Predictors of relapse in Chinese schizophrenia patients: a prospective, multi-center study

Working memory deterioration as an early warning sign for relapse in remitted psychosis: A one-year naturalistic follow-up study

BACKGROUND

Relapse prevention is an important goal in the clinical management of psychosis. Cognitive deficits/deterioration can provide useful insights for monitoring relapse in psychosis patients.

METHODS

This was a prospective, naturalistic 1-year follow-up study involving 110 psychosis patients with full clinical remission. Relapse, defined as the recurrence of psychotic symptoms, was monitored monthly along with digital tracking of verbal and visual working memory using a mobile app developed for this study. Cognitive deterioration was defined as worsening performance over 2 months prior to relapse or study termination, whichever was earlier. Other clinical, cognitive, functioning, and psychosocial variables were also collected.

RESULTS

At 1 year, 18 (16.36%) patients relapsed, of which 6 (33.33%) required hospitalization. Relapse was predicted by verbal working memory deterioration 2 months prior to relapse (p = 0.029), worse medication adherence (p = 0.018), and less resilience (p = 0.014).

CONCLUSIONS

Verbal working memory deterioration is a novel early sign of relapse. It is a clearly defined, objectively measurable, and reproducible marker that can help clinicians and healthcare workers identify patients at risk of relapse and make decisions about maintenance therapy. Moreover, digital monitoring is a viable tool in the management of relapse.

Antipsychotic dose reduction compared to dose continuation for people with schizophrenia

BACKGROUND

Antipsychotic drugs are the mainstay treatment for schizophrenia, yet they are associated with diverse and potentially dose-related side effects which can reduce quality of life. For this reason, the lowest possible doses of antipsychotics are generally recommended, but higher doses are often used in clinical practice. It is still unclear if and how antipsychotic doses could be reduced safely in order to minimise the adverse-effect burden without increasing the risk of relapse.

OBJECTIVES

To assess the efficacy and safety of reducing antipsychotic dose compared to continuing the current dose for people with schizophrenia.

