The beneficial effects of combining pharmacological and psychosocial treatment on remission and functional outcome in outpatients with schizophrenia

Cerebral, Psychosocial, Family Functioning and Disability of Persons with Schizophrenia

The human brain is the most cognitively capable of mammalian brains, endowed as it is with an overdeveloped cerebral cortex that, in parallel, renders it vulnerable to mental disorders. Schizophrenia is the expression of the dysregulation of the neuronal activity of cortical and subcortical regions due to modifications in the levels of the various neurotransmitters, especially of dopamine, with a reciprocal, intimate relationship among genes with environmental and psychosocial factors. If the dopaminergic system increases the function prefrontal cortex will be reduced: this is the main reason of social, occupational and familiar disruption. The present article describes the function of the brain in schizophrenia and its relation with anatomical, physiological, and genetic changes, in addition to identifying, psychosocial and family factors that can be determinant in the functionality of the patient. A review of national and international bibliography was conducted bearing in mind the following variables: functioning at the cerebral level; psychosocial functioning, familial functioning, disability, and functionality in persons with schizophrenia. Due to the variety of the issues included in this review, it can be concluded that schizophrenia is the product of a complex array of symptoms, deficits and disabilities. It was identified that there is a reciprocal confluence of diverse genetic, psychosocial, familial, environmental, educative, and social factors which affect the functionality of persons with this disorder. The latter makes it necessary to study the patient taking into consideration all of these components in an integral manner.

Psychosocial Interventions for Adults With Schizophrenia: An Overview and Update of Systematic Reviews

OBJECTIVE

The authors of this systematic review (SR) sought to provide evidence for effects of commonly used psychosocial interventions on several outcomes among adults with schizophrenia.

METHODS

MEDLINE, the Cochrane Library, and PsycINFO databases were searched through July 2020. Eligible studies were SRs and trials of at least 12 weeks duration and with ≥50 participants that compared psychosocial interventions with treatment as usual among adults with schizophrenia. Study design, year, setting, country, sample size, eligibility criteria, population, clinical and intervention characteristics, results, and funding source were extracted, along with quality criteria. The evidence was evaluated on quality and strength of evidence stratified by intervention area and outcome, according to the Evidence-Based Practice Centers Methods Guide of the Agency for Healthcare Research and Quality.

RESULTS

Nine SRs and 30 trials (N=23,921 patients) in 11 intervention areas were included. Trials were mostly of fair quality and had low-to-moderate strength of evidence. Compared with treatment as usual, most psychosocial interventions were more effective in improving intervention-targeted outcomes, including core illness symptoms. Compared with treatment as usual, assertive community treatment, cognitive-behavioral therapy (CBT), family interventions, psychoeducation, social skills training, supported employment, and early interventions for first-episode psychosis (FEP) improved various functional outcomes. CBT and early interventions for FEP improved quality of life. Family interventions, psychoeducation, illness self-management, and early interventions for FEP reduced relapse.

CONCLUSIONS

Compared with treatment as usual, most psychosocial interventions improved functional outcomes, quality of life, and core illness symptoms, and several reduced relapse frequency among adults with schizophrenia.

Schizophrenia pregnancies should be given greater health priority in the global health agenda: results from a large-scale meta-analysis of 43,611 deliveries of women with schizophrenia and 40,948,272 controls

