The personal impact of schizophrenia in Europe

A penny for your thoughts: three perspectives on financial problems and their associated factors of people with psychotic disorders

PURPOSE

Financial problems are of influence on mental health, and vice versa. Indeed, finances are a key challenge for people with psychosis. To gain deeper insights into these challenges, a qualitative approach focusing on all perspectives within the therapeutic triad is needed. This study aims to investigate perspectives of people with psychosis, family members and mental healthcare professionals on people with psychosis' financial problems, and associated factors.

METHODS

Fourteen people with psychosis, 15 family members and 16 professionals were recruited using purposive sampling, and participated in semi-structured, one-on-one interviews. Data was analysed using iterative thematic data-analysis.

RESULTS

Interviews revealed five themes of financial problems: Covering expenses, Financial performance, Living conditions and housing, Personal conflicts and victimization, and Regulations and legislation. Five themes were identified as factors associated with financial problems: Psychotic symptoms, Indirect factors related to psychosis, Substance use and addiction, Financial upbringing and life events, and Societal contextual factors.

DISCUSSION

People in the therapeutic triad largely mentioned similar, wide-ranging, and often co-occurring (factors associated with) financial problems of people with psychosis, risking vicious cycles. Fostering awareness and collaborative efforts among stakeholders is essential to breaking these cycles of financial problems for individuals with psychosis.

Perceived Burden and Quality of Life in Caregivers of Patients with Schizophrenia in Saudi Arabia's Eastern Province: A Cross-sectional Study

Background and Aims

Family Caregivers (FCGs) of patients with schizophrenia (PwS) may face unanticipated sources of stress and responsibility, which can negatively impact their quality of life (QoL). This study aimed to assess FCGs' QoL and the impact of clinical characteristics of patients and sociodemographic factors on their QoL.

Patients and Methods

A cross-sectional questionnaire-based study surveyed 340 FCGs from outpatient clinics of PwS in two large psychiatric hospitals in Saudi Arabia's eastern province using a convenience sampling approach. We used the Adult Carer Quality of Life (AC-QoL) scale, which has eight subscales and 40 items, to assess QoL. AC-QoL is translated into Arabic in this study.

Results

The study included 216 FCGs, with 127 (58.8%) being men, 117 (54.2%) being over 45 years old, 91 (42.1%) being a sibling of a PwS, and 82 (38%) being a parent of a PwS. The mean score in our sample was 78.2 ± 21.24 out of 120, indicating mid-range QoL. Lower QoL was associated with more time spent in caregiving per day, a lower educational level of FCG, and recent admission of PwS to an inpatient unit.

Conclusion

PwS FCGs have a mid-range QoL. FCGs reported a moderate financial burden and low levels of support from healthcare professionals. FCG's QoL and stress can be reduced through healthcare providers, participation in a community support group, and addressing an FCG's in an individual setting.

Comparing stigma between French people experiencing schizophrenia versus bipolar disorders

BACKGROUND

Among the multiple challenges that people experiencing mental illness in general, and schizophrenia or bipolar disorders in particular, have to face, stigma appears to be one of the most difficult to tackle. In France, the body of research about stigma regarding people experiencing schizophrenia or bipolar disorders is growing, but not as much as in other western countries.

AIMS

In this context, our study aims to explore and compare stigma in French people experiencing schizophrenia or bipolar disorders, along with their respective mental healthcare system experience, in order to better address them within public health policies.

METHODS

20 French mental health service users experiencing schizophrenia and 20 experiencing bipolar disorders answered the Stigma Scale, which assesses three dimensions of stigma (discrimination, difficulties of divulgation and lack of positive aspects). A semi-structured interview was used to collect information about the experience of the mental healthcare system (level of information, access to diagnosis, treatment, access to psychoeducation, etc.).

RESULTS

People experiencing schizophrenia and people experiencing bipolar disorders are different populations in terms of social impairment. However, they share a comparable negative experience of the mental healthcare system and a comparable level of information about their illness, to the exception of diagnosis divulgation, as people experiencing bipolar disorders have a better access to their diagnosis. People experiencing schizophrenia perceive a higher actual discrimination than people experiencing bipolar disorders.