SEARCH METHODS

We conducted a systematic search on 10 February 2021 at the Cochrane Schizophrenia Group's Study-Based Register of Trials, which is based on CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, PubMed, ClinicalTrials.gov, ISRCTN, and WHO ICTRP. We also inspected the reference lists of included studies and previous reviews.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing any dose reduction against continuation in people with schizophrenia or related disorders who were stabilised on their current antipsychotic treatment.  DATA COLLECTION AND ANALYSIS: At least two review authors independently screened relevant records for inclusion, extracted data from eligible studies, and assessed the risk of bias using RoB 2. We contacted study authors for missing data and additional information. Our primary outcomes were clinically important change in quality of life,  rehospitalisations and dropouts due to adverse effects; key secondary outcomes were clinically important change in functioning, relapse, dropouts for any reason, and at least one adverse effect. We also examined scales measuring symptoms, quality of life, and functioning as well as a comprehensive list of specific adverse effects. We pooled outcomes at the endpoint preferably closest to one year. We evaluated the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included 25 RCTs, of which 22 studies provided data with 2635 participants (average age 38.4 years old). The median study sample size was 60 participants (ranging from 18 to 466 participants) and length was 37 weeks (ranging from 12 weeks to 2 years). There were variations in the dose reduction strategies in terms of speed of reduction (i.e. gradual in about half of the studies (within 2 to 16 weeks) and abrupt in the other half), and in terms of degree of reduction (i.e. median planned reduction of 66% of the dose up to complete withdrawal in three studies). We assessed risk of bias across outcomes predominantly as some concerns or high risk.  No study reported data on the number of participants with a clinically important change in quality of life or functioning, and only eight studies reported continuous data on scales measuring quality of life or functioning. There was no difference between dose reduction and continuation on scales measuring quality of life (standardised mean difference (SMD) -0.01, 95% confidence interval (CI) -0.17 to 0.15, 6 RCTs, n = 719, I2 = 0%, moderate certainty evidence) and scales measuring functioning (SMD 0.03, 95% CI -0.10 to 0.17, 6 RCTs, n = 966, I2 = 0%, high certainty evidence). Dose reduction in comparison to continuation may increase the risk of rehospitalisation based on data from eight studies with estimable effect sizes; however, the 95% CI does not exclude the possibility of no difference (risk ratio (RR) 1.53, 95% CI 0.84 to 2.81, 8 RCTs, n = 1413, I2 = 59% (moderate heterogeneity), very low certainty evidence). Similarly, dose reduction increased the risk of relapse based on data from 20 studies (RR 2.16, 95% CI 1.52 to 3.06, 20 RCTs, n = 2481, I2 = 70% (substantial heterogeneity), low certainty evidence).   More participants in the dose reduction group in comparison to the continuation group left the study early due to adverse effects (RR 2.20, 95% CI 1.39 to 3.49, 6 RCTs with estimable effect sizes, n = 1079, I2 = 0%, moderate certainty evidence) and for any reason (RR 1.38, 95% CI 1.05 to 1.81, 12 RCTs, n = 1551, I2 = 48% (moderate heterogeneity), moderate certainty evidence). Lastly, there was no difference between the dose reduction and continuation groups in the number of participants with at least one adverse effect based on data from four studies with estimable effect sizes (RR 1.03, 95% CI 0.94 to 1.12, 5 RCTs, n = 998 (4 RCTs, n = 980 with estimable effect sizes), I2 = 0%, moderate certainty evidence).  AUTHORS' CONCLUSIONS: This review synthesised the latest evidence on the reduction of antipsychotic doses for stable individuals with schizophrenia. There was no difference between dose reduction and continuation groups in quality of life, functioning, and number of participants with at least one adverse effect. However, there was a higher risk for relapse and dropouts, and potentially for rehospitalisations, with dose reduction. Of note, the majority of the trials focused on relapse prevention rather potential beneficial outcomes on quality of life, functioning, and adverse effects, and in some studies there was rapid and substantial reduction of doses. Further well-designed RCTs are therefore needed to provide more definitive answers.

Clinical and demographic factors associated with early relapse in patients with schizophrenia: a naturalistic observation study

Schizophrenia is a chronic psychiatric disorder progressing in relapses. Identification of many factors that may potentially increase the risk of relapse will be an important step in preventing relapses. The aim of this study was to determine the rate of early relapse in patients with schizophrenia and possible risk factors related to early relapse. The sample of this prospective study with the naturalistic observation design consisted of 308 patients with schizophrenia. The cutoff value for early relapse was determined as 1 year. The mean age of participants was 37.38 ± 12.28 years and 66.6% of them were male (n = 205). The early relapse rate was 38.3%. The age younger than 35 [hazard ratio (HR) = 2.313; 95% confidence interval (CI), 1.518-3.526; P < 0.001], use of psychoactive substance (HR = 2.200; 95% CI, 1.407-3.440; P = 0.001), previous attempt of suicide (HR = 1.565; 95% CI, 1.028-2.384; P = 0.037), bad adherence to treatment (HR = 3.102; 95% CI, 1.358-7.086; P = 0.007), long-acting injectables (LAIs) antipsychotics in the treatment (HR = 0.534; 95% CI, 0.351-0.812; P = 0.003), combination typical-atypical antipsychotics (HR = 0.326; 95% CI, 0.131-0.807; P = 0.015), number of episodes (HR = 1.088; 95% CI, 1.043-1.134), and the score on the Side Effect factor of the Clinical Global Impressions Scale (HR = 1.826; 95% CI, 1.357-2.458; P < 0.001) were identified as the independent predictors of early relapse. It is remarkable that treatment bad adherence, use of psychoactive substance, no LAIs antipsychotics included in the treatment, and the no presence of the combination of typical and atypical antipsychotics are alterable predictors of early relapse.

