and outline future research questions.

Cognitive remediation and professional insertion of people with schizophrenia: RemedRehab, a randomized controlled trial

Background

People suffering from schizophrenia cannot easily access employment in European countries. Different types of vocational programs coexist in France: supported employment, sheltered employment (ShE), and hybrid vocational programs. It is now acknowledged that the frequent cognitive impairments constitute a major obstacle to employment for people with schizophrenia. However, cognitive remediation (CR) is an evidence-based nonpharmacological treatment for these neurocognitive deficits.

Methods

RemedRehab was a multicentric randomized comparative open trial in parallel groups conducted in eight centers in France between 2013 and 2018. Participants were recruited into ShE firms before their insertion in employment (preparation phase). They were randomly assigned to cognitive training Cognitive Remediation for Schizophrenia (RECOS) or Treatment As Usual (TAU). The aim of the study was to compare with the benefits of the RECOS program on access to employment and work attendance for people with schizophrenia, measured by the ratio: number of hours worked on number of hours stipulated in the contract.

Results

Seventy-nine patients were included in the study between October 2018 and September 2019. Fifty-three patients completed the study. Hours worked / planned hours equal to 1 or greater than 1 were significantly higher in the RECOS group than in the TAU group.

Conclusions

Participants benefited from a RECOS individualized CR program allows a better rate of work attendance in ShE, compared to the ones benefited from TAU. Traditional vocational rehabilitation enhanced with individualized CR in a population of patients with schizophrenia is efficient on work attendance during the first months of work integration.

A Method to Compare the Delivery of Psychiatric Care for People with Treatment-Resistant Schizophrenia

INTRODUCTION

Community services are gaining ground when it comes to attention to patients with psychiatric diseases. Regarding patients with treatment-resistant schizophrenia (TRS), the use of information and communication technology (ICT) could help to shift the focus from hospital-centered attention to community services. This study compares the differences in mental health services provided for patients with TRS in Budapest (Hungary), Tel-Aviv (Israel) and Catalonia (Spain) by means of a method for the quick appraisal of gaps among the three places, for a potential implementation of the same ICT tool in these regions.

METHODS

An adapted version of the Description and Standardised Evaluation of Services and Directories in Europe for Long Term Care (DESDE-LTC) instrument was made by researchers in Semmelweis University (Budapest, Hungary), Gertner Institute (Tel-Aviv, Israel) and Hospital de la Santa Creu I Sant Pau and Parc Sanitari Sant Joan de Déu (Catalonia, Spain).

RESULTS

Two types of outpatient care services were available in the three regions. Only one type of day-care facility was common in the whole study area. Two residential care services, one for acute and the other for non-acute patients were available in every region. Finally, two self-care and volunteer-care facilities were available in the three places.

CONCLUSION

Although the availability of services was different in each region, most of the services provided were sufficiently similar to allow the implementation of the same ICT solution in the three places.

The mediating role of depression in pathways linking positive and negative symptoms in schizophrenia. A longitudinal analysis using latent variable structural equation modelling

BACKGROUND

The interaction between positive, negative and depressive symptoms experienced by people with schizophrenia is complex. We used longitudinal data to test the hypothesis that depressive symptoms mediate the links between positive and negative symptoms.

METHODS

We analyzed data from the European Schizophrenia Cohort, randomly sampled from outpatient services in France, Germany and the UK (N = 1208). Initial measures were repeated after 6 and 12 months. Depressive symptoms were identified using the Calgary Depression Scale for Schizophrenia (CDSS), while positive and negative symptoms were assessed with the Positive and Negative Syndrome Scale (PANSS). Latent variable structural equation modelling was used to investigate the mediating role of depression assessed at 6 months in relation to the longitudinal association between positive symptoms at baseline and negative symptoms at 12 months.

RESULTS

We found longitudinal associations between positive symptoms at baseline and negative symptoms at 12 months, as well as between both of these and CDSS levels at 6 months. However depression did not mediate the longitudinal association between PANSS scores; all the effect was direct.

CONCLUSIONS

Our findings are incompatible with a mediating function for depression on the pathway from positive to negative symptoms, at least on this timescale. The role of depression in schizophrenic disorders remains a challenge for categorical and hierarchical diagnostic systems alike. Future research should analyze specific domains of both depressive and negative symptoms (e.g. motivational and hedonic impairments). The clinical management of negative symptoms using antidepressant treatments may need to be reconsidered.

Duration of untreated psychosis and clinical outcomes of first episode psychosis: An observational and an instrumental variables analysis

AIM

Duration of untreated psychosis (DUP) is considered as a key prognostic variable in psychosis. Yet, it is unclear whether a longer DUP causes worse outcomes or whether reported associations have alternative explanations.

METHODS

Data from 2 cohorts of patients with first episode psychosis were used (n = 2134). Measures of DUP were assessed at baseline and outcomes at 12 months. Regression models were used to investigate the associations between DUP and outcomes. We also investigated whether any associations were replicated using instrumental variables (IV) analysis to reduce the effect of residual confounding and measurement bias.

RESULTS

There were associations between DUP per 1-year increase and positive psychotic symptoms (7.0% in symptom score increase 95% confidence interval (CI) 4.0%, 10.0%, P < .001), worse recovery (risk difference [RD] 0.78, 95%, CI 0.68, 0.83, P < .001) and worse global functioning (0.62 decrease in functioning score 95% CI -1.19, -0.04, P = .035). There was no evidence of an association with negative psychotic symptoms (1.0%, 95%, CI -2.0%, 5.0%, P = .455). The IV analysis showed weaker evidence of associations in the same direction between DUP per 1-year increase and positive psychotic symptoms, recovery and global functioning. However, there was evidence of an inverse association with negative psychotic symptoms (decrease of 15.0% in symptom score 95% CI -26.0%, -3.0%, P = .016).

CONCLUSIONS

We have confirmed previous findings of a positive association between positive psychotic symptoms, global functioning and recovery and DUP using regression analysis. IV analysis shows some support for these findings. Future investigation using IV analysis should be repeated in large data sets.

Positive and negative symptoms in schizophrenia: A longitudinal analysis using latent variable structural equation modelling

BACKGROUND

Recent network models of schizophrenia propose it is the consequence of mutual interaction between its symptoms. While cross-sectional associations between negative and positive symptoms are consistent with this idea, they may merely reflect their involvement in the diagnostic process. Longitudinal analyses however may allow the identification of possible causal relationships. The European Schizophrenia Cohort (EuroSC) provides data suitable for this purpose.

METHODS

EuroSC includes 1208 patients randomly sampled from outpatient services in France, Germany and the UK. Initial measures were repeated after 12 and 24 months. Latent variable structural equation modelling was used to investigate the direction of effect between positive and negative symptoms assessed with the Positive and Negative Syndrome Scale, controlling for the effects of depressed mood and antipsychotic medication.

