Development of a schizophrenia scale sensitive to change

The role of control groups in non-pharmacological randomised controlled trials of treatment-resistant schizophrenia: A systematic review and meta-analysis

Control groups used in randomised controlled trials investigating psychological interventions for depression and anxiety disorders have effects of their own. This has never been investigated for schizophrenia, in particular treatment-resistant schizophrenia. This systematic review and meta-analysis aimed to examine how control groups in randomised controlled trials on psychological interventions for treatment-resistant schizophrenia behave in their effects on general symptomatology. In a search of various databases until July 2023, 31 eligible studies with 3125 participants were found whose control groups were assigned to four categories: active, inactive, treatment as usual and waitlist. The analyses showed that psychological interventions had a greater effect on symptom reduction to all control groups combined. When separating the control groups, only compared to TAU and waitlist controls the psychological interventions were superior. The difference was larger when less active control groups (e.g. waitlist - or treatment as usual control groups) were used. All control groups were associated with an improvement in symptoms from pre- to post-measurement point, with the greatest improvement observed in the inactive control group. The results are preliminary, but they suggest that the choice of the control group has a considerable impact on study effects as it has been shown in other psychiatric diagnoses.

Psychological and psychosocial interventions for treatment-resistant schizophrenia: a systematic review and network meta-analysis

BACKGROUND

Many patients with schizophrenia have symptoms that do not respond to antipsychotics. This condition is called treatment-resistant schizophrenia and has not received specific attention as opposed to general schizophrenia. Psychological and psychosocial interventions as an add-on treatment to pharmacotherapy could be useful, but their role and comparative efficacy to each other and to standard care in this population are not known. We investigated the efficacy, acceptability, and tolerability of psychological and psychosocial interventions for patients with treatment-resistant schizophrenia.

METHODS

In this systematic review and network meta-analysis (NMA), we searched for published and unpublished randomised controlled trials (RCTs) through a systematic database search in BIOSIS, CINAHL, Embase, LILACS, MEDLINE, PsychInfo, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform for articles published from inception up to Jan 31, 2020. We also searched the Cochrane Schizophrenia Group registry for studies published from inception up to March 31, 2022, and PubMed and Cochrane CENTRAL for studies published from inception up to July 31, 2023. We included RCTs that included patients with treatment-resistant schizophrenia. The primary outcome was overall symptoms. We did random-effects pairwise meta-analyses and NMAs to calculate standardised mean differences (SMDs) or risk ratios with 95% CIs. No people with lived experience were involved throughout the research process. The study protocol was registered in PROSPERO, CRD42022358696.

FINDINGS

We identified 30 326 records, excluding 24 526 by title and abstract screening. 5762 full-text articles were assessed for eligibility, of which 5540 were excluded for not meeting the eligibility criteria, and 222 reports corresponding to 60 studies were included in the qualitative synthesis. Of these, 52 RCTs with 5034 participants (1654 [33·2%] females and 3325 [66·8%] males with sex indicated) comparing 20 psychological and psychosocial interventions provided data for the NMA. Mean age of participants was 38·05 years (range 23·10-48·50). We aimed to collect ethnicity data, but they were scarcely reported. According to the quality of evidence, cognitive behavioural therapy for psychosis (CBTp; SMD -0·22, 95% CI -0·35 to -0·09, 35 trials), virtual reality intervention (SMD -0·41, -0·79 to -0·02, four trials), integrated intervention (SMD -0·70, -1·18 to -0·22, three trials), and music therapy (SMD -1·27, -1·83 to -0·70, one study) were more efficacious than standard care in reducing overall symptoms. No indication of publication bias was identified.

INTERPRETATION

We provide robust findings that CBTp can reduce the overall symptoms of patients with treatment-resistant schizophrenia, and therefore clinicians can prioritise this intervention in their clinical practice. Other psychological and psychosocial interventions showed promising results but need further investigation.

FUNDING

DAAD-ASFE.

Les troubles dépressifs chez les schizophrènes vus en ambulatoire : Allure sémiologique et problèmes méthodologiques d’évaluation

Les symptômes d’un groupe de schizophrènes ambulatoires ont été évalués de manière transversale. 95 patients ont été inclus dans une première étude et 87 d’entre eux réévalués un an après.

Les patients étaient considérés comme déprimés quand ils avaient : soit un score égal ou supérieur à 3 à une appréciation clinique globale de la dépression (de score maximum égal à 5), soit un score de 20 ou plus à la M.A.D.R.S.*.

La fréquence de la dépression était de 20 % environ selon les deux modes d’évaluation.

Les patients déprimés avaient aussi la symptomatologie psychiatrique d’ensemble la plus sévère comme en témoignaient leurs scores à la B.P.R.S.*, à l’échelle de schizophrénie extraite de la C.P.R.S.*, et à la check-list d’auto-évaluation S.C.L. 90*.

Les deux modes d’évaluation de la dépression ont paru mesurer deux aspects différents du syndrome : dans la première étude, 20 patients étaient déprimés selon le score clinique global, 20 également selon la M.A.D.R.S., mais 12 seulement selon les deux modes d’évaluation. Comparée au score global, la M.A.D.R.S. paraît retenir des patients dont la pathologie globale et dépressive est plus sévère. Les cliniciens ont hésité à juger cliniquement comme déprimés des malades déficitaires même lorsque leurs profils cliniques avaient par ailleurs une configuration franchement dépressive.

Long-term studies of antipsychotic drugs in schizophrenia

Studies on long-term efficacy and safety should be a main concern in the evaluation of novel antipsychotics. The present paper is a review of important issues related to the design and performance of such trials. The variability of the natural course of schizophrenia, the variability in treatment response, and the variability of actions of different neuroleptics need to be considered. Long-term studies need to address maintenance of efficacy, prevention of relapse and recurrence, health economics, quality of life and a large number of safety issues in order to get approval for new drug applications and reimbursement on expensive new medicines. Assessment instruments for efficacy, tolerability and safety, need to be supplemented with rating scales for various aspects of psychopathology (positive, negative, deficit symptoms), social and work functioning, drug induced mental side effects, quality of life and accounts of total treatment costs.

Atypical lymphocytes in schizophrenia

Blood was drawn from 18 inpatients fullfilling the DSMIII criteria for schizophrenia and their 15 age- and sex-matched clinically infection-free controls before and after neuroleptic treatment. Blood films were stained with MGG solution, mixed, and subsequently read in random order by one observer. The lymphocytes were examined by light microscopy and classified into six types: normal lymphocytes, Downey type I atypical lymphocytes, Downey type III atypical lymphocytes, stress lymphocytes, plasmocytoid lymphocytes, and large granular lymphocytes. Downey type I and III atypical lymphocytes were classified into small, medium, and large lymphocytes. Schizophrenic patients had significantly more Downey type III medium size cells before treatment (p = 0.019 before treatment and p = 0.056 after treatment) and less Downey type I small size cells (p = 0.113 before treatment and p = 0.026 after treatment). Our study supports the idea of a possible subgroup of schizophrenia exhibiting immunological aberrations. In the present study, we found morphologically more specified cells which could be involved in this alteration.

Psychosocial interventions for people with both severe mental illness and substance misuse

BACKGROUND

Even low levels of substance misuse by people with a severe mental illness can have detrimental effects.

OBJECTIVES

To assess the effects of psychosocial interventions for reduction in substance use in people with a serious mental illness compared with standard care.

SEARCH METHODS

The Information Specialist of the Cochrane Schizophrenia Group (CSG) searched the CSG Trials Register (2 May 2018), which is based on regular searches of major medical and scientific databases.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) comparing psychosocial interventions for substance misuse with standard care in people with serious mental illness.

DATA COLLECTION AND ANALYSIS

Review authors independently selected studies, extracted data and appraised study quality. For binary outcomes, we calculated standard estimates of risk ratio (RR) and their 95% confidence intervals (CIs) on an intention-to-treat basis. For continuous outcomes, we calculated the mean difference (MD) between groups. Where meta-analyses were possible, we pooled data using a random-effects model. Using the GRADE approach, we identified seven patient-centred outcomes and assessed the quality of evidence for these within each comparison.