Women with schizophrenia and their newborns are at risk of adverse pregnancy, delivery, neonatal and child outcomes. However, robust and informative epidemiological estimates are lacking to guide health policies to prioritise and organise perinatal services. For the first time, we carried out a systematic review and meta-analysis to synthesise the accumulating evidence on pregnancy, delivery, neonatal complications, and infant mortality among women with schizophrenia and their newborns (N = 43,611) vs. controls (N = 40,948,272) between 1999 and 2021 (26 population-based studies from 11 high-income countries) using random effects. Women with schizophrenia had higher odds (OR) of gestational diabetes (2.35, 95% CI: [1.57-3.52]), gestational hypertension, pre-eclampsia/eclampsia (OR 1.55, 95% CI: [1.02-2.36]; 1.85, 95% CI: [1.52-2.25]), antepartum and postpartum haemorrhage (OR 2.28, 95% CI: [1.58-3.29]; 1.14, 95% CI: [1.04-1.24]), placenta abruption, threatened preterm labour, and premature rupture of membrane (OR 2.20, 95% CI: [2.02-2.39]; 2.91, 95% CI: [1.57-5.40]; 1.29, 95% CI: [1.06-1.58]), c-section (OR 1.33, 95% CI: [1.22-1.45]), foetal distress (OR 1.80, 95% CI: [1.43-2.26]), preterm and very preterm delivery (OR 1.79, 95% CI: [1.62-1.98]; 2.31, 95% CI: [1.78-2.98]), small for gestational age and low birth weight (OR 1.63, 95% CI: [1.48-1.80]; 1.75, 95% CI: [1.46-2.11]), congenital malformations (OR 1.86, 95% CI: [1.71-2.03]), and stillbirths (OR 2.06, 95% CI: [1.83-2.31]). Their newborns had higher odds of neonatal death (OR 1.41, 95% CI: [1.03-1.94]), post-neonatal death (OR 2.87, 95% CI: [2.11-3.89]) and infant mortality (OR 2.33, 95% CI: [1.81-3.01]). This large-scale meta-analysis confirms that schizophrenia is associated with a substantially increased risk of very preterm delivery, stillbirth, and infant mortality, and metabolic risk in mothers. No population-based study has been carried out in low- and middle-income countries in which health problems of women with schizophrenia are probably more pronounced. More research is needed to better understand the complex needs of women with schizophrenia and their newborns, determine how care delivery could be optimised, and define best practices. Study registration: PROSPERO CRD42020197446.

Psychoeducation, motivational interviewing, cognitive remediation training, and/or social skills training in combination for psychosocial functioning of patients with schizophrenia spectrum disorders: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVES

Psychoeducation, motivational interviewing, cognitive remediation training, and social skills training have been found to be effective interventions for patients with schizophrenia spectrum disorders. However, their efficacy on psychosocial functioning when provided in combination remains unclear, compared with all types of control conditions. It would also be meaningful to explore the differences of efficacy in patients with first-episode psychosis (FEP) and those with longer term of illness.

METHODOLOGY

The present review followed the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Full-text English journal articles of randomized controlled trials published in the past decade in the databases of PubMed, CINAHL Complete, Embase, and PsycINFO were searched. Included studies were all randomized controlled trials (RCTs) with participants diagnosed with schizophrenia spectrum disorders. The included studies should test combined interventions with at least two components from: psychoeducation, motivational interviewing, cognitive remediation training, and social skills training and incorporate assessment of psychosocial functioning at least at baseline and post-intervention.

RESULTS

Seven studies were included for systematic review, and six of them were eligible for meta-analysis. Five out of the seven studies reported effects on psychosocial functioning that favored combined interventions over any type of control condition. A significant pooled effect was derived from the six studies, SMD = 1.03, 95% CI [0.06, 2.00], Z = 2.09, p = 0.04, I ² = 96%. However, the pool effect became insignificant when synthesizing five of the studies with non-FEP patients as participants and four of the studies testing relative effects of combined interventions compared with stand-alone interventions/interventions with one less component. None of the included studies adopted motivational interviewing and only one of the studies worked with FEP patients.

CONCLUSION

Psychoeducation, cognitive remediation training, and social skills training in combination can effectively enhance psychosocial functioning of patients with schizophrenia spectrum disorders. It is warranted to conduct more RCTs to test the effects of different specific combinations of the above interventions on psychosocial functioning, especially in FEP patients.