RESULTS

The structural model provided acceptable overall fit [χ² (953) = 2444.32, P < 0.001; CFI = 0.909; RMSEA = 0.046 (90% CI: 0.043, 0.048); SRMR = 0.052]. Both positive and negative symptoms were persistent, and strongly auto-correlated. There were also persistent cross-sectional associations between positive and negative symptoms. While the path from latent positive to negative symptoms from T1 to T2 approached conventional levels of statistical significance (P = 0.051), that from T2 to T3 did not (P = 0.546). Pathways in the reverse direction were uniformly non-significant.

CONCLUSIONS

There was no evidence that negative symptoms predict later positive symptoms. The prediction of negative symptoms by positive symptoms was ambiguous. We discuss implications for conceptualization of schizophrenic processes.

Prevalence of comorbid substance use in schizophrenia spectrum disorders in community and clinical settings, 1990-2017: Systematic review and meta-analysis

BACKGROUND

Comorbidity is highly prevalent between substance use disorders (SUDs) and schizophrenia. This systematic review and meta-analysis estimated prevalence rates of SUDs in epidemiological and treatment-seeking patients diagnosed with schizophrenia or first episode psychosis.

METHODS

A literature search of Medline, EMBASE, PsycINFO and CINAHL databases was conducted from 1990 to 2017 inclusive. Prevalence of co-morbid SUDs and schizophrenia were extracted and odds ratios (ORs) were calculated using random effects meta-analysis. Combining like studies was dictated how authors reported substance use.

RESULTS

There were 123 included articles with a total sample size of 165,811 subjects that yielded six epidemiological studies, 11 national or state case-registry studies, 20 large cohort studies and 86 clinical studies using in- or out-patient samples. The prevalence of any SUD was 41.7%, followed by illicit drugs (27.5%), cannabis (26.2%), alcohol (24.3%) and stimulant use (7.3%). Meta-analysis showed the pooled variance of any SUD in males was 48% which was significantly higher than that for females with schizophrenia (22.1%, OR 3.43, 95% CI 3.01, 3.92). Patients with SUD had an earlier age of onset of schizophrenia. Meta-regression showed prevalence increased over time for illicit drugs but not for other substances, including alcohol.

CONCLUSIONS

The meta-analysis revealed that SUDs in schizophrenia is highly prevalent and rates have not changed over time. This indicates SUD are difficult to treat in this patient population and there is an urgent need for more informative studies to help develop better prevention, detection and treatment of SUDs in persons with schizophrenia and co-morbid disorders.

Paranoia and maladaptive behaviours in homelessness: The mediating role of emotion regulation

OBJECTIVES

Current research has implicated a role for cognitive and emotional processes in the pathways to becoming homeless. Evidence implicates three risk factors, which are often associated with an increased incidence of homelessness: paranoid thinking, emotion regulation, and engaging in maladaptive behaviours. Maladaptive behaviours include deliberate self-harm, substance misuse, and high-risk sexual practices. Currently, no studies have investigated the specific psychological mechanisms, such as difficulty regulating emotions, which underpin the association between paranoia and maladaptive behaviours.

DESIGN

A mediational design was employed in a group of homeless individuals.

METHOD

Participants (N = 40), who were homeless at the time of the study, completed a single-session assessment of paranoia, emotion regulation, and maladaptive behaviours.

RESULTS

Mediation analyses indicated that individuals scoring high on paranoia were more likely to engage in maladaptive behaviours, particularly substance misuse and aggression, when they had difficulty regulating their emotions. These results demonstrate a novel finding relating to the effect of emotion regulation in maintaining psychopathology and behaviours in vulnerable individuals, which may in turn sustain periods of homelessness.

CONCLUSIONS

Emotion regulation may therefore be one particular psychological mechanism through which severe mental illness affects engagement in self-destructive behaviours in homelessness. These findings have valuable clinical implications for targeted therapeutic interventions, in this often difficult to treat homeless population.

PRACTITIONER POINTS

Psychosis is over-represented in the homeless population; the cycle of homelessness may be attenuated by addressing psychotic symptomology. Homeless individuals engage in drug abuse, self-harm, aggression, and high-risk sexual practices due to an inability to regulate distressing emotions effectively. Therapeutic interventions, such as MBT and DBT, which target emotion regulation difficulties, may be useful in reducing maladaptive behaviours and preventing homelessness, by providing emotion regulation strategies to cope when homeless persons become distressed.

Prevalence of Mental Disorders and Addictions among Homeless People in the Greater Paris Area, France

The Samenta study was conducted in 2009 in the Greater Paris area to estimate the prevalence of psychiatric disorders in homeless people. A cross-sectional survey was performed with a three-stage random sample of homeless people (n = 859), including users of day services, emergency shelters, hot meal distribution, long-term rehabilitation centres, and social hotels. Information was collected by a lay interviewer, using the Mini International Neuropsychiatric Interview, and completed by a psychologist through an open clinical interview. In the end, a psychiatrist assessed the psychiatric diagnosis according to the International Statistical Classification of Diseases and Related Health Problems (ICD, 10th revision). One third of homeless people in the Paris area had at least one severe psychiatric disorder (SPD): psychotic disorders (13%), anxiety disorders (12%), or severe mood disorders (7%). One in five was alcohol-dependent and 18% were drug users. Homeless women had significantly higher prevalence of anxiety disorders and depression compared to men, who were more likely to suffer from psychotic disorders. Homeless people of French origin were at higher risk of SPD, as well as people who experienced various adverse life events before the age of 18 (running away, sexual violence, parental disputes, and/or addictions) and those who experienced homelessness for the first time before the age of 26. The prevalence rates of the main psychiatric disorders within the homeless population of our study are consistent with those reported in other Western cities. Our results advocate for an improvement in the detection, housing, and care of psychiatric homeless people.

Healthcare resource use in schizophrenia, EuroSC findings

Background: It is unclear if the burden associated with schizophrenia is affected by the type and severity of patient's symptoms. Objective: This study aims to quantify healthcare resource use associated with different profiles of schizophrenia symptoms. Study design: Post-hoc analysis of data from a naturalistic follow-up study. Setting: Secondary psychiatric services in France, Germany and the UK. Patients: EuroSC cohort:, representative sample of 1,208 schizophrenia patients Main outcome measure: We classified patients into eight health states, according to the Lenert classification (HS1-HS8), and estimated 6-month healthcare resource use (outpatient and day clinic visits, and hospitalisations) across the health states. Results: Approximately half of the patients were classed as having mild symptoms (HS1), with around 20% experiencing moderate, predominantly negative symptoms (HS2). The remaining health states were represented by <10% of patients each. Very few patients experienced extremely severe symptoms (HS8). No health state was associated with excess utilisation across all resource types. In terms of outpatient visits, patients were estimated to see a psychiatrist most often (3.01-4.15 visits over 6 months). Hospital admission was needed in 11%(HS1) - 35%(HS8) of patients and inpatient stays were generally prolonged for all health states (39-57 days). The average number of inpatient days was highest for patients in HS8 (18.17 days), followed by patients with severe negative symptoms (HS4; 13.37 days). In other health states characterised by severe symptoms (HS5-HS7), the average number of inpatient days was approximately half of those seen for HS4 (6.09-7.66). Conclusion: While none of the symptom profiles was associated with excess resource usage, hospitalization days were highest for HS with severe, predominantly negative or extremely severe symptoms. Patients with predominantly negative, moderate or severe symptoms appeared to have a high number of psychologist visits - an interesting finding that may reflect a specific therapeutic approach to the treatment of these patients.