MAIN RESULTS

Our review now includes 41 trials with a total of 4024 participants. We have identified nine comparisons within the included trials and present a summary of our main findings for seven of these below. We were unable to summarise many findings due to skewed data or because trials did not measure the outcome of interest. In general, evidence was rated as low- or very-low quality due to high or unclear risks of bias because of poor trial methods, or inadequately reported methods, and imprecision due to small sample sizes, low event rates and wide confidence intervals. 1. Integrated models of care versus standard care (36 months) No clear differences were found between treatment groups for loss to treatment (RR 1.09, 95% CI 0.82 to 1.45; participants = 603; studies = 3; low-quality evidence), death (RR 1.18, 95% CI 0.39 to 3.57; participants = 421; studies = 2; low-quality evidence), alcohol use (RR 1.15, 95% CI 0.84 to 1.56; participants = 143; studies = 1; low-quality evidence), substance use (drug) (RR 0.89, 95% CI 0.63 to 1.25; participants = 85; studies = 1; low-quality evidence), global assessment of functioning (GAF) scores (MD 0.40, 95% CI -2.47 to 3.27; participants = 170; studies = 1; low-quality evidence), or general life satisfaction (QOLI) scores (MD 0.10, 95% CI -0.18 to 0.38; participants = 373; studies = 2; moderate-quality evidence). 2. Non-integrated models of care versus standard care There was no clear difference between treatment groups for numbers lost to treatment at 12 months (RR 1.21, 95% CI 0.73 to 1.99; participants = 134; studies = 3; very low-quality evidence). 3. Cognitive behavioural therapy (CBT) versus standard care There was no clear difference between treatment groups for numbers lost to treatment at three months (RR 1.12, 95% CI 0.44 to 2.86; participants = 152; studies = 2; low-quality evidence), cannabis use at six months (RR 1.30, 95% CI 0.79 to 2.15; participants = 47; studies = 1; very low-quality evidence) or mental state insight (IS) scores by three months (MD 0.52, 95% CI -0.78 to 1.82; participants = 105; studies = 1; low-quality evidence). 4. Contingency management versus standard care We found no clear differences between treatment groups for numbers lost to treatment at three months (RR 1.55, 95% CI 1.13 to 2.11; participants = 255; studies = 2; moderate-quality evidence), number of stimulant positive urine tests at six months (RR 0.83, 95% CI 0.65 to 1.06; participants = 176; studies = 1) or hospitalisations (RR 0.21, 95% CI 0.05 to 0.93; participants = 176; studies = 1); both low-quality evidence. 5. Motivational interviewing (MI) versus standard care We found no clear differences between treatment groups for numbers lost to treatment at six months (RR 1.71, 95% CI 0.63 to 4.64; participants = 62; studies = 1). A clear difference, favouring MI, was observed for abstaining from alcohol (RR 0.36, 95% CI 0.17 to 0.75; participants = 28; studies = 1) but not other substances (MD -0.07, 95% CI -0.56 to 0.42; participants = 89; studies = 1), and no differences were observed in mental state general severity (SCL-90-R) scores (MD -0.19, 95% CI -0.59 to 0.21; participants = 30; studies = 1). All very low-quality evidence. 6. Skills training versus standard care At 12 months, there were no clear differences between treatment groups for numbers lost to treatment (RR 1.42, 95% CI 0.20 to 10.10; participants = 122; studies = 3) or death (RR 0.15, 95% CI 0.02 to 1.42; participants = 121; studies = 1). Very low-quality, and low-quality evidence, respectively. 7. CBT + MI versus standard care At 12 months, there was no clear difference between treatment groups for numbers lost to treatment (RR 0.99, 95% CI 0.62 to 1.59; participants = 327; studies = 1; low-quality evidence), number of deaths (RR 0.60, 95% CI 0.20 to 1.76; participants = 603; studies = 4; low-quality evidence), relapse (RR 0.50, 95% CI 0.24 to 1.04; participants = 36; studies = 1; very low-quality evidence), or GAF scores (MD 1.24, 95% CI -1.86 to 4.34; participants = 445; studies = 4; very low-quality evidence). There was also no clear difference in reduction of drug use by six months (MD 0.19, 95% CI -0.22 to 0.60; participants = 119; studies = 1; low-quality evidence).

AUTHORS' CONCLUSIONS

We included 41 RCTs but were unable to use much data for analyses. There is currently no high-quality evidence to support any one psychosocial treatment over standard care for important outcomes such as remaining in treatment, reduction in substance use or improving mental or global state in people with serious mental illnesses and substance misuse. Furthermore, methodological difficulties exist which hinder pooling and interpreting results. Further high-quality trials are required which address these concerns and improve the evidence in this important area.

Prevalence and characteristics of multi-modal hallucinations in people with psychosis who experience visual hallucinations

Hallucinations can occur in single or multiple sensory modalities. Historically, greater attention has been paid to single sensory modality experiences with a comparative neglect of hallucinations that occur across two or more sensory modalities (multi-modal hallucinations). With growing evidence suggesting that visual hallucinations may be experienced along with other hallucinations, this study aimed to explore multi-modal hallucinations in a sample of people with psychotic disorders who reported visual hallucinations (n = 22). No participants reported just visual hallucinations i.e. all reported related or unrelated auditory hallucinations. Twenty-one participants reported multi-modal hallucinations that were serial in nature, whereby they saw visual hallucinations and heard unrelated auditory hallucinations at other times. Nineteen people out of the twenty two also reported simultaneous multi-modal hallucinations, with the most common being an image that talked to and touched them. Multi-modal related and simultaneous hallucinations appeared to be associated with greater conviction that the experiences were real, and greater distress. Theoretical and clinical implications of multi-modal hallucinations are discussed.

Cognitive behavioural therapy for visual hallucinations: an investigation using a single-case experimental design

There has been limited application of cognitive behavioural therapy (CBT) to the treatment of distressing visual hallucinations (VH) in people with psychosis. Preliminary research applying interventions to a novel presenting issue are enhanced by utilizing designs that allow strong inferences to be made about the effect of the intervention. Hence, this study aimed to measure change in appraisal, affect, and behaviour as a consequence of CBT VH, to improve understanding of the process of change. A multiple-baseline experimental single-case design methodology was used with five participants who received a CBT VH treatment package. Participants used daily diary measures to record appraisals, affect, and behaviours related to the distressing VH. Standardized measures were completed at each phase change. Four individuals completed therapy. Formal visual analysis of the data supported by statistical analysis indicated significant changes for appraisal and affect, with replication across three participants. Changes in frequency of VH were reported in two cases. Change was not evident on the standardized measures. This study replicates and extends the findings in showing potential value of CBT VH. Further research should consider alternative methods of capturing behavioural change. Attempts should also be made to replicate across therapists and centres.

Factor Structure and Differential Validity of the Expanded Brief Psychiatric Rating Scale

The Brief Psychiatric Rating Scale (BPRS) is one of the most widely used measures in psychiatric outcome and clinical psychopharmacology research. To date, however, research on the psychometric properties of the expanded version of the BPRS (BPRS-E) has been limited. An exploratory factor analysis (n = 360) using maximum likelihood extraction with oblimin rotation found a four-factor solution (Thought Disturbance, Animation, Mood Disturbance, Apathy) to underlie the BPRS-E. Furthermore, these factors were logical in nature and estimates of internal consistency were acceptable. A confirmatory factor analysis conducted on a second, independent sample (n = 280) found that for the five models currently available in the literature, the model developed herein provided the best fit to the data. Again, estimates of internal consistency were found acceptable. Finally, the four factors demonstrated appropriate differential validity with regards to both demographic variables and various psychiatric diagnoses.

Supportive therapy for schizophrenia

BACKGROUND

Supportive therapy is often used in everyday clinical care and in evaluative studies of other treatments.

OBJECTIVES

To review the effects of supportive therapy compared with standard care, or other treatments in addition to standard care for people with schizophrenia.

SEARCH METHODS

For this update, we searched the Cochrane Schizophrenia Group's register of trials (November 2012).

SELECTION CRITERIA

All randomised trials involving people with schizophrenia and comparing supportive therapy with any other treatment or standard care.

DATA COLLECTION AND ANALYSIS

We reliably selected studies, quality rated these and extracted data. For dichotomous data, we estimated the risk ratio (RR) using a fixed-effect model with 95% confidence intervals (CIs). Where possible, we undertook intention-to-treat analyses. For continuous data, we estimated the mean difference (MD) fixed-effect with 95% CIs. We estimated heterogeneity (I(2) technique) and publication bias. We used GRADE to rate quality of evidence.