What characterizes a good mental health professional in court-mandated treatment settings?: Findings from a qualitative study with older patients and mental health care professionals

BACKGROUND

Therapist-related activities and characteristics such as empathy and genuineness are factors that significantly contribute to psychotherapy outcome. As they play a role in psychotherapy more generally, it can be expected that they are equally important in the treatment of court-mandated patients more specifically. At the same time, these treatment settings come with specific challenges-e.g. due to coercion and control-and it could thus be that some therapist-related characteristics might have a different empathy on the therapy. This interview study sought to investigate service providers' and users' perspectives on therapist-related characteristics in the context of detention.

METHODS

We conducted a qualitative interview study with 41 older incarcerated persons mandated to treatment, and 63 mental health professionals (MHP). The data analysis followed thematic analysis.

RESULTS

Patients and experts both emphasized the importance of treating patients with respect by taking a humanistic approach, that is, condemn the deeds but embrace the person and display genuine interest in supporting patients with any issue or concern that is of relevance to them. Furthermore, interviewees underscored that the coerciveness of the therapy context required to incorporate patients' wishes into treatment planning, recognize and respond to the patients' needs, and allow some choice within the given framework. Such inclusive attitude was deemed critical to engage and motivate patients to participate in treatment. In addition, it was emphasized that feedback and advice by the therapists need to be concrete, detailed and applied to each person's current situation. Lastly, patients questioned MHP's qualification when they did not progress in therapy.

DISCUSSION

Our findings indicate that some therapist-related activities and characteristics are of particular importance in court-mandated settings. These include genuine interest in the patient, a respectful and positive attitude, as well as the capacity to target sensitive issues in a directive but non-confrontational manner. Further research needs to identify specific expressions and behaviors that are linked to the aforementioned characteristics in the forensic context. Our study therefore contributes to much-needed empirical research on clinician and patient perspectives on therapist characteristics and activities in the treatment of court-mandated patients.

A conceptual framework to develop a patient-reported experience measure of the quality of mental health care: a qualitative study of the PREMIUM project in France

Background: The objective of this study was to develop a conceptual framework to define a domain map describing the experience of patients with severe mental illnesses (SMIs) on the quality of mental health care. Methods: This study used an exploratory qualitative approach to examine the subjective experience of adult patients (18-65 years old) with SMIs, including schizophrenia (SZ), bipolar disorder (BD) and major depressive disorder (MDD). Participants were selected using a purposeful sampling method. Semistructured interviews were conducted with 37 psychiatric inpatients and outpatients recruited from the largest public hospital in southeastern France. Transcripts were subjected to an inductive analysis by using two complementary approaches (thematic analysis and computerized text analysis) to identify themes and subthemes. Results: Our analysis generated a conceptual model composed of 7 main themes, ranked from most important to least important as follows: interpersonal relationships, care environment, drug therapy, access and care coordination, respect and dignity, information and psychological care. The interpersonal relationships theme was divided into 3 subthemes: patient-staff relationships, relations with other patients and involvement of family and friends. All themes were spontaneously raised by respondents. Conclusion: This work provides a conceptual framework that will inform the subsequent development of a patient-reported experience measure to monitor and improve the performance of the mental health care system in France. The findings showed that patients with SMIs place an emphasis on the interpersonal component, which is one of the important predictors of therapeutic alliance. Trial registration: NCT02491866.