Psychosocial functioning, quality of life and clinical correlates of comorbid alcohol and drug dependence syndromes in people with schizophrenia across Europe

Little is known about the correlates of comorbid drug and alcohol dependence in people with schizophrenia outside the USA. We tested hypotheses that dependence on alcohol/drugs would be associated with more severe symptoms, and poorer psychosocial functioning and quality of life. The EuroSC Cohort study (N=1204), based in France, Germany and the UK, used semi-structured clinical interviews for diagnoses, and standardized tools to assess correlates. We used mixed models to compare outcomes between past-year comorbid dependence on alcohol/drugs, controlling for covariates and modelling both subject and country-level effects. Participants dependent on alcohol or drugs had fewer negative symptoms on PANSS than their non-dependent counterparts. However, those dependent on alcohol scored higher on PANSS general psychopathology than those who were not, or dependent only on drugs. People with schizophrenia dependent on drugs had poorer quality of life, more extrapyramidal side effects, and scored worse on Global Assessment of Functioning (GAF) than those without dependence. People with alcohol dependence reported more reasons for non-compliance with medication, and poorer functioning on GAF, though not on Global Assessment of Relational Functioning. In people with schizophrenia, comorbid dependence on alcohol or drugs is associated with impaired clinical and psychosocial adjustment, and poorer quality of life.

Predictive models to estimate utility from clinical questionnaires in schizophrenia: findings from EuroSC

OBJECTIVE

The clinical symptoms of schizophrenia are associated with serious social, quality of life and functioning alterations. Typically, data on health utilities are not available in clinical studies in schizophrenia. This makes the economic evaluation of schizophrenia treatments challenging. The purpose of this article was to provide a mapping function to predict unobserved utility values in patients with schizophrenia from the available clinical and socio-demographic information.

METHODS

The analysis was performed using data from EuroSC, a 2-year, multi-centre, cohort study conducted in France (N = 288), Germany (N = 618), and the UK (N = 302), totalling 1208 patients. Utility was calculated based on the EQ-5D questionnaire. The relationships between the utility values and the patients' socio-demographic and clinical characteristics (Positive and Negative Syndrome Scale--PANSS, Calgary Depression Scale for Schizophrenia--CDSS, Global Assessment of Functioning--GAF, extra-pyramidal symptoms measured by Barnes Akathisia Scale-BAS, age, sex, country, antipsychotic type) were modelled using a random and a fixed individual effects panel linear model.

RESULTS

The analysis demonstrated the prediction ability of the used parameters for estimating utility measures in patients with schizophrenia. Although there are small variations between countries, the same variables appear to be the key predictors. From a clinical perspective, age, gender, psychopathology, and depression were the most important predictors associated with the EQ-5D.

CONCLUSION

This paper proposed a reliable, robust and easy-to-apply mapping method to estimate EQ-5D utilities based on demographic and clinical measures in schizophrenia.

Association between social contact frequency and negative symptoms, psychosocial functioning and quality of life in patients with schizophrenia

The lack of social contacts may be an important element in the presumed vicious circle aggravating, or at least stabilising negative symptoms in patients with schizophrenia. A European 2-year cohort study collected negative symptom scores, psychosocial functioning scores, objective social contact frequency scores and quality of life scores every 6 months. Bivariate analyses, correlation analyses, multivariate regressions and random effects regressions were conducted to describe relations between social contact and outcomes of interest and to gain a better understanding of this relation over time. Using data from 1208 patients with schizophrenia, a link between social contact frequency and negative symptom scores, functioning and quality of life at baseline was established. Regression models confirmed the significant association between social contact and negative symptoms as well as psychosocial functioning. This study aimed at demonstrating the importance of social contact for deficient behavioural aspects of schizophrenia.

Epidemiology and Treatment Guidelines of Negative Symptoms in Schizo-phrenia in Central and Eastern Europe: A Literature Review

AIM

To gather and review data describing the epidemiology of schizophrenia and clinical guidelines for schizophrenia therapy in seven Central and Eastern European countries, with a focus on negative symptoms. Methods : A literature search was conducted which included publications from 1995 to 2012 that were indexed in key databases. Results : Reports of mean annual incidence of schizophrenia varied greatly, from 0.04 to 0.58 per 1,000 population. Lifetime prevalence varied from 0.4% to 1.4%. One study reported that at least one negative symptom was present in 57.6% of patients with schizophrenia and in 50-90% of individuals experiencing their first episode of schizophrenia. Primary negative symptoms were observed in 10-30% of patients. Mortality in patients with schizophrenia was greater than in the general population, with a standardized mortality ratio of 2.58-4.30. Reasons for higher risk of mortality in the schizophrenia population included increased suicide risk, effect of schizophrenia on lifestyle and environment, and presence of comorbidities. Clinical guidelines overall supported the use of second-generation antipsychotics in managing negative symptoms of schizophrenia, although improved therapeutic approaches are needed. Conclusion : Schizophrenia is one of the most common mental illnesses and poses a considerable burden on patients and healthcare resources alike. Negative symptoms are present in many patients and there is an unmet need to improve treatment offerings for negative symptoms beyond the use of second-generation antipsychotics and overall patient outcomes.

Utility decrements associated with side effects in schizophrenia

OBJECTIVE

Most of the existing studies investigating the impact of schizophrenia on utility have focused on the different stages of the disease. The objective of this study was to describe and quantify the impact of treatment-related side-effects on utility in patients with schizophrenia, using data from an observational study.

METHODS

This study used data from the European Schizophrenia Cohort (EuroSC), a multi-center 2-year cohort study conducted in France, England, and Germany. The EQ-5D questionnaire was completed every 6 months, as well as the Subjective Side Effect Rating Scale, assessing patient distress over extrapyramidal symptoms (EPS), weight gain, sedation, and sexual dysfunction, used to assess whether or not the patient experienced the side-effect. At first a bivariate analysis was conducted to describe utility values with and without side-effects. Then, a random effects regression analysis was performed on utility, where random effects were controlled for repeated measures on the same subjects, with potential confounding factors. Finally, findings were compared with those of previous publications.

RESULTS

This sample consisted of 1208 patients with schizophrenia. At the baseline visit, the most reported side-effect was EPS (almost 60% of patients), followed by sedation and weight gain (∼50% of patients for each), and sexual dysfunction (almost 30% of patients). Significant association with severity of symptoms, functioning abilities, and utility were found. Patients reporting none of the studied side-effects had an average EQ-5D index score of 0.81, found to be higher than scores of patients reporting EPS (0.70), sexual dysfunction (0.67), sedation (0.70), or weight gain (0.72). The random effects model reported a utility decrement of 0.042 for EPS, 0.022 for weight gain, 0.022 for sexual dysfunction, and 0.019 for sedation. Although the external validation was difficult due to the different methods or definitions of the side-effects, as well as the paucity of data for weight gain, sedation and sexual dysfunction, the results were generally consistent with previous studies.