MAIN RESULTS

Four new trials were added after the 2012 search. The review now includes 24 relevant studies, with 2126 participants. Overall, the evidence was very low quality.We found no significant differences in the primary outcomes of relapse, hospitalisation and general functioning between supportive therapy and standard care.There were, however, significant differences favouring other psychological or psychosocial treatments over supportive therapy. These included hospitalisation rates (4 RCTs, n = 306, RR 1.82 CI 1.11 to 2.99, very low quality of evidence), clinical improvement in mental state (3 RCTs, n = 194, RR 1.27 CI 1.04 to 1.54, very low quality of evidence) and satisfaction of treatment for the recipient of care (1 RCT, n = 45, RR 3.19 CI 1.01 to 10.7, very low quality of evidence). For this comparison, we found no evidence of significant differences for rate of relapse, leaving the study early and quality of life.When we compared supportive therapy to cognitive behavioural therapy CBT), we again found no significant differences in primary outcomes. There were very limited data to compare supportive therapy with family therapy and psychoeducation, and no studies provided data regarding clinically important change in general functioning, one of our primary outcomes of interest.

AUTHORS' CONCLUSIONS

There are insufficient data to identify a difference in outcome between supportive therapy and standard care. There are several outcomes, including hospitalisation and general mental state, indicating advantages for other psychological therapies over supportive therapy but these findings are based on a few small studies where we graded the evidence as very low quality. Future research would benefit from larger trials that use supportive therapy as the main treatment arm rather than the comparator.

High-yield cognitive behavioral techniques for psychosis delivered by case managers to their clients with persistent psychotic symptoms: an exploratory trial

Case managers spend more time with clients with schizophrenia than any other professional group does in most clinical settings in the United States. Cognitive behavioral therapy (CBT) adapted for individuals with persistent psychotic symptoms, referred to as CBT-p, has proven to be a useful intervention when given by expert therapists in randomized clinical trials. It is currently unknown whether techniques derived from CBT-p could be safely and effectively delivered by case managers in community mental health agencies. Thirteen case managers at a community mental health center took part in a 5-day training course and had weekly supervision. In an open trial, 38 clients with schizophrenia had 12 meetings with their case managers during which high-yield cognitive behavioral techniques for psychosis (HYCBt-p) were used. The primary outcome measure was overall symptom burden as measured by the Comprehensive Psychopathological Rating Scale, which was independently administered at baseline and end of intervention. Secondary outcomes were dimensions of hallucinations and delusions, negative symptoms, depression, anxiety, social functioning, and self-rated recovery. Good and poor clinical outcomes were defined a priori as a 25% improvement or deterioration. t-Tests and Wilcoxon's signed-ranks tests showed significant improvements in all primary and secondary outcomes by the end of the intervention except for delusions, social functioning, and self-rated recovery. Cohen's d effect sizes were medium to large for overall symptoms (d = 1.60; 95% confidence interval [CI], -2.29 to 5.07), depression (d = 1.12; 95% CI, -0.35 to 1.73), and negative symptoms (d = 0.87; 95% CI, -0.02 to 1.62). There was a weak effect on dimensions of hallucinations but not delusions. Twenty-three (60.5%) of 38 patients had a good clinical result. One (2.6%) of 38 patients had a poor clinical result. No patients dropped out. This exploratory trial provides evidence supportive of the safety and the benefits of case managers being trained to provide HYCBt-p to their clients with persistent psychosis. The benefits reported here are particularly pertinent to the domains of overall symptom burden, depression, and negative symptoms and implementation of recovery-focused services.

Psychosocial interventions for people with both severe mental illness and substance misuse

BACKGROUND

Even low levels of substance misuse by people with a severe mental illness can have detrimental effects.

OBJECTIVES

To assess the effects of psychosocial interventions for reduction in substance use in people with a serious mental illness compared with standard care.

SEARCH METHODS

For this update (2013), the Trials Search Co-ordinator of the Cochrane Schizophrenia Group (CSG) searched the CSG Trials Register (July 2012), which is based on regular searches of major medical and scientific databases. The principal authors conducted two further searches (8 October 2012 and 15 January 2013) of the Cochrane Database of Systematic Reviews, MEDLINE and PsycINFO. A separate search for trials of contingency management was completed as this was an additional intervention category for this update.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) comparing psychosocial interventions for substance misuse with standard care in people with serious mental illness.

DATA COLLECTION AND ANALYSIS

We independently selected studies, extracted data and appraised study quality. For binary outcomes, we calculated standard estimates of relative risk (RR) and their 95% confidence intervals (CI) on an intention-to-treat basis. For continuous outcomes, we calculated the mean difference (MD) between groups. For all meta-analyses we pooled data using a random-effects model. Using the GRADE approach, we identified seven patient-centred outcomes and assessed the quality of evidence for these within each comparison.

MAIN RESULTS

We included 32 trials with a total of 3165 participants. Evaluation of long-term integrated care included four RCTs (n = 735). We found no significant differences on loss to treatment (n = 603, 3 RCTs, RR 1.09 CI 0.82 to 1.45, low quality of evidence), death by 3 years (n = 421, 2 RCTs, RR 1.18 CI 0.39 to 3.57, low quality of evidence), alcohol use (not in remission at 36 months) (n = 143, 1 RCT, RR 1.15 CI 0.84 to 1.56,low quality of evidence), substance use (n = 85, 1 RCT, RR 0.89 CI 0.63 to 1.25, low quality of evidence), global assessment of functioning (n = 171, 1 RCT, MD 0.7 CI 2.07 to 3.47, low quality of evidence), or general life satisfaction (n = 372, 2 RCTs, MD 0.02 higher CI 0.28 to 0.32, moderate quality of evidence).For evaluation of non-integrated intensive case management with usual treatment (4 RCTs, n = 163) we found no statistically significant difference for loss to treatment at 12 months (n = 134, 3 RCTs, RR 1.21 CI 0.73 to 1.99, very low quality of evidence).Motivational interviewing plus cognitive behavioural therapy compared to usual treatment (7 RCTs, total n = 878) did not reveal any advantage for retaining participants at 12 months (n = 327, 1 RCT, RR 0.99 CI 0.62 to 1.59, low quality of evidence) or for death (n = 493, 3 RCTs, RR 0.72 CI 0.22 to 2.41, low quality of evidence), and no benefit for reducing substance use (n = 119, 1 RCT, MD 0.19 CI -0.22 to 0.6, low quality of evidence), relapse (n = 36, 1 RCT, RR 0.5 CI 0.24 to 1.04, very low quality of evidence) or global functioning (n = 445, 4 RCTs, MD 1.24 CI 1.86 to 4.34, very low quality of evidence).Cognitive behavioural therapy alone compared with usual treatment (2 RCTs, n = 152) showed no significant difference for losses from treatment at 3 months (n = 152, 2 RCTs, RR 1.12 CI 0.44 to 2.86, low quality of evidence). No benefits were observed on measures of lessening cannabis use at 6 months (n = 47, 1 RCT, RR 1.30 CI 0.79 to 2.15, very low quality of evidence) or mental state (n = 105, 1 RCT, Brief Psychiatric Rating Scale MD 0.52 CI -0.78 to 1.82, low quality of evidence).We found no advantage for motivational interviewing alone compared with usual treatment (8 RCTs, n = 509) in reducing losses to treatment at 6 months (n = 62, 1 RCT, RR 1.71 CI 0.63 to 4.64, very low quality of evidence), although significantly more participants in the motivational interviewing group reported for their first aftercare appointment (n = 93, 1 RCT, RR 0.69 CI 0.53 to 0.9). Some differences, favouring treatment, were observed in abstaining from alcohol (n = 28, 1 RCT, RR 0.36 CI 0.17 to 0.75, very low quality of evidence) but not other substances (n = 89, 1 RCT, RR -0.07 CI -0.56 to 0.42, very low quality of evidence), and no differences were observed in mental state (n = 30, 1 RCT, MD 0.19 CI -0.59 to 0.21, very low quality of evidence).We found no significant differences for skills training in the numbers lost to treatment by 12 months (n = 94, 2 RCTs, RR 0.70 CI 0.44 to 1.1, very low quality of evidence).We found no differences for contingency management compared with usual treatment (2 RCTs, n = 206) in numbers lost to treatment at 3 months (n = 176, 1 RCT, RR 1.65 CI 1.18 to 2.31, low quality of evidence), number of stimulant positive urine tests at 6 months (n = 176, 1 RCT, RR 0.83 CI 0.65 to 1.06, low quality of evidence) or hospitalisations (n = 176, 1 RCT, RR 0.21 CI 0.05 to 0.93, low quality of evidence).We were unable to summarise all findings due to skewed data or because trials did not measure the outcome of interest. In general, evidence was rated as low or very low due to high or unclear risks of bias because of poor trial methods, or poorly reported methods, and imprecision due to small sample sizes, low event rates and wide confidence intervals.