Specialised early intervention teams (extended time) for recent-onset psychosis

BACKGROUND

Psychosis is an illness characterised by the presence of hallucinations and delusions that can cause distress or a marked change in an individual's behaviour (e.g. social withdrawal, flat or blunted effect). A first episode of psychosis (FEP) is the first time someone experiences these symptoms that can occur at any age, but the condition is most common in late adolescence and early adulthood. This review is concerned with FEP and the early stages of a psychosis, referred to throughout this review as 'recent-onset psychosis.' Specialised early intervention (SEI) teams are community mental health teams that specifically treat people who are experiencing, or have experienced, a recent-onset psychosis. SEI teams provide a range of treatments including medication, psychotherapy, psychoeducation, educational and employment support, augmented by assertive contact with the service user and small caseloads. Treatment is time limited, usually offered for two to three years, after which service users are either discharged to primary care or transferred to a standard adult community mental health team. Evidence suggests that once SEI treatment ends, improvements may not be sustained, bringing uncertainty about the optimal duration of SEI to ensure the best long-term outcomes. Extending SEI has been proposed as a way of providing continued intensive treatment and continuity of care, of usually up to five years, in order to a) sustain the positive initial outcomes of SEI; and b) improve the long-term trajectory of the illness.

OBJECTIVES

To compare extended SEI teams with treatment as usual (TAU) for people with recent-onset psychosis. To compare extended SEI teams with standard SEI teams followed by TAU (standard SEI + TAU) for people with recent-onset psychosis.

SEARCH METHODS

On 3 October 2018 and 22 October 2019, we searched Cochrane Schizophrenia's study-based register of trials, including registries of clinical trials.

SELECTION CRITERIA

We selected all randomised controlled trials (RCTs) comparing extended SEI with TAU for people with recent-onset psychosis and all RCTs comparing extended SEI with standard SEI + TAU for people with recent-onset psychosis. We entered trials meeting these criteria and reporting usable data as included studies.

DATA COLLECTION AND ANALYSIS

We independently inspected citations, selected studies, extracted data and appraised study quality. For binary outcomes we calculated the risk ratios (RRs) and their 95% confidence intervals (CIs). For continuous outcomes we calculated the mean difference (MD) and their 95% CIs, or if assessment measures differed for the same construct, we calculated the standardised mean difference (SMD) with 95% CIs. We assessed risk of bias for included studies and created a 'Summary of findings' table using the GRADE approach.

MAIN RESULTS

We included three RCTs, with a total 780 participants, aged 16 to 35 years. All participants met the criteria for schizophrenia spectrum disorders or affective psychoses. No trials compared extended SEI with TAU. All three trials randomly allocated people approximately two years into standard SEI to either extended SEI or standard SEI + TAU. The certainty of evidence for outcomes varied from low to very low. Our primary outcomes were recovery and disengagement from mental health services. No trials reported on recovery, and we used remission as a proxy. Three trials reported on remission, with the point estimate suggesting a 13% increase in remission in favour of extended SEI, but this included wide confidence intervals (CIs) and a very uncertain estimate of no benefit (RR 1.13, 95% CI 0.97 to 1.31; 3 trials, 780 participants; very low-certainty evidence). Two trials provided data on disengagement from services with evidence that extended SEI care may result in fewer disengagements from mental health treatment (15%) in comparison to standard SEI + TAU (34%) (RR 0.45, 95% CI 0.27 to 0.75; 2 trials, 380 participants; low-certainty evidence). There may be no evidence of a difference in rates of psychiatric hospital admission (RR 1.55, 95% CI 0.68 to 3.52; 1 trial, 160 participants; low-certainty evidence), or the number of days spent in a psychiatric hospital (MD -2.70, 95% CI -8.30 to 2.90; 1 trial, 400 participants; low-certainty evidence). One trial found uncertain evidence regarding lower global psychotic symptoms in extended SEI in comparison to standard SEI + TAU (MD -1.90, 95% CI -3.28 to -0.52; 1 trial, 156 participants; very low-certainty evidence). It was uncertain whether the use of extended SEI over standard SEI + TAU resulted in fewer deaths due to all-cause mortality, as so few deaths were recorded in trials (RR 0.38, 95% CI 0.09 to 1.64; 3 trials, 780 participants; low-certainty evidence). Very uncertain evidence suggests that using extended SEI instead of standard SEI + TAU may not improve global functioning (SMD 0.23, 95% CI -0.29 to 0.76; 2 trials, 560 participants; very low-certainty evidence). There was low risk of bias in all three trials for random sequence generation, allocation concealment and other biases. All three trials had high risk of bias for blinding of participants and personnel due to the nature of the intervention. For the risk of bias for blinding of outcome assessments and incomplete outcome data there was at least one trial with high or unclear risk of bias.