Disease burden of schizophrenia patients visiting a Chinese regional mental health centre

Aim & methods: A decision-analytic model was constructed to simulate a real-world cohort of Chinese patients visiting a Chinese regional mental health center for long-term health outcomes and direct medical costs. Results: When compared with age and gender-matched general population, the Chinese patients with schizophrenia were associated with reduced overall survival by 20.6 years (27.6 vs 48.2 years) and reduced quality-adjusted life years (QALY) by 18.4 QALY (18.4 vs 36.8 QALY), respectively, and increased lifetime direct medical costs by about three-times (US$84,324 vs 33,387 as of 31 December 2017) on average. Conclusion: The burden of schizophrenia was mainly driven by the mortality associated with relapsed schizophrenia and direct medical costs for schizophrenia in local mental health rehabilitation institutes.

Neuroinflammation in the dorsolateral prefrontal cortex in elderly chronic schizophrenia

Cognitive deterioration and symptom progression occur in schizophrenia over the course of the disorder. A dysfunction of the immune system/neuroinflammatory pathways has been linked to schizophrenia (SZ). These altered processes in the dorsolateral prefrontal cortex (DLPFC) could contribute to the worsening of the deficits. However, limited studies are available in this brain region in elderly population with long-term treatments. In this study, we explore the possible deregulation of 21 key genes involved in immune homeostasis, including pro- and anti-inflammatory cytokines, cytokine modulators (toll-like receptors, colony-stimulating factors, and members of the complement system) and microglial and astroglial markers in the DLPFC in elderly chronic schizophrenia. We used quantitative real-time reverse transcriptase polymerase chain reaction (RT-PCR) on extracts from postmortem DLPFC of elderly subjects with chronic SZ (n = 14) compared to healthy control individuals (n = 14). We report that CSF1R, TLR4, IL6, TNFα, TNFRSF1A, IL10, IL10RA, IL10RB, and CD68 were down-regulated in elderly SZ subjects. Moreover, we found that the expression levels of all the altered inflammatory genes in SZ correlated with the microglial marker CD68. However, no associations were found with the astroglial marker GFAP. This study reveals a decrease in the gene expression of cytokines and immune response/inflammation mediators in the DLPFC of elderly subjects with chronic schizophrenia, supporting the idea of a dysfunction of these processes in aged patients and its possible relationship with active microglia abundance. These findings include elements that might contribute to the cognitive decline and symptom progression linked to DLPFC functioning at advanced stages of the disease.

The association between season of birth, age at onset, and clozapine use in schizophrenia

OBJECTIVE

This study aimed to determine whether the rate of clozapine use, an indicator of refractoriness in schizophrenia, is associated with the season of birth and age at onset in patients with schizophrenia based on nationwide data.

METHODS

Patients with schizophrenia (n = 114 749) who received prescriptions for antipsychotic medication between 2008 and 2014 were retrospectively identified from the Korean National Health Insurance Service database. The study population was divided into three groups based on their age at the onset of schizophrenia (early, middle, and late onset). We assessed differences in the month of birth between patients and the general population. In addition, the cumulative clozapine use was calculated.

RESULTS

Compared to the late-onset schizophrenia group, the early- and middle-onset groups showed a higher probability of birth during the winter season. In addition, the early-onset group showed the highest cumulative clozapine use rate. In the middle-onset group, the initiation of clozapine use was significantly earlier for patients born in winter compared to those born in summer.

CONCLUSION

Our results indicate that the age at onset is an important factor in predicting the prognosis of schizophrenia patients. The season of birth also affects the prognosis, but with less robustness. Specifically, it appears that early disease onset and winter birth might be associated with poor outcomes in Korean patients with schizophrenia.