AUTHORS' CONCLUSIONS

We included 32 RCTs and found no compelling evidence to support any one psychosocial treatment over another for people to remain in treatment or to reduce substance use or improve mental state in people with serious mental illnesses. Furthermore, methodological difficulties exist which hinder pooling and interpreting results. Further high quality trials are required which address these concerns and improve the evidence in this important area.

Cognitive behaviour therapy for psychosis can be adapted for minority ethnic groups: a randomised controlled trial

Cognitive behavioural therapy (CBT) is recommended in treatment guidelines for psychotic symptoms (NICE, 2009) but clients from some minority groups have been shown to have higher dropout rates and poorer outcomes. A recent qualitative study in ethnic minority groups concluded that CBT would be acceptable and may be more effective if it was culturally adapted to meet their needs (Rathod et al., 2010).

AIM

This study assessed the effectiveness of a culturally adapted CBT for psychosis (CaCBTp) in Black British, African Caribbean/Black African and South Asian Muslim participants.

METHOD

A randomised controlled trial was conducted in two centres in the UK (n=35) in participants with a diagnosis of a disorder from the schizophrenia group. Assessments were conducted at three time points: baseline, post-therapy and at 6 months follow-up, using the Comprehensive Psychopathological Rating Scale (CPRS) and Insight Scale. Outcomes on specific subscales of CPRS were also evaluated. Participants in the treatment arm completed the Patient Experience Questionnaire (PEQ) to measure satisfaction with therapy. Assessors blind to randomisation and treatment allocation conducted administration of outcome measures. In total, n=33 participants were randomly allocated to CaCBTp arm (n=16) and treatment as usual (TAU) arm (n=17) after (n=2) participants were excluded. CaCBTp participants were offered 16 sessions of CaCBTp with trained therapists and the TAU arm continued with their standard treatment.

RESULTS

Analysis was based on the principles of intention to treat (ITT). This was further supplemented with secondary sensitivity analyses. Post-treatment, the intervention group showed statistically significant reductions in symptomatology on overall CPRS scores, CaCBTp Mean (SD)=16.23 (10.77), TAU=18.60 (14.84); p=0.047,with a difference in change of 11.31 (95% CI:0. 14 to 22.49); Schizophrenia change: CaCBTp=3.46 (3.37); TAU=4.78 (5.33) diff 4.62 (95% CI: 0.68 to 9.17); p=0.047 and positive symptoms (delusions; p=0.035, and hallucinations; p=0.056). At 6 months follow-up, MADRAS change=5.6 (95% CI: 2.92 to 7.60); p<0.001. Adjustment was made for age, gender and antipsychotic medication. Overall satisfaction was significantly correlated with the number of sessions attended (r=0.563; p=0.003).

CONCLUSION

Participants in the CaCBTp group achieved statistically significant results post-treatment compared to those in the TAU group with some gains maintained at follow-up. High levels of satisfaction with the CaCBTp were reported.

Increased frequency of aberrant CSF circulation in schizophrenic patients compared to healthy volunteers

In a previous cisternographic study of the cerebrospinal fluid (CSF) circulation in schizophrenic patients, indications for disturbed flow dynamics were found in 10 of 30 subjects. In order to replicate and investigate the clinical and pathophysiological significance of this finding, 39 schizophrenic patients and 42 healthy subjects were examined with an improved method for measurement of CSF circulation. (99m)Tc-DTPA was injected intrathecally and the gamma cisternograms were evaluated blindly. Correlations between cisternography findings and age, duration of disease, previous hospitalizations, positive or negative symptomatology, exposure to neuroleptics, psychiatric family history, CT findings and CSF levels of protein, tryptophan and monoamine metabolites, were calculated. Seven of the patients showed abnormalities in the cisternograms with a slow or obstructed flow of CSF over the convexities (P < 0.01) whereas none of the healthy volunteers showed abnormalities. There were no correlations between disturbed CSF circulation in the patients and the clinical and biochemical parameters, thus the significance of the deviations, similar to other biological aberrations found in schizophrenic patients, is not known. Recent developments in magnetic resonance imaging offer new possibilities to further examine CSF circulation abnormalities in schizophrenia.

Brief PANSS to assess and monitor the overall severity of schizophrenia

AIMS

The aim of the present study was to develop a subscale of the Positive and Negative Syndrome Scale (PANSS) that would be brief and sensitive to changes in the clinical features of schizophrenia (i.e. the Brief PANSS, or bPANSS).

METHODS

The PANSS before and after treatment, and the Clinical Global Impression-Change (CGI-C) was rated for 714 schizophrenia patients. Of these, Clinical Global Impression-Severity (CGI-S) was also evaluated in 30 of these patients. The bPANSS items were extracted from full PANSS items based on the following aims: (i) to develop a brief scale; (ii) to develop a scale sensitive to changes resulting from antipsychotic treatment; and (iii) to reflect the broad spectrum of schizophrenia symptoms.

RESULTS

The following six items were extracted to serve as the bPANSS: delusion, suspiciousness, emotional withdrawal, passive/apathetic social withdrawal, tension, and unusual thought content. The coefficients of correlation between the bPANSS and full PANSS before and after treatment were 0.86 and 0.92, respectively (both P < 0.001). The coefficient of correlation between the degrees of change in the scores for the bPANSS and the full PANSS was 0.93 (P < 0.001), and that between delta bPANSS and CGI-C was 0.73 (P < 0.001).

CONCLUSIONS

bPANSS is able to capture the overall clinical features of schizophrenia within a short assessment period.

Transthyretin in cerebrospinal fluid from suicide attempters

BACKGROUND

Earlier studies have found that transthyretin (TTR) is reduced in cerebrospinal fluid (CSF) from patients with major depressive disorder and that levels correlate negatively with suicidal ideation. The purpose of this study was to examine CSF-TTR in a cohort of suicide attempters with different psychiatric diagnoses and to further assess the relationship between CSF-TTR and suicidal behaviour as well as psychiatric symptoms.

METHODS

TTR was measured using enzyme-enhanced Mancini. Diagnostics were performed with the Diagnostic and Statistical Manual of Mental Disorders. Psychiatric symptoms and suicidal behaviour were rated using the Comprehensive Psychopathological Rating Scale (CPRS), the Suicide Assessment Scale and the Suicidal Intent Scale.

RESULTS

We found no significant difference in CSF-TTR levels between groups of different psychiatric diagnoses and controls. CSF-TTR correlated negatively to the CPRS item 17, "failing memory". No significant correlations between CSF-TTR and suicidal behaviour or suicide intent were found.

LIMITATIONS

Correlation analysis is an indirect method of investigation and does not demonstrate causal relationships.

CONCLUSIONS

We conclude that CSF-TTR is unlikely to be relevant for suicidal behaviour and that further studies in non-suicidal psychiatric patients are needed before a role of CSF-TTR in depression can be established.

Psychosocial interventions for people with both severe mental illness and substance misuse

BACKGROUND

Even low levels of substance misuse by people with a severe mental illness can have detrimental effects.

OBJECTIVES

To assess the effects of psychosocial interventions for substance reduction in people with a serious mental illness.

SEARCH STRATEGY

For this update (2007) we searched the Cochrane Schizophrenia Group Trials Register (May 2006) which is based on regular searches of major databases.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) comparing psychosocial interventions for substance misuse with standard care in people with serious mental illness.

DATA COLLECTION AND ANALYSIS

We extracted data independently. For dichotomous data we calculated relative risks (RR) and their 95% confidence intervals (CI) on an intention-to-treat basis, based on a random effects model. We calculated numbers needed to treat/harm (NNT/NNH) where data were homogeneous. For continuous data, we calculated weighted mean differences (WMD) again based on a random effects model.