CONCLUSION

This study aimed at quantifying the direct impact of main side-effects associated with antipsychotics on patients' utility. RESULTS suggested a significant direct impact of side-effects, with EPS being the most impactful.

Exploring the Response Shift Effect on the Quality of Life of Patients with Schizophrenia

Background. Interpretation of quality of life (QoL) scores over time can be difficult because of possible changes in internal standards, values, and conceptualization of QoL by individuals. This effect is called a response shift (RS). The purpose of this study was to examine whether an RS effect occurred over a 24-mo period in patients who were suffering from schizophrenia. Methods. The random forest method was applied to detect any RS reprioritization in a multicenter cohort study. QoL was recorded using a generic questionnaire (SF36) at baseline (T0), 12 mo (T12), and 24 mo (T24). Patients were categorized into 3 groups based on psychotic symptoms and relapse (stable, improved, and worsened groups) from their clinical profiles. The random forest method was performed to predict the General Health score of the SF36 from the other QoL domain scores of the SF36. We estimated the average variable importance of the QoL domain for each of the 3 groups. Results. A total of 124 (53.2%) patients were defined as stable, 59 (25.3%) as improved, and 50 (21.5%) as worsened. Among the stable group, the Social Functioning domain became more important over time. Of those classified as improved, the Mental Health domain became more important over time, while the Vitality domain became less important. Among those in the group who worsened, the Mental Health domain became less important while the Vitality and Bodily Pain domains became more important. Conclusions. Our study identified differential RS reprioritization among patients with different clinical profiles. Further work is needed to determine whether RS should be interpreted as a measurement bias or as an effect integrated in a true change.

Equipercentile linking of scales measuring functioning and symptoms: examining the GAF, SOFAS, CGI-S, and PANSS

The Global Assessment of Functioning (GAF) and the Social and Occupational Functioning Assessment Scale (SOFAS) are rating scales commonly used to assess the level of functioning in patients with schizophrenia. To understand the correspondence of scores between GAF and SOFAS, and what they mean from a clinical point of view, we examined the linkage of (a) GAF with SOFAS total scores, (b) GAF with Clinical Global Impressions Scale (CGI) and Positive and Negative Syndrome Scale (PANSS), and (c) SOFAS with CGI and PANSS. We used the equipercentile linking method to identify corresponding scores of simultaneous GAF, SOFAS, PANSS and CGI ratings in 1208 patients from a naturalistic European cohort study. Data were collected at baseline and at months 6, 12, 18 and 24. GAF and SOFAS total scores were found to be practically exchangeable. Both scales had strong negative correlations with CGI and PANSS; the linkage also suggested the presence of slight impairment in functioning even when patients are free from symptoms. These findings are important for the comparison of scores when different rating scales are used. We present a detailed conversion table in an online supplement.

Evaluation of different approaches for confounding in nonrandomised observational data: a case-study of antipsychotics treatment

Although randomised controlled trials are regarded as the gold standard for treatments efficacy, evidence from observational studies remains relevant. To address the problem of possible confounding in these studies, investigators must employ analysis methods that adjust for confounders and lead to an unbiased estimation of the treatment effect. In this paper, the authors describe two relevant statistical methods. The first method represents the classical approach consisting of a multiple regression model including the effects of treatment and covariates. This approach considers the relation between prognostic factors and the outcome variable as a relevant criterion for adjustment. The second method is based on the propensity score, and focuses on the relation between prognostic factors and treatment assignment. These approaches were applied to a cohort of 183 French schizophrenic patients who were followed for a 2-year period (from 1998 to 2000). The probability of relapse according to antipsychotic treatment exposure was modelled using Cox regression models with the two statistical methods. Goodness-of-fit criteria were used to compare the modelling approaches. This study demonstrates that the propensity score, a predicted probability, has an important balancing property that underscores its value in strengthening the results of nonrandomised observational studies.

Quantification of relevance of quality of life assessment for patients with cognitive impairment: the suitability indices

Background

The extent to which MS patients with cognitive dysfunction can accurately self-report outcomes has been a crucial issue. The aim of this study was to quantify and compare the relevance of the quality of life (QoL) assessment between two populations with a high occurrence of cognitive dysfunction, specifically in individuals with multiple sclerosis (MS) and in individuals suffering from schizophrenia (SCZ).

Methods

Design: A cross-sectional study was performed using the following inclusion criteria: MS and SCZ patients were diagnosed according to the McDonald criteria and DSM-IV criteria, respectively. Data on sociodemographic (age, gender, education level) and clinical (disease severity, disease duration) factors, QoL (disease-specific questionnaires, MusiQoL and SQoL) and cognitive performance (executive, memory, and attention functions) were collected. Non-impaired and impaired populations were defined according to the French norms. Psychometric properties were compared to those reported in reference populations, which were assessed in the respective validation studies. Suitability indices were provided used to quantitatively compare how the structures in the different populations matched with the initial structure of the questionnaires (reference populations).

Results

One hundred and twenty-four MS patients and 113 SCZ patients were enrolled. Factor analysis was performed on the impaired populations and revealed that the questionnaire structure adequately matched the initial structure of the disease-specific QoL questionnaires. All of the suitability indices of construct and external validity in the non-impaired populations ranged from 70 to 100%.

Conclusions

Our study suggested that cognitive dysfunction did not compromise the reliability or validity of the self-reported QoL questionnaires among subjects with cognitive dysfunction, such as MS and SCZ. Thus, this report may clarify the relevance of using self-reported QoL assessments in clinical practice.

Schizophrenia--time to commit to policy change

Care and outcomes for people with schizophrenia have improved in recent years, but further progress is needed to help more individuals achieve an independent and fulfilled life. This report sets out the current need, informs policy makers and all relevant stakeholders who influence care quality, and supports their commitment to creating a better future. The authors recommend the following policy actions, based on research evidence, stakeholder consultation, and examples of best practice worldwide. (1) Provide an evidence-based, integrated care package for people with schizophrenia that addresses their mental and physical health needs. (2) Provide support for people with schizophrenia to enter and to remain in their community, and develop mechanisms to help guide them through the complex benefit and employment systems. (3) Provide concrete support, information, and educational programs to families and carers on how to enhance care for an individual living with schizophrenia in a manner that entails minimal disruption to their lives. (4) All stakeholders, including organizations that support people living with schizophrenia, should be consulted to regularly revise, update, and improve policy on the management of schizophrenia. (5) Provide support, which is proportionate to the impact of the disease, for research and development of new treatments. (6) Establish adequately funded, ongoing, and regular awareness-raising campaigns that form an integral part of routine plans of action. Implementation of the above recommendations will require engagement by every stakeholder, but with commitment from all, change can be achieved.

The size, burden and cost of disorders of the brain in the UK

AIM

The aim of this paper is to increase awareness of the prevalence and cost of psychiatric and neurological disorders (brain disorders) in the UK.