The magnitude of and health system responses to the mental health treatment gap in adults in India and China

This Series paper describes the first systematic effort to review the unmet mental health needs of adults in China and India. The evidence shows that contact coverage for the most common mental and substance use disorders is very low. Effective coverage is even lower, even for severe disorders such as psychotic disorders and epilepsy. There are vast variations across the regions of both countries, with the highest treatment gaps in rural regions because of inequities in the distribution of mental health resources, and variable implementation of mental health policies across states and provinces. Human and financial resources for mental health are grossly inadequate with less than 1% of the national health-care budget allocated to mental health in either country. Although China and India have both shown renewed commitment through national programmes for community-oriented mental health care, progress in achieving coverage is far more substantial in China. Improvement of coverage will need to address both supply-side barriers and demand-side barriers related to stigma and varying explanatory models of mental disorders. Sharing tasks with community-based workers in a collaborative stepped-care framework is an approach that is ripe to be scaled up, in particular through integration within national priority health programmes. India and China need to invest in increasing demand for services through active engagement with the community, to strengthen service user leadership and ensure that the content and delivery of mental health programmes are culturally and contextually appropriate.

Prolactin related symptoms during risperidone maintenance treatment: results from a prospective, multicenter study of schizophrenia

BACKGROUND

This study aimed to investigate prolactin related symptoms (PRS) in individuals with schizophrenia during risperidone maintenance treatment for one year, as well as to identify the risk factors for PRS.

METHODS

In a multicenter, randomized, controlled, longitudinal study, clinically stabilized schizophrenia patients (N = 374) were randomized to a no-dose-reduction group (N = 129) and 4-week (N = 125) and 26-week (N = 120) reduction groups, in which the original dose was followed by a 50 % reduction over 8 weeks and subsequently maintained. PRS were assessed via a scale of prolactin related adverse events, which included 16 items: menstrual cycle, menstrual period, menstrual volume, menstrual irregularities, amenorrhea, dysmenorrhea, postpartum lactation, gynecomastia, breast tenderness, sexual dysfunction, decreased sexual desire, erectile dysfunction, ejaculatory dysfunction, impotence, increased body hair, and acne. The occurrence of PRS was assessed at baseline and monthly for six months, followed by every two months. A mixed model was used.

RESULTS

PRS at baseline were reported in 18.4, 15.0, and 14.0 % of the 4-week, 26-week, and no-dose-reduction groups, respectively. Female gender, younger age at onset, and the Positive and Negative Syndrome Scale (PANSS) total scores at entry predicted the development of PRS. The mixed model indicated that PRS were more severe in females and at a high dose. In the 237 patients who remained in the study after one year, the incidence of PRS decreased to 9.6, 11.1, and 7.6 % in the 4-week, 26-week, and no-dose-reduction groups, respectively.

CONCLUSION

These findings indicate that the PRS severity was alleviated during the one year treatment period because of the dose reduction. Attention should focus on the side effects of hyperprolactinemia during long-term treatment, especially with a high dose, females, younger age at onset, and more severe patients.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT00848432 . Registered February 19, 2009.

Psychiatrist's adherence: a new factor in relapse prevention of schizophrenia. A randomized controlled study on relapse control through telemedicine system

ACCESSIBLE SUMMARY

Exposure to psychotic states has detrimental effects on the long-term outcome of schizophrenia and brain integrity. Therefore, improving relapse prevention is a key component of long-term management of schizophrenia. Previous studies using continuous monitoring of an individual's early signs of relapse and adopting preventative pharmacological interventions, when early signs are detected, showed promising clinical results in terms of relapse risk reduction. This 18-month multi-centre parallel randomized controlled, open label, trial with telemedicine relapse prevention programme ITAREPS failed to show superiority of maintenance plus prodrome-based targeted medication strategy over treatment as usual. The study, marked by low investigator's adherence, confirmed that absence of pharmacological intervention at early stage of prodrome, critically influenced the risk of relapse. This and previous randomized controlled trials with telemedicine programme ITAREPS suggested that substantial improvement in relapse prevention in schizophrenia is likely to be unattainable under current clinical settings. Future preventive strategies in schizophrenia would require rapid pharmacological intervention upon occurrence of subclinical prodromal symptoms that are undetectable under conventional outpatient practice. Studies with ITAREPS suggested that integration of telemedicine relapse prevention systems and visiting nurse service might together represent practical solution capable to address those requirements.