MAIN RESULTS

Evaluation of long-term integrated care included 4 RCTs (total n=735). We found no significant difference on measures of substance use (n=85, 1 RCT, RR 0.89 CI 0.6 to 1.3) or loss to treatment (n=603, 3 RCTs, RR 1.09 CI 0.8 to 1.5). For the non-integrated intensive case management trials (4 RCTs, total n=151) we also found no significant difference for loss (n=134, 3 RCTs, RR 1.35 CI 0.8 to 2.2). Motivational interviewing plus cognitive behavioural therapy (3 RCTs, total n=276) did not reveal any advantage for retaining participants (n=36, 1 RCT, RR lost to treatment 0.50 CI 0.1 to 5.0) or for relapse (n=36, 1 RCT, RR 0.58 CI 0.3 to 1.1), and no benefit for reducing substance use (n=119, 1 RCT, RR 0.19 CI -0.2 to 0.6). Cognitive behavioural therapy alone (4 trials, total n=260) showed fewer participants lost from treatment (n=260, 4 RCTs, p=0.02, RR 0.61 CI 0.4 to 0.9). No benefits were observed on measures of lessening cannabis use (n=47, 1 RCT, RR 1.30 CI 0.8 to 2.2) or on the number of participants using substances (alcohol; n=46, 1 RCT, RR 5.88 CI 0.8 to 44.0, drugs; n=46, 1 RCT, RR 2.02 CI 0.9 to 4.8) and no differences were observed on measures of mental state (n=105, 1 RCT, RR 0.52 CI -0.8 to 1.8). We found no advantage for motivational interviewing alone (5 trials, total n=338) in reducing 'lost to evaluation' (n=338, 5 RCTs, RR 0.96 CI 0.6 to 1.5) compared with treatment as usual, although significantly more participants in the motivational interviewing group reported for their first aftercare appointment (n=93, 1 RCT, RR 0.69 CI 0.5 to 0.9, NNT 4 CI 3 to 12). Some differences were observed in abstaining from alcohol favouring treatment (n=28, 1 RCT, RR 0.36 CI 0.2 to 0.8, NNT 2 CI 2 to 5), but not other substances (n=89, 1 RCT, RR -0.07 CI -0.6 to 0.4) and no differences were observed in mental state (n=30, 1 RCT, WMD -4.20 CI -18.7 to 10.3). Finally, we found no significant differences for skills training in the numbers lost to treatment by 12 months (n=94, 2 RCTs, RR 0.70 CI 0.4 to 1.1).

AUTHORS' CONCLUSIONS

We included 25 RCTs and found no compelling evidence to support any one psychosocial treatment over another to reduce substance use (or improve mental state) by people with serious mental illnesses. Furthermore, methodological difficulties exist which hinder pooling and interpreting results; high drop out rates, varying fidelity of interventions, varying outcome measures, settings and samples and comparison groups may have received higher levels of treatment than standard care. Further studies are required which address these concerns and improve the evidence in this important area.

A randomized controlled trial of cognitive-behavior therapy for persistent symptoms in schizophrenia: a five-year follow-up

Meta-analyses of randomized controlled trials support the efficacy of cognitive behavioral therapy (CBT) in the treatment of symptoms of schizophrenia refractory to antipsychotic medication. This article addresses the issue of medium term durability. A five-year follow-up was undertaken of a sample of 90 subjects who participated in a randomized controlled trial of CBT and befriending (BF). Patients received routine care throughout the trial and the follow-up period. Intention to treat multivariate analysis was performed by an independent statistician following multiple imputation of missing data. Fifty-nine out of ninety patients were followed up at 5 years (CBT=31, BF=28). In comparison to BF and usual treatment, CBT showed evidence of a significantly greater and more durable effect on overall symptom severity (NNT=10.36, CI -10.21, 10.51) and level of negative symptoms (NNT=5.22, CI -5.06 -5.37). No difference was found between CBT and BF on either overall symptoms of schizophrenia or depression. The initial cost of an adjunctive course of CBT for individuals with medication refractory schizophrenia may be justified in light of symptomatic benefits that persist over the medium term.

Supportive therapy for schizophrenia

BACKGROUND

Supportive therapy is often used in everyday clinical care and in evaluative studies of other treatments.

OBJECTIVES

To estimate the effects of supportive therapy for people with schizophrenia.

SEARCH STRATEGY

We searched the Cochrane Schizophrenia Group's register of trials (January 2004), supplemented by manual reference searching and contact with authors of relevant reviews or studies.

SELECTION CRITERIA

All randomised trials involving people with schizophrenia and comparing supportive therapy with any other treatment or standard care.

DATA COLLECTION AND ANALYSIS

We reliably selected studies, quality rated these and extracted data. For dichotomous data, we estimated the relative risk (RR) fixed effect with 95% confidence intervals (CI). Where possible, we undertook intention-to-treat analyses. For statistically significant results, we calculated the number needed to treat/harm (NNT/H). We estimated heterogeneity (I-square technique) and publication bias.

MAIN RESULTS

We included 21 relevant studies. We found no significant differences in the primary outcomes between supportive therapy and standard care. There were, however, significant differences favouring other psychological or psychosocial treatments over supportive therapy. These included hospitalisation rates (3 RCTs, n=241, RR 2.12 CI 1.2 to 3.6, NNT 8) but not relapse rates (5 RCTs, n=270, RR 1.18 CI 0.9 to 1.5). We found that the results for general functioning significantly favoured cognitive behavioural therapy compared with supportive therapy in the short (1 RCT, n=70, WMD -9.50 CI -16.1 to -2.9), medium (1 RCT, n=67, WMD -12.6 CI -19.4 to -5.8) and long term (2 RCTs, n=78, SMD -0.50 CI -1.0 to -0.04), but the clinical significance of these findings based on few data is unclear. Participants were less likely to be satisfied with care if receiving supportive therapy compared with cognitive behavioural treatment (1 RCT, n=45, RR 3.19 CI 1.0 to 10.1, NNT 4 CI 2 to 736). The results for mental state and symptoms were unclear in the comparisons with other therapies. No data were available to assess the impact of supportive therapy on engagement with structured activities.

AUTHORS' CONCLUSIONS

There are insufficient data to identify a difference in outcome between supportive therapy and standard care. There are several outcomes, including hospitalisation and general mental state, indicating advantages for other psychological therapies over supportive therapy but these findings are based on a few small studies. Future research would benefit from larger trials that use supportive therapy as the main treatment arm rather than the comparator.

Supportive therapy for schizophrenia

BACKGROUND

Supportive therapy is often used in everyday clinical care and in evaluative studies of other treatments.

OBJECTIVES

To estimate the effects of supportive therapy for people with schizophrenia.

SEARCH STRATEGY

We searched the Cochrane Schizophrenia Group's register of trials (January 2004), supplemented by manual reference searching and contact with authors of relevant reviews or studies.

SELECTION CRITERIA

All randomised trials involving people with schizophrenia and comparing supportive therapy with any other treatment or standard care.

DATA COLLECTION AND ANALYSIS

We reliably selected studies, quality rated these and extracted data. For dichotomous data, we estimated the relative risk (RR) fixed effect with 95% confidence intervals (CI). Where possible, we undertook intention-to-treat analyses. For statistically significant results, we calculated the number needed to treat/harm (NNT/H). We estimated heterogeneity (I-square technique) and publication bias.

MAIN RESULTS

We included 21 relevant studies. We found no significant differences in the primary outcomes between supportive therapy and standard care. There were, however, significant differences favouring other psychological or psychosocial treatments over supportive therapy. These included hospitalisation rates (3 RCTs, n=241, RR 2.12 CI 1.2 to 3.6, NNT 8) but not relapse rates (5 RCTs, n=270, RR 1.18 CI 0.9 to 1.5). We found that the results for general functioning significantly favoured cognitive behavioural therapy compared with supportive therapy in the short (1 RCT, n=70, WMD -9.50 CI -16.1 to -2.9), medium (1 RCT, n=67, WMD -12.6 CI -19.4 to -5.8) and long term (2 RCTs, n=78, SMD -0.50 CI -1.0 to -0.04), but the clinical significance of these findings based on few data is unclear. Participants were less likely to be satisfied with care if receiving supportive therapy compared with cognitive behavioural treatment (1 RCT, n=45, RR 3.19 CI 1.0 to 10.1, NNT 4 CI 2 to 736). The results for mental state and symptoms were unclear in the comparisons with other therapies. No data were available to assess the impact of supportive therapy on engagement with structured activities.