METHOD

UK data for 18 brain disorders were extracted from a systematic review of European epidemiological data and prevalence rates and the costs of each disorder were summarized (2010 values).

RESULTS

There were approximately 45 million cases of brain disorders in the UK, with a cost of €134 billion per annum. The most prevalent were headache, anxiety disorders, sleep disorders, mood disorders and somatoform disorders. However, the five most costly disorders (€ million) were: dementia: €22,164; psychotic disorders: €16,717; mood disorders: €19,238; addiction: €11,719; anxiety disorders: €11,687. Apart from psychosis, these five disorders ranked amongst those with the lowest direct medical expenditure per subject (<€3000). The approximate breakdown of costs was: 50% indirect costs, 25% direct non-medical and 25% direct healthcare costs.

DISCUSSION

The prevalence and cost of UK brain disorders is likely to increase given the ageing population. Translational neurosciences research has the potential to develop more effective treatments but is underfunded. Addressing the clinical and economic challenges posed by brain disorders requires a coordinated effort at an EU and national level to transform the current scientific, healthcare and educational agenda.

Quality of life is predictive of relapse in schizophrenia

BACKGROUND

The objective of this study was to evaluate whether quality of life (QoL), as measured by the SF36 and the Quality of Life Interview (QoLI), is predictive of relapse for patients with schizophrenia.

METHODS

Using data from a multicenter cohort study conducted in France, Germany, and the United-Kingdom (EuroSC), we performed Cox proportional-hazards models to estimate the associations between QoL at baseline and the occurrence of relapse over a 24-month period, with adjustment for age; gender; positive, negative and general psychopathology PANSS factors; functioning (GAF); medication; side-effects; and compliance measures.

RESULTS

Our sample consisted of 1,024 patients; 540 (53%) had at least one period of relapse, and 484 (47%) had no relapse. QoL levels were the most important features predicting relapse. We found that a higher level of QoL predicts a lower rate of relapse at 24 months: HR = 0.82 (0.74; 0.91), p < 0.001 for the SF36-Physical Composite Score; and HR = 0.88 (0.81; 0.96), p = 0.002 for the SF36-Mental Composite Score. These results were not confirmed using the QoLI: HR = 0.91 (0.81; 1.01), p = 0.083. To a lesser extent, older age, better functioning, and a higher compliance score also predict a lower rate of relapse at 24 months (HRs from 0.97 to 0.98; p < 0.05).

CONCLUSIONS

QoL, as assessed by the SF36, is an independent predictor of relapse at a 24-month follow-up in schizophrenia. This finding may have implications for future use of the QoL in psychiatry. Moreover, our findings may support the development and monitoring of complementary therapeutic approaches, such as 'recovery-oriented' combined with traditional mental health cares to prevent relapse.

The lifetime and past-year prevalence of dual diagnosis in people with schizophrenia across Europe: findings from the European Schizophrenia Cohort (EuroSC)

Relatively little is known about rates of comorbid drug and alcohol problems in people with schizophrenia outside the USA. Most studies have recruited from single countries. Newly available data provided an unmatched opportunity to investigate the prevalence of comorbid dependence on alcohol and other psychoactive substances in people with schizophrenia in France, Germany and the UK at the same time. The European Schizophrenia Cohort study data set used semi-structured clinical interviews to establish DSM-IV diagnoses. 1,208 patients were interviewed in nine centres. The lifetime rate for comorbid dependence on any substance was highest in the UK (35 %), but considerably lower in Germany (21 %) and in France (19 %), and generally more than double the past-year rates. Dependence on alcohol and on other psychoactive substances showed similar variations (comorbid alcohol dependence: UK 26 %; Germany 18 %; France 14 %; comorbid drug dependence: UK 18 %; Germany 8 %; France 7 %). Differences within countries persisted after controlling for individual characteristics. The relative odds of dependence were higher than in the general population, but varied between countries and centres. Dependence disorders are a common problem in people with schizophrenia in Western Europe, although effective service configurations have yet to be developed. Overall, these European rates are less than those reported from the USA. Research comparing people with current comorbidity with those who are no longer dependent is needed.

A prospective study of health care resource utilisation and selected costs of schizophrenia in France

Background

Schizophrenia is among the most burdensome and costly illnesses worldwide. To estimate the cost of schizophrenia in France, a longitudinal study was carried out between 1998 and 2002. The main objective of this study was to describe and update the cost of schizophrenia in a longitudinal, representative sample of French patients. The second objective was to identify cost drivers in the treatment of schizophrenia.

Methods

Based on a cohort of 288 French schizophrenic patients during 2 years of prospective follow-up, this study collected clinical, patient reported outcomes, quality of life, functioning, patient management, care giver involvement and resource utilisation data every 6 months. For each service, information was collected on the type of service, the frequency of attendance and type of intervention provided to the patient. Unit costs were based on available French databases. Mean service use and costs over the five time points were estimated using between-effects regression models.

Results

In the total sample of 288 patients aged 18-64 years, the mean total cost (€ 3 534) was mainly accounted for by the cost of inpatient treatment (€ 1 390) and day care (€ 1 331). The estimate of the annual cost for direct medical health care for all French schizophrenic patients was € 1 581 million, including € 621 million for inpatient treatment and € 595 million for day care (77%). The costs for medication accounted for 16.1% of total annual costs. The remaining costs (6.9%) included visits to psychiatrists, general practitioners, other physicians and psychologists. The direct resource allocation showed inpatient treatment as the main direct cost. Unemployment was identified as a major indirect cost of schizophrenia treatment. Positive and depressive schizophrenia symptoms at baseline and relapse occurrence during the follow-up period were associated with a higher cost of treatment. Health satisfaction or negative symptoms of schizophrenia at baseline were associated with lower costs.

Conclusion

Several cost drivers were identified. Based on the results obtained in France, we suggest further analysis of mechanisms that influence the service-specific costs for schizophrenia in other areas of the world.

Missing link in community psychiatry: When a patient with schizophrenia was expelled from her home

Treatment and disposition of homeless patients with schizophrenia represent a great challenge in clinical practice. We report a case of this special population, and discuss the development of homelessness, the difficulty in disposition, their utilization of health services, and possible applications of mandatory community treatment in this group of patients. A 51-year-old homeless female was brought to an emergency department for left femur fracture caused by an assault. She was diagnosed with schizophrenia about 20 years ago but received little help from mental health services over the decades. During hospitalization, her psychotic symptoms were only partially responsive to treatment. Her family refused to handle caretaking duties. The social welfare system was mobilized for long-term disposition. Homeless patients with schizophrenia are characterized by family disruption, poor adherence to health care, and multiple emergency visits and hospitalization. We hope this article can provide information about the current mental health policy to medical personnel. It is possible that earlier intervention and better outcome can be achieved by utilizing mandatory community treatment in the future, as well as preventing patients with schizophrenia from losing shelters.