ABSTRACT

The Information Technology Aided Relapse Prevention Programme in Schizophrenia (ITAREPS) presents a telemedicine solution for weekly monitoring and management of schizophrenia. This study aims to evaluate the effectiveness of the programme in reducing the number of hospitalizations during the 18-month multi-centre parallel randomized controlled, open label, trial. Outpatients with schizophrenia or schizoaffective disorder were randomized to the active (n = 74) or control group (n = 72). In the active arm, investigators increased the antipsychotic dose upon occurrence of prodrome announced by the system. Intention-to-treat analysis showed no between-group difference in the hospitalization-free survival rate [Kaplan-Meier method; hazard ratio (HR) = 1.21, 95% confidence interval (CI): 0.56-2.61, P = 0.6). In a post hoc multivariate Cox proportional hazards model, out of 13 potential predictors, only ITAREPS-related variables (number of alerts without pharmacological intervention/HR = 1.38, P = 0.042/ and patient non-adherence with ITAREPS /HR = 1.08, P = 0.009/) increased the risk of hospitalization. In this trial ITAREPS was not effective. The results in context with previous ITAREPS studies suggest non-adherence of both psychiatrists and patients as the main reasons for the failure of this preventive strategy. Tertiary prevention in schizophrenia have to be regarded a major challenge, warranting the need for implementation of strategies with more active participation of both patient and treating psychiatrist.

A review on schizophrenia and relapse--a quest for user-friendly psychopharmacotherapy

OBJECTIVE

Schizophrenia in general is notoriously associated with relapses rendering the illness progressive to worse outcomes, a concept of which is compatible with neurotoxicity. Therefore, relapse prevention is of utmost clinical relevance.

METHODS

In this review, we aim to put relapse into clinical context in the realm of natural history of, or heterogeneity in, schizophrenia and summarize risk factors of relapse. We discuss how to effectively 'define' relapse in schizophrenia and recent meta-analytic studies on this topic to highlight the importance of continuous antipsychotic treatment.

RESULTS

The following issues emerged: 'How low maintenance antipsychotic dosage could be?’, 'How extended dosing could be?’, 'Who could be successfully withdrawn from antipsychotics?’ and 'How relapse could be defined in the first place?’ The question in particular is how better to deliver antipsychotics at the lowest possible, whereby dose and dosing interval are relevant. While ongoing antipsychotic treatment is the rule, recent works are pointing to a possibility of lower dosage in the maintenance phase of the illness.

CONCLUSIONS

Bearing in mind that suboptimal adherence and withdrawal from antipsychotics are an established and unequivocal risk factor for relapse, further investigations are certainly needed to explore user-friendly manner of psychopharmacotherapy to prevent relapse in schizophrenia.

Factors associated with early response to olanzapine and clinical and functional outcomes of early responders treated for schizophrenia in the People's Republic of China

BACKGROUND

The aims of this analysis were to identify factors associated with early response (at 4 weeks) to olanzapine treatment and to assess whether early response is associated with better longer-term outcomes for patients with schizophrenia in the People's Republic of China.

METHODS

A post hoc analysis of a multi-country, 6-month, prospective, observational study of outpatients with schizophrenia or bipolar mania who initiated or switched to treatment with oral olanzapine was conducted using data from the Chinese schizophrenia subgroup (n=330). Factors associated with early response were identified using a stepwise logistic regression with baseline clinical characteristics, baseline participation in a weight control program, and adherence with antipsychotics during the first 4 weeks of treatment. Mixed models for repeated measures with baseline covariates were used to compare outcomes over time between early responders and early nonresponders to olanzapine.

RESULTS

One hundred and thirty patients (40%) achieved an early response. Early response was independently predicted by higher baseline Clinical Global Impressions-Severity score (odds ratio [OR] 1.51, 95% confidence interval [CI] 1.15-1.97), fewer years since first diagnosis (OR 0.94, CI 0.90-0.98), a greater number of social activities (OR 1.22, CI 1.05-1.40), participation in a weight control program (OR 1.81, CI 1.04-3.15), and high adherence with antipsychotics during the first 4 weeks of treatment (OR 2.98, CI 1.59-5.58). Relative to early nonresponders, early responders were significantly more likely to meet treatment response criteria at endpoint, had significantly greater symptom improvement (Clinical Global Impressions-Severity), and had significantly greater improvement in functional outcomes (all P<0.05).