AUTHORS' CONCLUSIONS

There may be preliminary evidence of benefit from extending SEI team care for treating people experiencing psychosis, with fewer people disengaging from mental health services. Evidence regarding other outcomes was uncertain. The certainty of evidence for the measured outcomes was low or very low. Further, suitably powered studies that use a consistent approach to outcome selection are needed, but with only one further ongoing trial, there is unlikely to be any definitive conclusion for the effectiveness of extended SEI for at least the next few years.

Specialised early intervention teams for recent-onset psychosis

BACKGROUND

Psychosis is an illness characterised by the presence of hallucinations and delusions that can cause distress or a marked change in an individual's behaviour (e.g. social withdrawal, flat or blunted effect). A first episode of psychosis (FEP) is the first time someone experiences these symptoms that can occur at any age, but the condition is most common in late adolescence and early adulthood. This review is concerned with first episode psychosis (FEP) and the early stages of a psychosis, referred to throughout this review as 'recent-onset psychosis.' Specialised early intervention (SEI) teams are community mental health teams that specifically treat people who are experiencing, or have experienced a recent-onset psychosis. The purpose of SEI teams is to intensively treat people with psychosis early in the course of the illness with the goal of increasing the likelihood of recovery and reducing the need for longer-term mental health treatment. SEI teams provide a range of treatments including medication, psychotherapy, psychoeducation, and occupational, educational and employment support, augmented by assertive contact with the service user and small caseloads. Treatment is time limited, usually offered for two to three years, after which service users are either discharged to primary care or transferred to a standard adult community mental health team. A previous Cochrane Review of SEI found preliminary evidence that SEI may be superior to standard community mental health care (described as 'treatment as usual (TAU)' in this review) but these recommendations were based on data from only one trial. This review updates the evidence for the use of SEI services.

OBJECTIVES

To compare specialised early intervention (SEI) teams to treatment as usual (TAU) for people with recent-onset psychosis.

SEARCH METHODS

On 3 October 2018 and 22 October 2019, we searched Cochrane Schizophrenia's study-based register of trials, including registries of clinical trials.

SELECTION CRITERIA

We selected all randomised controlled trials (RCTs) comparing SEI with TAU for people with recent-onset psychosis. We entered trials meeting these criteria and reporting useable data as included studies.

DATA COLLECTION AND ANALYSIS

We independently inspected citations, selected studies, extracted data and appraised study quality. For binary outcomes we calculated the risk ratios (RRs) and their 95% confidence intervals (CIs). For continuous outcomes we calculated the mean difference (MD) and their 95% CIs, or if assessment measures differed for the same construct, we calculated the standardised mean difference (SMD) with 95% CIs. We assessed risk of bias for included studies and created a 'Summary of findings' table using the GRADE approach.