A pharmacoeconomic analysis of sertindole in the treatment of schizophrenia in Sweden

BACKGROUND

Atypical antipsychotics have similar clinical efficacy in the treatment of schizophrenia; variability in their tolerability represents the discerning factor in treatment choices. Sertindole has a relatively good tolerability profile that favours long-term patient adherence and, therefore, is associated with lower rates of relapse and rehospitalization.

AIM

A model was developed to compare the cost-effectiveness of a 5-year treatment strategy starting with sertindole versus olanzapine, risperidone, aripiprazole or the typical antipsychotic agent, haloperidol.

METHODS

The model was based on published trials and local clinical practice, and considered costs from the perspective of the Swedish National Health Insurance Board.

RESULTS

All atypical agents were clinically superior and more cost-effective than haloperidol with a cost per quality-adjusted life year gained of approximately 490,000 Swedish kroner. Sertindole was associated with the lowest direct and indirect medical costs, driven by its tolerability profile.

CONCLUSIONS

Sertindole represents a useful alternative to the current treatment options available in Sweden.

CLINICAL IMPLICATIONS

The relatively good tolerability profile of sertindole translates into lower costs of schizophrenia management, primarily driven by substantially lower direct and indirect costs. Sertindole appears to be a clinically and cost-effective alternative in the management of patients with schizophrenia in Sweden.

Cost of disorders of the brain in Europe 2010

BACKGROUND

The spectrum of disorders of the brain is large, covering hundreds of disorders that are listed in either the mental or neurological disorder chapters of the established international diagnostic classification systems. These disorders have a high prevalence as well as short- and long-term impairments and disabilities. Therefore they are an emotional, financial and social burden to the patients, their families and their social network. In a 2005 landmark study, we estimated for the first time the annual cost of 12 major groups of disorders of the brain in Europe and gave a conservative estimate of €386 billion for the year 2004. This estimate was limited in scope and conservative due to the lack of sufficiently comprehensive epidemiological and/or economic data on several important diagnostic groups. We are now in a position to substantially improve and revise the 2004 estimates. In the present report we cover 19 major groups of disorders, 7 more than previously, of an increased range of age groups and more cost items. We therefore present much improved cost estimates. Our revised estimates also now include the new EU member states, and hence a population of 514 million people.

AIMS

To estimate the number of persons with defined disorders of the brain in Europe in 2010, the total cost per person related to each disease in terms of direct and indirect costs, and an estimate of the total cost per disorder and country.

METHODS

The best available estimates of the prevalence and cost per person for 19 groups of disorders of the brain (covering well over 100 specific disorders) were identified via a systematic review of the published literature. Together with the twelve disorders included in 2004, the following range of mental and neurologic groups of disorders is covered: addictive disorders, affective disorders, anxiety disorders, brain tumor, childhood and adolescent disorders (developmental disorders), dementia, eating disorders, epilepsy, mental retardation, migraine, multiple sclerosis, neuromuscular disorders, Parkinson's disease, personality disorders, psychotic disorders, sleep disorders, somatoform disorders, stroke, and traumatic brain injury. Epidemiologic panels were charged to complete the literature review for each disorder in order to estimate the 12-month prevalence, and health economic panels were charged to estimate best cost-estimates. A cost model was developed to combine the epidemiologic and economic data and estimate the total cost of each disorder in each of 30 European countries (EU27+Iceland, Norway and Switzerland). The cost model was populated with national statistics from Eurostat to adjust all costs to 2010 values, converting all local currencies to Euro, imputing costs for countries where no data were available, and aggregating country estimates to purchasing power parity adjusted estimates for the total cost of disorders of the brain in Europe 2010.

RESULTS

The total cost of disorders of the brain was estimated at €798 billion in 2010. Direct costs constitute the majority of costs (37% direct healthcare costs and 23% direct non-medical costs) whereas the remaining 40% were indirect costs associated with patients' production losses. On average, the estimated cost per person with a disorder of the brain in Europe ranged between €285 for headache and €30,000 for neuromuscular disorders. The European per capita cost of disorders of the brain was €1550 on average but varied by country. The cost (in billion €PPP 2010) of the disorders of the brain included in this study was as follows: addiction: €65.7; anxiety disorders: €74.4; brain tumor: €5.2; child/adolescent disorders: €21.3; dementia: €105.2; eating disorders: €0.8; epilepsy: €13.8; headache: €43.5; mental retardation: €43.3; mood disorders: €113.4; multiple sclerosis: €14.6; neuromuscular disorders: €7.7; Parkinson's disease: €13.9; personality disorders: €27.3; psychotic disorders: €93.9; sleep disorders: €35.4; somatoform disorder: €21.2; stroke: €64.1; traumatic brain injury: €33.0. It should be noted that the revised estimate of those disorders included in the previous 2004 report constituted €477 billion, by and large confirming our previous study results after considering the inflation and population increase since 2004. Further, our results were consistent with administrative data on the health care expenditure in Europe, and comparable to previous studies on the cost of specific disorders in Europe. Our estimates were lower than comparable estimates from the US.

DISCUSSION

This study was based on the best currently available data in Europe and our model enabled extrapolation to countries where no data could be found. Still, the scarcity of data is an important source of uncertainty in our estimates and may imply over- or underestimations in some disorders and countries. Even though this review included many disorders, diagnoses, age groups and cost items that were omitted in 2004, there are still remaining disorders that could not be included due to limitations in the available data. We therefore consider our estimate of the total cost of the disorders of the brain in Europe to be conservative. In terms of the health economic burden outlined in this report, disorders of the brain likely constitute the number one economic challenge for European health care, now and in the future. Data presented in this report should be considered by all stakeholder groups, including policy makers, industry and patient advocacy groups, to reconsider the current science, research and public health agenda and define a coordinated plan of action of various levels to address the associated challenges.

RECOMMENDATIONS

Political action is required in light of the present high cost of disorders of the brain. Funding of brain research must be increased; care for patients with brain disorders as well as teaching at medical schools and other health related educations must be quantitatively and qualitatively improved, including psychological treatments. The current move of the pharmaceutical industry away from brain related indications must be halted and reversed. Continued research into the cost of the many disorders not included in the present study is warranted. It is essential that not only the EU but also the national governments forcefully support these initiatives.

Relapse according to antipsychotic treatment in schizophrenic patients: a propensity-adjusted analysis

OBJECTIVE

To compare the rate of relapse as a function of antipsychotic treatment (monotherapy vs. polypharmacy) in schizophrenic patients over a 2-year period.

METHODS

Using data from a multicenter cohort study conducted in France, we performed a propensity-adjusted analysis to examine the association between the rate of relapse over a 2-year period and antipsychotic treatment (monotherapy vs. polypharmacy).

RESULTS

Our sample consisted in 183 patients; 50 patients (27.3%) had at least one period of relapse and 133 had no relapse (72.7%). Thirty-eight (37.7) percent of the patients received polypharmacy. The most severely ill patients were given polypharmacy: the age at onset of illness was lower in the polypharmacy group (p = 0.03). Patients that received polypharmacy also presented a higher general psychopathology PANSS subscore (p = 0.04) but no statistically significant difference was found in the PANSS total score or the PANSS positive or negative subscales. These patients were more likely to be given prescriptions for sedative drugs (p < 0.01) and antidepressant medications (p = 0.03). Relapse was found in 23.7% of patients given monotherapy and 33.3% given polypharmacy (p = 0.16). After stratification according to quintiles of the propensity score, which eliminated all significant differences for baseline characteristics, antipsychotic polypharmacy was not statistically associated with an increase of relapse: HR = 1.686 (0.812; 2.505).