CONCLUSION

High levels of adherence to prescribed antipsychotics and participation in a weight control program were associated with early response to olanzapine in Chinese patients with schizophrenia. Early response was associated with greater improvement in symptomatic, functional, and quality of life outcomes at 6 months compared with early nonresponse. Current findings are consistent with previous research outside of the People's Republic of China.

Does participation in a weight control program also improve clinical and functional outcomes for Chinese patients with schizophrenia treated with olanzapine?

OBJECTIVES

This study examined whether participation in a weight control program (WCP) by patients with schizophrenia treated with olanzapine was also associated with improvements in clinical and functional outcomes.

METHODS

A post-hoc analysis was conducted using data from the Chinese subgroup (n=330) of a multi-country, 6-month, prospective, observational study of outpatients with schizophrenia who initiated or switched to oral olanzapine. At study entry and monthly visits, participants were assessed with the Clinical Global Impression of Severity, and measures of patient insight, social activities, and work impairment. The primary comparison was between the 153 patients who participated in a WCP at study entry (n=93) or during the study (n=60) and the 177 patients who did not participate in a weight control program (non-WCP). Mixed Models for Repeated Measures with baseline covariates were used to compare outcomes over time. Kaplan-Meier survival analysis was used to assess time to response.

RESULTS

Participants had a mean age of 29.0 years and 29.3 years, and 51.0% and 57.6% were female for WCP and non-WCP groups, respectively. Average initiated daily dose for olanzapine was 9.5±5.4 mg. WCP participants gained less weight than non-participants (3.9 kg vs 4.9 kg, P=0.03) and showed statistically significant better clinical and functional outcomes: greater improvement in illness severity (-2.8 vs -2.1, P<0.001), higher treatment response rates (94.1% vs 80.9%, P<0.001), shorter time to response (P<0.001), and greater improvement in patients' insight (P<0.001). Patients who enrolled in a WCP during the study had greater initial weight gain than those who enrolled at baseline (P<0.05), but similar total weight gain.

CONCLUSION

Participation in a WCP may not only lower the risk of clinically significant weight gain in olanzapine-treated patients, but may also be associated with additional clinical and functional benefits.

The personal, societal, and economic burden of schizophrenia in the People's Republic of China: implications for antipsychotic therapy

BACKGROUND

This article describes the personal, societal, and economic burden attributable to schizophrenia in the People's Republic of China and highlights the potential for effective outpatient treatment to reduce this burden given recent changes in the Chinese health care system. The importance of effective antipsychotic therapy in reducing the burden of schizophrenia is also examined.

METHODS

Published research on the burden, disability, management, and economic costs of schizophrenia in the People's Republic of China was examined in the context of the larger body of global research. Research written in English or Chinese and published before June 2012 was identified using PubMed, CNKI, and Wanfang Med database searches. The contribution of effective antipsychotic therapy in reducing the risk for relapse and hospitalization and improving patients' functioning is described.

RESULTS

Schizophrenia imposes a substantial burden on Chinese society, with indirect costs accounting for the majority of the total cost. Functional impairment is high, leading to lost wages and work impairment. In the People's Republic of China, schizophrenia is the most common diagnosis among hospitalized psychiatric patients. Ongoing changes in the Chinese health care system may reduce some barriers to effective relapse prevention in schizophrenia and potentially reduce hospitalizations. The use of antipsychotics for acute episodes and maintenance treatment has been shown to decrease symptom severity and reduce the risk for relapse and hospitalization. However, discontinuing antipsychotic medication appears common and is a strong predictor of relapse. Cost-effectiveness research in the People's Republic of China is needed to examine the potential gains from improved outpatient antipsychotic treatment.