MAIN RESULTS

We included three RCTs and one cluster-RCT with a total of 1145 participants. The mean age in the trials was between 23.1 years (RAISE) and 26.6 years (OPUS). The included participants were 405 females (35.4%) and 740 males (64.6%). All trials took place in community mental healthcare settings. Two trials reported on recovery from psychosis at the end of treatment, with evidence that SEI team care may result in more participants in recovery than TAU at the end of treatment (73% versus 52%; RR 1.41, 95% CI 1.01 to 1.97; 2 studies, 194 participants; low-certainty evidence). Three trials provided data on disengagement from services at the end of treatment, with fewer participants probably being disengaged from mental health services in SEI (8%) in comparison to TAU (15%) (RR 0.50, 95% CI 0.31 to 0.79; 3 studies, 630 participants; moderate-certainty evidence). There was low-certainty evidence that SEI may result in fewer admissions to psychiatric hospital than TAU at the end of treatment (52% versus 57%; RR 0.91, 95% CI 0.82 to 1.00; 4 studies, 1145 participants) and low-certainty evidence that SEI may result in fewer psychiatric hospital days (MD -27.00 days, 95% CI -53.68 to -0.32; 1 study, 547 participants). Two trials reported on general psychotic symptoms at the end of treatment, with no evidence of a difference between SEI and TAU, although this evidence is very uncertain (SMD -0.41, 95% CI -4.58 to 3.75; 2 studies, 304 participants; very low-certainty evidence). A different pattern was observed in assessment of general functioning with an end of trial difference that may favour SEI (SMD 0.37, 95% CI 0.07 to 0.66; 2 studies, 467 participants; low-certainty evidence). It was uncertain whether the use of SEI resulted in fewer deaths due to all-cause mortality at end of treatment (RR 0.21, 95% CI 0.04 to 1.20; 3 studies, 741 participants; low-certainty evidence). There was low risk of bias for random sequence generation and allocation concealment in three of the four included trials; the remaining trial had unclear risk of bias. Due to the nature of the intervention, we considered all trials at high risk of bias for blinding of participants and personnel. Two trials had low risk of bias and two trials had high risk of bias for blinding of outcomes assessments. Three trials had low risk of bias for incomplete outcome data, while one trial had high risk of bias. Two trials had low risk of bias, one trial had high risk of bias, and one had unclear risk of bias for selective reporting.

AUTHORS' CONCLUSIONS

There is evidence that SEI may provide benefits to service users during treatment compared to TAU. These benefits probably include fewer disengagements from mental health services (moderate-certainty evidence), and may include small reductions in psychiatric hospitalisation (low-certainty evidence), and a small increase in global functioning (low-certainty evidence) and increased service satisfaction (moderate-certainty evidence). The evidence regarding the effect of SEI over TAU after treatment has ended is uncertain. Further evidence investigating the longer-term outcomes of SEI is needed. Furthermore, all the eligible trials included in this review were conducted in high-income countries, and it is unclear whether these findings would translate to low- and middle-income countries, where both the intervention and the comparison conditions may be different.

Impact of Psychotherapy in Psychosis: A Retrospective Case Control Study

Background: The need for psychological therapies for psychosis has become apparent since long-term antipsychotic drug treatment has a range of adverse side effects, with moderate therapeutic effects at best. Aims: To investigate whether the psychotherapeutic approach, dialogue therapy (DT) is associated with improvements of symptoms and functioning beyond standard psychiatric treatment (ST) in both schizophrenia and other psychosis. Methods: A retrospective case-control design, comparing 54 patients with different psychoses who received DT with 54 patients in a control group receiving ST was carried out. The groups were matched on diagnosis, age, sex, and treatment start. Outcome measures were Global assessment of functioning (GAF) scores, medications at follow up, and hospital stays after completed outpatient treatment. Results: Mean time in treatment from inclusion to follow-up was 3 years and 5 months. At follow-up, GAF functioning (GAF-F) and GAF symptom (GAF-S) scores both were significantly higher in the DT group than the ST group. Effect sizes (Cohen's d) were large; 1.8 for GAF-S and 2.1 for GAF-F. At follow-up, the use of psychoactive drugs was significantly reduced despite a shorter time in psychotherapy in the DT group compared to the ST group. Days of hospitalizations after end of treatment in the study period were significantly reduced in both groups compared to the period before start of treatment. Conclusions: The findings from this exploratory study are consistent with the possibility that dialogue therapy may lead to improvements in symptoms and functioning compared to standard treatment in psychosis.