CONCLUSION

After propensity score adjustment, antipsychotic polypharmacy is not statistically associated to an increase of relapse. Future randomised studies are needed to assess the impact of antipsychotic polypharmacy in schizophrenia.

Reliability and validity of the global assessment of relational functioning (GARF) in a psychiatric family therapy clinic

The reliability and validity of the Diagnostic and Statistical Manual of Mental Disorders-IV Global Assessment of Relational Functioning (GARF) was evaluated in consenting participants presenting to a family therapy training clinic. The purpose of this study was to (a) assess whether the GARF could be administered quickly in a marriage and family therapy training clinic, (b) assess the inter-rater and internal reliability of GARF ratings of intake sessions, (c) examine the relationship of GARF ratings to established measures of relationship functioning, and (d) compare GARF ratings to a measure of depressive symptoms. Study participants completed the General Functioning Subscale of the Family Assessment Device (GFS/FAD), the Quality of Marriage Index (QMI), and the Center for Epidemiologic Studies-Depression Scale (CES-D). After intake sessions were conducted with study participants, GARF ratings were made by an American Association for Marriage and Family Therapy Approved Supervisor or Supervisor-in-Training, a therapist trainee, and two observing trainees who had observed the session from behind a one-way mirror. Cronbach's coefficient alphas and the average intraclass correlation coefficients were both .82 when ratings of the supervisor and two observers were compared and .78 and .79, respectively, when ratings of the supervisor, two observers, and therapist were evaluated. There was significant agreement between GARF ratings made by the supervisor and therapist (but not observers) and scores on the GFS/FAD, QMI, and CES-D. Results suggest that GARF ratings can be made quickly and reliably, especially among raters with greater clinical experience, and are related to measures of relational functioning and depression. Implications for research and marriage and family therapy training are discussed.

Direct medical mental health care costs of schizophrenia in France, Germany and the United Kingdom - findings from the European Schizophrenia Cohort (EuroSC)

OBJECTIVES

To quantify and compare the resource consumption and direct costs of medical mental health care of patients suffering from schizophrenia in France, Germany and the United Kingdom.

METHODS

In the European Cohort Study of Schizophrenia, a naturalistic two-year follow-up study, patients were recruited in France (N=288), Germany (N=618), and the United Kingdom (N=302). Data about the use of services and medication were collected. Unit cost data were obtained and transformed into United States Dollar Purchasing Power Parities (USD-PPP). Mean service use and costs were estimated using between-effects regression models.

RESULTS

In the French/German/UK sample estimated means for a six-month period were respectively 5.7, 7.5 and 6.4 inpatient days, and 11.0, 1.3, and 0.7 day-clinic days. After controlling for age, sex, number of former hospitalizations and psychopathology (CGI score), mean costs were 3700/2815/3352 USD-PPP.

CONCLUSIONS

Service use and estimated costs varied considerably between countries. The greatest differences were related to day-clinic use. The use of services was not consistently higher in one country than in the others. Estimated costs did not necessarily reflect the quantity of service use, since unit costs for individual types of service varied considerably between countries.

Side-effects of antipsychotic medication and health-related quality of life in schizophrenia

OBJECTIVE

This analysis used data from the large (n = 1208) European Schizophrenia Cohort to examine the association between subjective side-effects of antipsychotic medication and the Mental and Physical Composite Scores (MCS; PCS) of the SF-36 scale.

METHOD

Relationships between the subjective evaluation of side-effects identified from the Subjective Side-Effects Scale and the adjusted mean score on the PCS and MCS were examined. Where appropriate, these associations of subjective side-effects were compared with those of the same side-effects measured objectively.

RESULTS

In this study, subjective side-effects of antipsychotic medication were linked either to both the PCS and the MCS or, in a few instances, to neither. Subjective evaluations of sexual side-effects were associated only with the MCS, those of sialorrhoea only with the PCS. Objective ratings of extrapyramidal side-effects were related neither to PCS nor to MCS.

CONCLUSION

These data suggest that side-effects, whether subjective or objective, may need to be considered individually in relation to their impact on quality of life.

Urban residence, victimhood and the appraisal of personal safety in people with schizophrenia: results from the European Schizophrenia Cohort (EuroSC)

BACKGROUND

Patients with schizophrenia are at increased risk of being victims of violent and non-violent crimes. We have determined how the experience of crime and subjective feelings of safety differ between urban and rural residential areas.

METHOD

We analysed data from the European Schizophrenia Cohort (EuroSC), a 2-year follow-up study of 1208 patients in the UK, France and Germany. Subjective safety and a history of victimhood were elicited with Lehman's Quality of Life Inventory. Regression models adjusted the effects of living environment for country, education, employment, financial situation, drug and alcohol abuse, criminal arrests and the level of schizophrenic symptoms.

RESULTS

Ten per cent of patients were victims of violent and 19% of non-violent crimes. There was no significant relationship between victim status and residential area. However, subjective safety was clearly worse in cities than in rural areas. Aspects of objective and subjective safety were related to different factors: being the victim of violence was most strongly associated with alcohol and drug abuse and with criminal arrests of the patients themselves, whereas impaired subjective safety was most strongly associated with poverty and victimhood experience.

CONCLUSIONS

Although urban living was not associated with increased objective threats to their security, patients did feel more threatened. Such stress and anxiety can be related to concepts of social capital, and may contribute unfavourably to the course of the illness, reflecting the putative role of appraisal in cognitive models of psychosis. Securing patients' material needs may provide a way to improve subjective safety.

Outcomes of public concern in schizophrenia

BACKGROUND

Schizophrenia is known to be associated with a range of adverse outcomes, which have an impact atthe societal level and are therefore of public concern.

AIMS

To examine the epidemiology and methods for measuring six adverse outcomes in schizophrenia: violence, victimisation, suicide/self-harm, substance use, homelessness and unemployment.

METHOD

A review ofthe literature was carried out for each adverse outcome, with attention to critical appraisal of existing measurement tools.

RESULTS

Schizophrenia is associated strongly with all six outcomes, although research has mainly focused on violence. Each outcome acts as a risk factor for at least some of the other outcomes. There are few standardised or validated measures for these 'hard' outcomes. Each measure has inherent biases but a growing trend is for these to be minimised by using multiple measures.

CONCLUSIONS

A single instrument which systematically measures multiple societal outcomes of schizophrenia would be extremely useful for both clinical and research purposes.