CONCLUSION

Schizophrenia is a very costly mental illness in terms of personal, economic, and societal burden, both in the People's Republic of China and globally. When treated effectively, patients tend to persist longer with antipsychotic treatment, have fewer costly relapses, and have improved functioning. Further research examining the long-term effects of reducing barriers to effective treatments on the societal burden of schizophrenia in the People's Republic of China is needed.

Predictors of outcomes for users of mental health rehabilitation services: a 5-year retrospective cohort study in inner London, UK

OBJECTIVE

There have been few recent studies reporting on the outcomes for users of psychiatric rehabilitation services. This group has complex, longer-term mental health problems. We aimed to investigate 5-year outcomes for this group and identify factors associated with outcome.

METHOD

Clinical outcome data on 141 users of a mental health rehabilitation service in inner London, UK, surveyed in 2005, were collected retrospectively 5 years later. Positive outcome was defined for those who were inpatients in 2005 as achieving and sustaining community discharge, and for those who were community patients, as progressing to and sustaining a less supported community placement. Negative outcome was defined as remaining in the same placement, moving to more supported placement or having a psychiatric admission.

RESULTS

Over 5 years, 17 (12 %) people died, 50 (40 %) had a positive outcome, 33 (27 %) remained in a placement with a similar level of support and 41 (38 %) moved to a more supported placement and/or had a psychiatric admission. Thirteen (10 %) people moved to independent accommodation and sustained their tenancy successfully. Those with a record of non-adherence with medication during the 5 years were more likely to have a negative outcome (OR 8.60, 95 % CI 3.41 to 21.70).

CONCLUSION

Adherence to medication is an important factor in facilitating successful community discharge for people with complex mental health problems who require psychiatric rehabilitation.

Self-management among Chinese people with schizophrenia and their caregivers: a qualitative study

This study explores the practice of self-management in Chinese people with schizophrenia and their caregivers. Twenty-one patients and 14 caregivers were interviewed. Four themes were identified, reflecting the practice of self-management from both the patients' and caregivers' perspective: managing medication, monitoring and dealing with symptoms, maintaining social relations, and seeking health information and maintaining medical appointments. In general, self-management practices among Chinese people with schizophrenia were not optimal. This study highlights the importance of developing and implementing family-based self-management programs for Chinese people with schizophrenia and their family in order to enhance their self-management abilities and improve care outcomes.

Role of aripiprazole in treatment-resistant schizophrenia

About one third of patients with schizophrenia respond unsatisfactorily to antipsychotic treatment and are termed "treatment-resistant". Clozapine is still the gold standard in these cases. However, 40%-70% of patients do not improve sufficiently on clozapine either. In the search for more efficacious strategies for treatment-resistant schizophrenia, drugs with different pharmacological profiles seem to raise new hopes, but are they valid? The aim of this review was to evaluate the evidence for aripiprazole as a potential strategy in monotherapy or combination therapy for patients with treatment-resistant schizophrenia. The evidence for aripiprazole monotherapy and for the combination of aripiprazole with psychotropics other than clozapine is scant, and no recommendation can be made on the basis of the currently available data. More effort has been made in describing combinations of aripiprazole and clozapine. Most of the open-label and case studies as well as case reports have shown positive effects of this combination on overall psychopathology and to some extent on negative symptoms. Several reports describe the possibility of dose reduction for clozapine in combination with aripiprazole, a strategy that might help so-called "treatment-intolerant" patients. The findings of four randomized controlled trials with respect to changes in psychopathology seem less conclusive. The most commonly found beneficial effects are better metabolic outcomes and indicators of the possibility of reducing the clozapine dose. However, other side effects, such as akathisia, are repeatedly reported. Further, none of the studies report longer-term outcomes. In the absence of alternatives, polypharmacy is a common strategy in clinical practice. Combining aripiprazole with clozapine in clozapine-resistant or clozapine-intolerant patients seems to be worthy of further investigation from the pharmacological and clinical points of view.