Meta-Analysis of Caregiver-Directed Psychosocial Interventions for Schizophrenia

With the recent movement toward a personal-recovery paradigm to treat schizophrenia, the locus of mental health care delivery has shifted toward community-based care. Family caregivers comprise a substantial component of that community, and are often providing care for longer periods, but often have no formal training or support. Caregiver-directed psychosocial interventions (CDPI) have been developed to train and assist caregivers in their efforts to maximize the odds of treatment success for those in their care. This meta-analysis compared CDPI versus treatment as usual (TAU) on outcomes such as hospitalization, relapse, non-compliance, and "other outcomes" (emergency services utilization, suicide attempt, and death). A systematic literature search (2005-2015) was conducted to identify randomized controlled trials of outpatient administered CDPI versus TAU to treat adult patients recovering from schizophrenia. Relative risks (RR) with 95% confidence intervals derived via random effects meta-analysis were calculated to compare CDPI versus TAU on the aforementioned outcomes. Eighteen of the 693 citations were retained for analysis. Overall RR for CDPI versus TAU suggested improved outcomes associated with CDPI: hospitalization [0.62 (0.46, 0.84) p < 0.00001], relapse [0.58 (0.47, 0.73) p < 0.00001] and other outcomes [0.70 (0.19, 2.57) p = 0.59]. CDPI was associated with significantly better compliance with medication and clinical activities combined [0.38 (0.19, 0.74) p = 0.005]. Medication compliance alone favored CDPI but was non-significant. Compliance with clinical activities alone favored CDPI significantly [0.22 (0.11, 0.47) p < 0.00001]. CDPI is associated with reductions in hospitalization, relapse, and treatment non-compliance.

Test of Mindfulness-Based Psychosocial Skills Training to İmprove Insight and Functional Recovery in Schizophrenia

This study was conducted with two groups (training and control) using a pretest/posttest design to determine the effect of mindfulness-based psychosocial skills training for improving insight and functional recovery levels in patients with schizophrenia. The study sample included 45 patients with schizophrenia (21 were in the training group/mindfulness-based psychosocial skills training and 24 were in the control group/standard drug medication). The data were collected using a Personal Information Form, Functional Remission of General Schizophrenia (FROGS) scale, and Beck Cognitive Insight Scale (BCIS). The training group was divided into two groups of 10 to 12 persons on average. Training was given as a group training for a total of 16 sessions, two sessions a week for 8 weeks. The training group scored significantly higher in functional recovery and insight levels than the control group after training ( p < .05). The study determined training has an effect on increasing the levels of insight and functional recovery in schizophrenia.

Interpersonal nurse-patient relationship with a young schizophrenic pregnant woman

The objective of this study was to investigate elements of the personal and psychiatric history, as well as the challenges related to motherhood, of a young schizophrenic female, through person-centered therapeutic interaction. The investigation had an exploratory scope, undertaken in a teaching hospital and data were collected during nondirective interaction on the part of the nurse with a young schizophrenic woman who had been treated in the institution for 10 years. Thematic analysis of the content was undertaken, with emphasis on the nuclei of meaning, identification of the themes and definition of the categories. The patient, called L. in this study, was 30 years old, had a two-year-old child and was three months pregnant when data were collected. Her trajectory was characterized by doubts, fears and uncertainties. The episodes of hospitalization, the coexistence with other patients, and the medications promoted insight into the symptoms, and acceptance of the diagnosis. The main challenge was experiencing pregnancy and the puerperium concomitantly with the psychiatric treatment. The interpersonal relationship established evidenced that, the young woman felling understood and that her needs were attended, overcame several difficulties she had reported and felt fulfilled and integrated into her social environment.

Predicting functional remission in patients with schizophrenia: a cross-sectional study of symptomatic remission, psychosocial remission, functioning, and clinical outcome

BACKGROUND

New approaches to assess outcome in schizophrenia include multidimensional measures such as remission, cognition, psychosocial functioning, and quality of life. Clinical and psychosocial measures have been recently introduced to assess functional outcome.

OBJECTIVE

The study presented here was designed to examine the rates of symptomatic remission, psychosocial remission, global functioning, and clinical global impressions in a sample of schizophrenia outpatients in order to assess functional remission and to identify predictive factors for functional remission.