AUTHORS' CONCLUSIONS

There are insufficient data to identify a difference in outcome between supportive therapy and standard care. There are several outcomes, including hospitalisation and general mental state, indicating advantages for other psychological therapies over supportive therapy but these findings are based on a few small studies. Future research would benefit from larger trials that use supportive therapy as the main treatment arm rather than the comparator.

The combined use of electroconvulsive therapy and antipsychotics in patients with schizophrenia

OBJECTIVES

We sought to review the literature on the use of combined antipsychotic medications and electroconvulsive therapy (ECT) for the treatment of schizophrenia, with regard to efficacy, side effects, and ECT technique.

METHODS

A computerized search of the literature published from 1980 to 2004 was conducted on Medline and PsychoInfo using the words schizophrenia, antipsychotic, neuroleptic, psychotropic, and ECT. Only studies including patients with the diagnosis of schizophrenia were included.

RESULTS

We identified 42 articles including 1371 patients. The majority of the reports consist of uncontrolled studies (n = 31), mostly with typical antipsychotics (n = 23). Results from open studies suggest that the combination of ECT and antipsychotics is a very useful and safe strategy for the treatment of refractory schizophrenia. Double-blind controlled studies (n = 8) were inconclusive. Twelve articles were on the combination of clozapine and ECT. Initial concerns about the safety of the coadministration of clozapine and ECT were not substantiated, but despite the auspicious results from several case reports and 2 open trials, this combination remains understudied. Most studies preferred the bitemporal placement (n = 28), but because of insufficient data derived from direct comparisons, no conclusion on placement superiority can be reached. One study indicates that with the bilateral placement higher electrical dosages yields faster responses in this population.

CONCLUSIONS

The body of the data provided by research is still insufficient to allow definitive conclusions on the combination of antipsychotics and ECT. However, the literature reviewed indicates that the combination is a safe and efficacious treatment strategy for patients with schizophrenia, especially those refractory to conventional treatments.

Effectiveness of a brief cognitive-behavioural therapy intervention in the treatment of schizophrenia

BACKGROUND

Little evidence exists to indicate whether community psychiatric nurses can achieve the results reported by expert cognitive-behavioural therapists in patients with schizophrenia.

AIMS

To assess the effectiveness and safety of a brief cognitive-behavioural therapy (CBT) intervention in a representative community sample of patients with schizophrenia in secondary care settings.

METHOD

A pragmatic randomised trial was performed involving 422 patients and carers to compare a brief CBT intervention against treatment as usual.

RESULTS

Patients who received CBT (n=257) improved in overall symptomatology (P=0.015; number needed to treat [NNT]=13), insight (P<0.001; NNT=10) and depression (P=0.003; NNT=9) compared with the control group (n=165). Insight was clinically significantly improved (risk ratio=1.15, 95% CI 1.01-1.31). There was no increase in suicidal ideation.

CONCLUSIONS

Community psychiatric nurses can safely and effectively deliver a brief CBT intervention to patients with schizophrenia and their carers.

Systematic meta-review of depot antipsychotic drugs for people with schizophrenia

BACKGROUND

Long-acting depot antipsychotic medication is a widely used treatment for schizophrenia.

AIMS

To synthesise relevant systematic Cochrane reviews.

METHOD

The Cochrane Database was searched and summary data were extracted from randomised controlled clinical trials of depots.

RESULTS

Standard dose depot v. placebo resulted in significantly less relapse but more movement disorders. Those on depots (v. oral drugs) showed more global change on one outcome measure; relapse and adverse effects showed no difference. Comparisons showed no convincing advantages for one depot over another.

CONCLUSIONS

Depot antipsychotics are safe and effective. They may confer a small benefit over oral drugs on global outcome. Those for whom depots are most indicated may not be represented. Large studies are required to discern differences in relapse rates and long-term adverse effects, and data on satisfaction, quality of life and economics.

Inverse correlation between hallucinations and serum prolactin in patients with non-affective psychoses

Serum prolactin (PRL) was correlated with clinical symptomatology in 17 drug-free patients suffering from non-affective psychoses. A clear-cut negative correlation was found between the Comprehensive Psychiatric Rating Scale (CPRS) items assessing hallucinations and serum PRL levels (r=-6.14, P=0.009). No correlation was observed between clinical measures (total CPRS score, schizophrenia subscale score or depression and anxiety subscale score) and serum PRL.

Cognitive-behavioural techniques for general psychiatrists in the management of patients with psychoses

BACKGROUND

Recent research progress showing the benefits of cognitive therapy in schizophrenia leaves the general psychiatrist unsure whether to attempt to use such techniques.

AIMS

To test whether cognitive-behavioural techniques are beneficial in the management of patients with schizophrenia in general psychiatric practice.

METHOD

A randomised controlled study comparing the use of cognitive-behavioural techniques and befriending in schizophrenia.

RESULTS

Significant improvement in symptoms occurred in the group treated with cognitive-behavioural techniques but not in the befriending group. During the 6-month follow-up period the cognitive-behavioural group tended to have shorter periods in hospital.

CONCLUSIONS

General psychiatrists could help their patients with schizophrenia by using cognitive-behavioural techniques. Such techniques are well within the capability of general psychiatrists, but their application would involve more of the consultant's time spent in direct contact with patients with psychoses.

Current antipsychotic dose correlates to mononuclear cell counts in the cerebrospinal fluid of psychotic patients

Elevated cerebrospinal fluid (CSF) angiotensin I-converting enzyme (ACE) levels have been evidenced in patients with schizophrenia who have been treated with antipsychotics. In order to explore a possible mononuclear cell origin of CSF ACE, the authors determined CSF ACE and CSF mononuclear cell counts from 25 acutely psychotic patients, who had been drug-free for at least 4 months but started on conventional antipsychotic medication within a few days before sampling. No correlations were found between CSF to serum ACE ratio and CSF mononuclear cell counts. However, CSF total mononuclear cell count, CSF lymphocyte count, and CSF mononuclear phagocyte count evidenced significant positive correlations with current dose of antipsychotic medication expressed as chlorpromazine equivalents. The authors conclude that no indication of a relationship between mononuclear cells and CSF ACE activity was found. Surprisingly, a relationship between chlorpromazine dose and CSF mononuclear cell counts was found, which may indicate drug-related changes in cell-mediated immunity. This finding needs replication and further corroboration in well-designed studies.

Pimozide for schizophrenia or related psychoses

BACKGROUND

Pimozide was first formulated in the late 1960s and marketed for the care of those with schizophrenia or related psychoses such as delusional disorder.

OBJECTIVES

To assess the effects of pimozide for people with schizophrenia, non-affective psychotic mental illness and delusional disorder in terms of clinical, social and economic outcomes.

SEARCH STRATEGY

Electronic searches of Biological Abstracts (1982-1995), The Cochrane Schizophrenia Group's Register, EMBASE (1980-1995), Janssen-Cilag UK's register of studies (1999), MEDLINE (1966-1995), PsycLIT (1974-1995), hand-searching the references of all included studies and contacting the manufacturers of the compound.

SELECTION CRITERIA

All randomised trials relating to people with schizophrenia, or similar disorders comparing pimozide to other drug treatments were sought. Studies where randomisation was implied rather than stated were included if they did not change the results. Primary outcomes were clinically significant change in global function, mental state, relapse, hospital admission, death, adverse events and acceptability of treatment.

DATA COLLECTION AND ANALYSIS

Studies were selected, rated and data extracted. For dichotomous data Relative Risks (RR) based on a random effects model with the 95% confidence intervals (CI) were estimated. The number needed to treat statistic (NNT) was calculated where indicated. Analysis was by intention-to-treat.

MAIN RESULTS

This review currently includes 34 studies focusing on those with schizophrenia, none on people with delusional disorder. Few people have been randomised to pimozide versus placebo, but data from three longer term studies does suggest that the active drug prevents relapse (RR 0.59 CI 0.4-0.8, NNT 4 CI 2-13). Pimozide has similar efficacy to that of typical antipsychotic drugs for the outcomes of change in global functioning, mental state, relapse and leaving the study early. People allocated to pimozide did not have a higher mortality than those taking other antipsychotics. Pimozide was more likely to cause parkinsonian tremor (RR 1.6 CI 1.1-2.3, NNH 6 CI 3-44) and lead to a requirement for antiparkinsonian medication more frequently (RR 1.8, CI 1.2-2.6, NNH 3 CI 2-5) than other drugs. It was, however, less likely to cause sedation (RR 0.38 CI 0.2-0.7, NNH 6 CI 4-16).