Correlates of subjective quality of life in people with schizophrenia: findings from the EuroSC study

Quality of life (QOL) is an important outcome for people with schizophrenia, but most previous studies of its correlates have had small sample sizes or explored a limited number of variables. We conducted an analysis of the baseline data from the European Schizophrenia Cohort (EuroSC) study, a naturalistic investigation of people with schizophrenia living in France, Germany, and the United Kingdom (N = 1208). German participants had the highest subjective QOL. Country of residence, depression, accommodation status, and employment were the most important factors in explaining subjective QOL. Many correlates of subjective QOL in people with schizophrenia were similar to those in the general population. Many of the factors important in explaining subjective QOL in people with schizophrenia are not readily amenable to change. Differences in mental health service provision in the United Kingdom and Germany may in part explain variations in the QOL of people with schizophrenia resident there.

Predicting clinical and social outcome of patients attending 'real world' mental health services: a 6-year multi-wave follow-up study

OBJECTIVE

The aims of this study were: i) to determine changes in symptoms and social disability, and ii) to explore predictors of clinical and social outcome in patients receiving community-based mental health care.

METHOD

A total of 354 patients treated in the South-Verona Community Mental Health Service were followed up over 6 years (with assessments made at baseline, 2 and 6 years) by using a set of standardized measures exploring psychopathology (Brief Psychiatric Rating Scale) and social disability (Disability Assessment Schedule). Generalized linear latent and mixed models were used to explore longitudinal predictors of clinical and social outcome.

RESULTS

Psychotic patients displayed clinical and social outcome characterized by complex patterns of exacerbation and remission over time; however, a clear trend towards a deteriorating course was not found, thus challenging the notion that psychotics are fatally prone to a destiny of chronicity. Non-psychotics reported a significant reduction in the core symptom of depression and in the observable physical and motor manifestations of tension and agitation, and a parallel increase in complaints about their physical health. Clinical and social dimensions of outcome are influenced by specific and different set of predictors.

CONCLUSION

The results of this study confirm the need to implement naturalistic outcome studies conducted in the 'real world' services to inform decisions and strategies to be adopted in routine clinical practice.

Clinical trials: bridging the gap between efficacy and effectiveness

The need for clinical psychiatry research to provide practical information to clinicians, families, and consumers has led to the development of new approaches to clinical trials. Efficacy trials, the historical backbone of clinical research, have many shortcomings in delivering practical information to stakeholders. The 'effectiveness' or 'public-health' model of intervention research targets a diverse group of patients across multiple settings that are outside of academic medical centres, with study design and outcomes that are selected on the basis of their potential to produce clinically meaningful information. The National Institute of Mental Health has funded three such clinical trials in recent years, respectively targeting schizophrenia and Alzheimer's disease, depression, and bipolar disorder. Each of these studies has made a major impact, and provided new insights into the challenges of public health orientated trials in psychiatry. In this review, we describe the underlying principles and practical considerations in efficacy and effectiveness-orientated trials.

Residential area and social contacts in schizophrenia. Results from the European Schizophrenia Cohort (EuroSC)

BACKGROUND

Social isolation is associated with poor prognosis in schizophrenia. We aim to determine the effect of rural or urban residence on frequency of social and family contacts.

METHOD

We analysed data from the European Schizophrenia Cohort, a two-year follow-up study of 1,208 patients in Britain, France and Germany. Frequency of contact was elicited with Lehman's Quality of Life Inventory. Between-effect error component regression models adjusted the effects of living environment for country, age, gender, education, schizophrenia symptoms and global functioning.

RESULTS

Across all living conditions, contact with family occurred more frequently than contact with others. Family visits, social visits and planned social activities were less common in urban compared to rural settings, whereas no significant differences were found for social and family telephone calls and time spent with a spouse. Patients living with a partner had more family, but fewer social contacts, while women had more contact by phone. Family and social contacts across all categories decreased with age. Employment increased social contacts, but did not affect visits or phone calls within the family. Schizophrenia symptoms, particularly negative symptoms, and impaired global functioning decreased all aspects of social and family contacts.

DISCUSSION

Contrasting with results of previous studies, we found rural living was associated with greater frequency of social contacts in patients suffering from schizophrenia. Beyond living environment, our findings stress the importance both of an adequate control of negative symptoms and of employment opportunities for schizophrenia patients in order to enhance their social networks.

Rates and correlates of employment in people with schizophrenia in the UK, France and Germany

BACKGROUND

Little is known about international variations in employment rates among people with schizophrenia or about the factors associated with employment in this disorder.

AIMS

To describe employment patterns and the variables associated with working in an international sample of people with schizophrenia.

METHOD

An analysis was made of baseline data from the European Schizophrenia Cohort study, a 2-year investigation of people with schizophrenia in contact with secondary services and living in France, Germany and the UK (n=1208).

RESULTS

Participants were working in all sections of the job market. People who had a degree, were living with their families or had experienced only a single episode of illness were more likely to be working. A continuous illness course, more severe non-psychotic symptoms and drug misuse reduced the odds of employment. There were large variations between centres in employment rates, which were highest in the three German study sites. These differences persisted after adjustment for individual characteristics.

CONCLUSIONS

Local social contexts may be as important as individual or illness-related factors in explaining employment status.

A prospective study of Quality of life in schizophrenia in three European countries

Only a small number of studies have tried to identify factors influencing the subjective QoL of patients suffering from schizophrenia in a longitudinal design. These studies suffer from small clinical samples or compare baseline data only with a single follow-up. The European Schizophrenia Cohort Study overcomes these shortcomings by providing data from five time points on 1208 patients in psychiatric treatment in three European countries over a period of 2 years. QoL was measured with the brief version of Lehman's Quality of Life Interview. Random effects, between-effects and within-effects regression models were computed in order to measure the influence on subjective QoL of patients' socio-demographic and clinical characteristics and objective QoL. Objective QoL scores were generally found to be related to the equivalent subjective QoL scores. People's financial situation, and depressive and positive symptoms had a general effect on almost all subjective domains. The significant effects of objective finances on subjective domains like health and social relations raise interesting possibilities for intervention. Sufficient financial resources appear to be a necessary condition for achieving satisfactory QoL in schizophrenia patients. However, changes in individual's characteristics and circumstances did not relate as strongly as expected to changes in QoL, suggesting effective intervention may be difficult.

Burden on caregivers of people with schizophrenia: comparison between Germany and Britain

BACKGROUND

Burden on the relatives of patients with schizophrenia may be influenced not only by patient and caregiver characteristics, but also by differences in mental health service provision.

AIMS

To analyse whether family burden is affected by national differences in the provision of mental health services.

METHOD

Patients with schizophrenia and their key relatives were examined in Germany (n=333) and Britain (n=170). Differences in family burden in both countries were analysed with regression models controlling for patient and caregiver characteristics.

RESULTS

Family burden was associated with patients'symptoms, male gender, unemployment and marital status, as well as caregivers'coping abilities, patient contact and being a patient's parent. However, even when these attributes were controlled for, British caregivers reported more burden than German caregivers.

CONCLUSIONS

National differences in family burden may be related to different healthcare systems in Germany and Britain. Support for patients with schizophrenia may be shifted from the professional to the informal healthcare sector more in Britain than in Germany.