METHODS

A total of 168 consecutive Mexican outpatients receiving pharmacological treatment at the National Institute of Psychiatry in Mexico City were enrolled in a cross-sectional study. Symptomatic remission was assessed according to the definition and criteria proposed by the Remission in Schizophrenia Working Group using the Positive and Negative Symptom Scale. Psychosocial remission was assessed according to Barak criteria using the Psychosocial Remission in Schizophrenia scale. Functioning was measured with the Global Assessment of Functioning, and clinical outcome with the Clinical Global Impressions (CGI) Scale.

RESULTS

Findings showed that 45.2% of patients fulfilled the symptomatic remission criteria, 32.1% achieved psychosocial remission, and 53% reported adequate functioning. However, the combination of these three outcome criteria - symptomatic, psychosocial remission, and functioning - indicated that 14.9% of the patients achieved our predefined functional remission outcome. The logistic regression model included five predictive variables for functional remission: (1) being employed, (2) use of atypical antipsychotics, (3) lower number of medications, (4) lower negative symptom severity, and (5) lower excitement symptom severity.

CONCLUSION

The study demonstrated that symptomatic remission, psychosocial remission, and functioning could be achievable goals for a considerable number of patients. The outcome of functional remission was achieved by a minority of patients, less than 15%. New approaches should include multidimensional measures to assess functional outcome in schizophrenia research.

Psychosocial rehabilitation and chronic mental illness: international trends and South African issues

Psychosocial rehabilitation of persons with chronic mental illness has received increasing research attention over the past three decades. It is now widely accepted that pharmacotherapy alone is insufficient to treat persons with chronic mental illness. Additionally, there has been a paradigm shift towards the integration of evidence-based rehabilitation models and recovery models, which focus on collaborative approaches to care. This article reviews research findings relating to psychosocial rehabilitation interventions and models, and considers the implementation of psychosocial rehabilitation policies and practices in the South African healthcare context. Challenges to implementation and recommendations are presented.

Negative symptoms of schizophrenia: clinical characteristics, pathophysiological substrates, experimental models and prospects for improved treatment

Schizophrenia is a complex and multifactorial disorder generally diagnosed in young adults at the time of the first psychotic episode of delusions and hallucinations. These positive symptoms can be controlled in most patients by currently-available antipsychotics. Conversely, they are poorly effective against concomitant neurocognitive dysfunction, deficits in social cognition and negative symptoms (NS), which strongly contribute to poor functional outcome. The precise notion of NS has evolved over the past century, with recent studies - underpinned by novel rating methods - suggesting two major sub-domains: "decreased emotional expression", incorporating blunted affect and poverty of speech, and "avolition", which embraces amotivation, asociality and "anhedonia" (inability to anticipate pleasure). Recent studies implicate a dysfunction of frontocortico-temporal networks in the aetiology of NS, together with a disruption of cortico-striatal circuits, though other structures are also involved, like the insular and parietal cortices, amygdala and thalamus. At the cellular level, a disruption of GABAergic-glutamatergic balance, dopaminergic signalling and, possibly, oxytocinergic and cannibinoidergic transmission may be involved. Several agents are currently under clinical investigation for the potentially improved control of NS, including oxytocin itself, N-Methyl-d-Aspartate receptor modulators and minocycline. Further, magnetic-electrical "stimulation" strategies to recruit cortical circuits and "cognitive-behavioural-psychosocial" therapies likewise hold promise. To acquire novel insights into the causes and treatment of NS, experimental study is crucial, and opportunities are emerging for improved genetic, pharmacological and developmental modelling, together with more refined readouts related to deficits in reward, sociality and "expression". The present article comprises an integrative overview of the above issues as a platform for this Special Issue of European Neuropsychopharmacology in which five clinical and five preclinical articles treat individual themes in greater detail. This Volume provides, then, a framework for progress in the understanding - and ultimately control - of the debilitating NS of schizophrenia.