REVIEWER'S CONCLUSIONS

Although there are shortcomings in the data there is enough overall consistency, over different outcomes and time scales, to confirm that pimozide is a drug with similar efficacy to other more commonly used antipsychotics such as chlorpromazine for those with schizophrenia. There are no data to support or refute its use for those with delusional disorder.

Dimensions of the Brief Psychiatric Rating Scale: an examination of stability during haloperidol treatment

The purpose of the study was to investigate invariance of the factor structure of the Brief Psychiatric Rating Scale (BPRS) during haloperidol treatment. Data were collected in a placebo-controlled, double-blind, crossover treatment study examining the relationship between haloperidol plasma level and clinical outcome. Subjects were 173 acutely exacerbated, newly admitted patients with a diagnosis of schizophrenia or schizoaffective disorder. Exploratory (EFA) and confirmatory (CFA) factor analyses were performed at four time points: (1) last day of the preplacebo period; (2) last day of the placebo period; (3) end of the first treatment week; and (4) end of the treatment period. EFAs demonstrated (1) good reproducibility of commonly used BPRS factors at the preplacebo time point, (2) substantial changes in the factor structure during the placebo period, and (3) a reemergence of the initial (preplacebo) factor structure for most of the factors during haloperidol treatment. CFAs showed that traditional clinical factors were correlated with each other at all time points and that there were substantial changes in correlation among these factors over time. Our results suggest that longitudinal applications of traditional BPRS subscales should take factorial stability over time into consideration. Since many clinical trials use placebo data as a standard for longitudinal comparisons, further psychometric investigation is necessary to increase construct reliability and temporal stability.

Depression and the experience of psychological deficits in schizophrenia

A study of the relationships between depression and the subjective experience of psychological deficits was carried out in a group of 50 schizophrenic patients selected from a population of long-term mentally ill patients. Experience of psychological deficits was associated with depression, and furthermore the temporal relationships between the phenomena supported the hypothesis that experience of psychological deficits is associated with vulnerability to depression in schizophrenia. In addition, the patients' self-reporting of depressed mood and negative cognitions was congruent with an observer's assessment of depression. These findings indicate that subjective experiences of deficits characteristic of the schizophrenic illness confer vulnerability to depression, but nonetheless the patients' experience of depression resembles that typical of depressed non-schizophrenic patients.

The composition of the negative syndrome of chronic schizophrenia

The clinical features of patients who satisfy a variety of criteria for the negative syndrome can be arranged in five groups of phenomena: (a) poverty of thought and speech, (b) blunted affect, (c) decreased motor activity, (d) apathy and abolition, and (e) diminished interpersonal interaction. We have shown that depressed mood and depressive cognition are not related to the negative syndrome, but there is some overlap between the specific phenomena of depressive illness and negative symptoms in schizophrenia. Items measuring cognitive impairment have a moderate correlation with the negative syndrome, but the negative syndrome accounts for less than half of the variance of cognitive performance. These items that define the negative syndrome can be as reliably measured as depressive and positive symptoms.

A double-blind comparison of raclopride and haloperidol in the acute phase of schizophrenia. The British Isles Raclopride Study Group

This is the first comparative double-blind study of raclopride. Ninety-one patients with acute schizophrenia received either raclopride 2-8 mg twice daily or haloperidol 5-20 mg twice daily for 4 weeks. Both neuroleptics produced clinical improvements. There were no significant between-drug differences in overall efficacy measurements as assessed by the schizophrenia change sub-scale of the Comprehensive Psychopathological Rating Scale and the Krawiecka (Manchester) Rating Scale. Assessment by the Clinical Global Impression scale found haloperidol to be more effective. There were significantly fewer extrapyramidal symptoms with raclopride and a significantly lower incidence of acute dystonia. The results suggest that raclopride has an antipsychotic effect with a low incidence of extrapyramidal side effects.

Inadequate treatment response to des-enkephalin-gamma-endorphin compared with thioridazine and placebo in schizophrenia

The possibility of an involvement of peptidergic systems in schizophrenia has been under investigation for a number of years. Studies of the efficacy of des-tyr-gamma-endorphin were equivocal; more recent studies with des-enkephalin-gamma-endorphin have reported some activity but the peptide has only been investigated as an adjunct to neuroleptic medication, apart from one very small active reference comparator study. In the multicentre study reported here, 96 patients suffering from schizophrenia (DSM-III with a current exacerbation if chronic) were allocated randomly to double-blind treatment with either des-enkephalin-gamma-endorphin (DE-gamma-E) (Org 5878) 10 mg given as a once daily intramuscular injection for 4 weeks, thioridazine 400 mg orally in 2 divided doses or placebo using a double-dummy technique to preserve blindness. There was a significant advantage for thioridazine compared with placebo registered on all measures at weeks 3 and 4. There was no difference between DE-gamma-E and placebo. There was a significant difference between thioridazine and DE-gamma-E at weeks 3 and 4 registered on the MSS and at week 3 registered on the BPRS. The lack of efficacy of DE-gamma-E suggests that the theories that the endorphins have an important role in schizophrenia have to be revised. The need for well designed placebo controlled studies for assessing efficacy in schizophrenia is emphasized.

A rating scale for assessment of alcohol withdrawal psychopathology (AWIP)

For patients in alcohol withdrawal, there are several scales designed to assess physiological disturbances, but there seems to be a lack of scales for assessment of psychopathology. To develop and evaluate a rating scale for psychopathology, items from the Comprehensive Psychopathological Rating Scale (CPRS) were selected, and patients meeting the DSMR-III-R criteria for alcohol dependence (303.90) were rated on these items. The patients were divided into two groups according to the length of time passed since their last period of alcohol consumption. The groups are referred to as the group (n = 53) in early withdrawal, rated daily during 1 week and the group (n = 13) in late withdrawal, rated once a week for 7 weeks. To justify inclusion in the new scale, items had to either indicate psychopathology in at least half of the patients in one of the groups in withdrawal, or be sensitive to changes over time at a 0.1% level of significance. Seventeen items fulfilled one of these criteria. The scale was tested for inter-rater reliability in a new sample of patients (n = 30) in early withdrawal. Inter-rater reliability, as well as internal consistency, was found satisfactory. This new scale, capable of identifying psychopathology and changes over time, may be used alone or together with physiological scales to identify subgroups of patients undergoing withdrawal.

The relationship between perphenazine plasma levels and clinical response in acute schizophrenia

1. Twelve patients with schizophrenia according to RDC participated in a double-blind study, comparing two dose levels of perphenazine, 16 or 32 mg, during four weeks. 2. The patients were assessed with a subscale to CPRS and global scores, measuring improvement of regular intervals during four weeks. 3. Blood samples for assay of plasma perphenazine were collected once a week. 4. These results are in many respects in accordance with earlier published data with perphenazine, that is a good clinical response is achieved with a plasma concentration of perphenazine between 1-5 nmol/L. 5. No incidence of severe adverse symptoms were observed.

Response to drugs in schizophrenia: the influence of family history, obstetric complications and ventricular enlargement

A prospective study of antipsychotic drug treatment showed no difference in response between schizophrenic in-patients with or without a familial predisposition to the illness (N = 53). All patients received at least 600 mg chlorpromazine equivalents antipsychotic medication for 6 weeks. Ventricle brain ratios, ratings of cortical sulcal widening and a history of obstetric complications also failed to account for the variability, but early age of onset was associated with unsatisfactory response.

The use of cholecystokinin in schizophrenia: a review

Cholecystokinin (CCK) is a peptide originally isolated from the gut. It has been investigated as a candidate treatment for schizophrenia on the assumption that the illness is associated with an imbalance between CCK and dopamine in the mesolimbic dopamine system. Many of the studies to assess the efficacy of CCK used open designs and are prone to observer bias and over-optimistic reporting. Most of the studies used CCK as an adjunct to standard neuroleptic treatment and are too small to be able to demonstrate extra efficacy above that of the active compound. Only three out of ten studies using CCK or placebo as an adjunct to neuroleptics reported limited efficacy. Of the 14 placebo-controlled reports only three were in drug-free patients. These were unfortunately too small, or too brief, to draw valid conclusions of efficacy. A summary of these data suggests that although 500 patients have received CCK, its efficacy in the treatment of schizophrenia has not been properly tested.

An open label trial of raclopride in acute schizophrenia. Confirmation of D2-dopamine receptor occupancy by PET

Raclopride, a highly selective D2-dopamine receptor antagonist, was administered in doses up to 4 mg b.i.d. to ten schizophrenic patients in an open label non-comparative study lasting 4 weeks. Safety, tolerability, potential antipsychotic effect, prolactin response and drug effect on plasma homovanillic acid were evaluated. Central D2-dopamine receptor occupancy was determined by positron emission tomography (PET). No major deviations were found in biochemical and physiological safety parameters. Raclopride was well tolerated. The mean BPRS score was reduced by 55% at endpoint. In the global evaluation seven patients were "very much" or "much" improved. Extrapyramidal side effects were recorded in four patients and disappeared after dose reduction or single doses of biperiden. An increase in plasma prolactin of short duration was observed in both sexes. A significant decrease of plasma HVA was obtained after 4 weeks of treatment. In two of the patients the central D2-dopamine receptors occupancy was measured using PET. The receptor occupancy was 68 and 72% which is the same as that found in patients treated with conventional neuroleptics.

Effects of mianserin in neuroleptic-induced parkinsonism

It has been proposed that serotonin (5-HT) antagonists counteract neuroleptic-induced extrapyramidal symptoms by disinhibition of dopamine activity. The effects of the 5-HT antagonist mianserin, the anticholinergic drug procyclidine and placebo were evaluated in 16 psychiatric patients with chronic neuroleptic-induced parkinsonism in a double-blind cross-over trial. The patients received each drug in random order in 3-week periods separated by washout periods of 2 weeks. The effect of mianserin did not significantly differ from that of placebo, while parkinsonian symptoms were significantly reduced during treatment with procyclidine (P less than 0.05). Although mianserin was ineffective in chronic neuroleptic-induced parkinsonism, it cannot be excluded that 5-HT antagonists may be effective in the treatment of acute extrapyramidal side effects.

Leicester ECT trial: results in schizophrenia

As part of the Leicester electroconvulsive therapy (ECT) study, the role of ECT in schizophrenia was investigated in a double-blind trial. The Present State Examination criteria for schizophrenia were fulfilled by 22 patients, of whom 19 gave consent and entered the trial. Neuroleptic medication was restricted during the trial period. Patients were randomly allocated to eight real ECT or eight simulated ECT. At the end of the four-week trial period, patients receiving real ECT showed a significantly greater improvement when measured on the Montgomery-Asberg Schizophrenia Scale (MASS), the visual analogue global psychopathology scale, and the depression scale. The differences on the MASS and visual analogue global psychopathology scale were not due to improvement in depressive symptoms. The superiority of real ECT was not demonstrated at the 12- and 28-week follow-up, when treatment was not controlled.

A rating scale for emotional distress in patients with malignant diseases

As a contribution to assessment of quality of survival in malignant disease a rating scale for emotional distress (EDS) has been developed. The scale consists of eight items with explicit definitions, and the ratings are based on short interviews. The scale was applied on 34 patients with malignant blood diseases, and ratings were performed at regular intervals both prior to and during cytostatic treatment courses. The patients accepted the interview procedure well and the scale proved to be easy to apply in a clinical setting. Raters with little previous experience (nurses and physicians) had good interrater reliability (r = 0.98). The EDS scores of patients in good somatic condition increased significantly (P less than 0.01) during cytostatic treatment courses while no change was found among the more severely ill. There was a tendency for pure cytostatic schedules to inflict more discomfort than those also containing high doses of steroids, indicating that the scale may discriminate between various treatments. There was a significant correlation (r = 0.73, P less than 0.01) between the EDS scores and the physical condition of the patients. The results indicate that the EDS may be a reliable and sensitive instrument which adds an important aspect to the evaluation of the quality of survival in the treatment of malignant disease. It may also be of value when comparing different treatment regimens.

The brief scale for anxiety: a subdivision of the comprehensive psychopathological rating scale

A rating scale suitable for recording anxious symptoms is described. It is a subdivision of the Comprehensive Psychopathological Rating Scale and comprises 10 items, all of which are rated on a 7 point scale. It is suitable for the rating of pathological anxiety alone or for anxiety occurring in the setting of other psychological or medical disorder.

The relationship of dopamine receptor blockade to clinical response in schizophrenic patients treated with pimozide or haloperidol

Pimozide and haloperidol were found to be equally effective in the treatment of acute schizophrenia in a double-blind clinical trial involving 22 patients. Drug plasma levels measured by radioimmunoassay (RIA) did not correlate with clinical response following either drug. Nor was there any correlation between clinical response and the dopamine receptor blocking activity of either drug as measured by radio receptor assay (RRA). Following pimozide plasma prolactin (PRL) levels correlated with clinical change, although the time courses of response of PRL and clinical response were dissimilar. There was no correlation between PRL and clinical response to haloperidol. RRA and RIA values correlated highly following pimozide but not haloperidol. Our findings lead us to conclude that the RRA technique reflects the plasma level of a drug rather than its central dopamine blocking activity. We also consider that the clinical response to antipsychotic drugs in schizophrenia may be less directly linked to dopamine receptor blockade than has previously been supposed.

Estimation of time and the subclassification of schizophrenic disorders

Estimation of short time intervals by 60 healthy subjects, 50 patients with schizophrenic disorders, and 8 with schizotypal personality disorders, was investigated using the three different methods, adjusting a metronome, verbal estimation, and operative estimation (production). The schizophrenic patients tended to over-estimate time with all three methods. Overestimation was also found when longer intervals were studied. Patients with different types of schizophrenic disorders, classified according to DSM-III criteria, over-estimated time about the same; no significant differences were found. Different courses of schizophrenia were also studied. Patients in remission over-estimated time to the same extent as chronic patients; the subchronic patients probably over-estimated less. Schizotypal personality disorders did not seem to be associated with a tendency to over-estimate short time intervals. The results were discussed in the context of perceptual disturbances in schizophrenic disorders.

Comparative double-blind study of flupenthixol decanoate and fluphenazine decanoate in the treatment of patients relapsing in a schizophrenic symptomatology

Thirty-two chronic schizophrenics who had relapsed entered a double-blind randomised study and were followed-up for 2 years with the intention of measuring any difference in therapeutic effect and side effects between flupenthixol decanoate and fluphenazine decanoate. No differences could be seen as regards the global effect or the effect on the schizophrenic symptomatology during the first 6 months. After 1 year of treatment flupenthixol decanoate showed a trend towards a better effect on schizophrenic symptomatology. A corresponding result was seen for the depressive symptoms. There were no differences in the appearance of side effects. The need for additional neuroleptics in the initial phase seemed to be identical for both drugs. A possible slow antipsychotic effect with flupenthixol decanoate is probably due to the administered dose being somewhat low (in the present study approximately 31 mg flupenthixol corresponding to 27 mg fluphenazine). This suggests that flupenthixol should have been given in a somewhat higher dose (25 mg fluphenazine decanoate corresponding to 40 mg flupenthixol decanoate).

A depot neuroleptic withdrawal study neurological effects

A double-blind withdrawal trial in 41 chronic schizophrenic outpatients was carried out over 6 months. Depot neuroleptics (fluphenazine decanoate or flupenthixol decanoate) were compared with placebo to evaluate neurological side effects during continued therapy and during withdrawal. The drugs were significantly more effective than placebo in preventing relapse and rehospitalization. In the placebo group 62% relapsed compared to 27% in the drug group. A difference was observed in the occurrence of extrapyramidal symptoms (EPS) between the neuroleptics in the study. Akathasia was observed in 9/38 (23.7%) cases, significantly more frequent in the fluphenazine decanoate group. Tardive dyskinesia (TD) was observed in six cases (15.8%); four cases existed at the start of the study and two others were observed after 3-6 weeks of withdrawal. There was no relation between TD symptoms and relapse. There was a significant decrease in the EPS scores during the placebo treatment and also a significant weight decrease.