CONCLUSIONS

Public health policies should take into account the strong perception of actual discrimination of people experiencing schizophrenia, with capitalizing on what seems beneficial for people experiencing bipolar disorders.

Promoting Intimate Relationships in Mental Illness: A Systematic Review of Interventions

Although persons with Serious Mental Illness (SMI) express a need for intimate relations with others, they still suffer from a severe lack of social participation in this domain. However, these unmet needs have received little attention until recently. This study reviews interventions that aim to facilitate the development and the maintenance of intimate relationships (IR) of persons with schizophrenia, bipolar disorder and major depression. A systematic review following PRISMA guidelines was conducted. Studies published in Scopus, PubMed, EBSCO (Psych INFO, Psych ARTICLES, Psychology and Behavioral Sciences Collection) from January 1, 2000, to December, 2021, were screened. The search using terms referring to "schizophrenia", "bipolar disorder", "major depression", "IR" and "interventions" revealed 11 studies. Among them, 10 reported interventions for persons with depression, including 9 for couple therapy. Most interventions targeted satisfaction with couple relationships as the main therapeutic objective. Heterogeneity in study design precludes any firm conclusions about their efficacy. Interestingly, only one intervention focused on single persons interested in developing IR. The results highlight the lack of interventions: (i) aimed at promoting IR, (ii) designed for single persons, and (iii) targeting persons with psychotic disorders. This result may reflect the persisting stigmatization of persons with psychotic disorders, and the taboo associated with the IR and sexuality of persons with mental illness. Further studies are needed to develop inclusive interventions promoting the development of IR in persons with mental illness.

Family-centered collaborative care for patients with chronic mental illness: A systematic review

Background

Chronic mental illnesses (CMI) are long lasting and reoccurring and require continuous care as well as an integrated and collaborative approach to organize the care. This study sought to examine whether family centered collaborative care is an acceptable treatment option for individuals with CMI.

Materials and Methods

From the years 2000 to 2021, ten electronic databases relating to family centered collaborative care for mental illness were searched adopting Preferred Reporting Items for Systematic Reviews and Meta Analysis checklist. Twenty seven relevant articles and a thesis from among 6956 studies retrieved, were assessed their quality appraisal through four standardized tools. The studies were rated as good, moderate, or poor. Studies were calibrated, different opinions were discussed, and extracted data were done.

Results

Evidence included 11 randomized controlled trials (from 19 articles), one randomized control trial, three mixed methods studies (from 3 articles and 1 thesis), and a qualitative study (from 4 articles). The quality of seven studies was good, 15 were moderate quality, and seven were poor quality. According to moderate to high quality qualitative research, family centered collaborative care was considered an acceptable intervention; though a few studies supported it.

Conclusion

The findings demonstrated that family involvement in the care of patients with CMI affects no recurrence of the disease, and no re hospitalization of patients with this disorder. As a result, engaging family members in the care process can have a positive impact on the health and well being of these patients.

Quality of life in patients with schizophrenia: A 2-year cohort study in primary mental health care in rural China

Objective

Quality of life (QoL) has been always an important way to evaluate the outcomes of schizophrenia, but there have been few previous longitudinal studies and few in middle-income countries. This study aimed to explore the QoL in Chinese patients with schizophrenia treated in primary mental health care and the risk factors of QoL over time.

Methods

Patients with schizophrenia treated in primary mental health care in rural/regional areas in Luoding, Guangdong, PR China, were evaluated with an extended questionnaire including the Chinese version of the World Health Organization Quality of Life (WHOQOL-BREF) at baseline and 2-year follow-up. Bivariate and multivariate analyses were conducted including Generalized Estimated Equation analyses (GEE).

Results

Four hundred and ninety-one patients with schizophrenia in primary care completed the 2-year follow up evaluation. The QoL physical, environmental, and social relationships domains showed improvement after the 2-year period, but the psychological domain did not. GEE results showed that earlier age of onset, older age, being employed, being unmarried, the thicker waist circumference, less use of clozapine or other SGAs, fewer hospitalizations, more frequent insomnia, more severe depressive and negative symptoms as well as worse treatment insight were independently associated with poor QoL in patients with schizophrenia.

Conclusion

According to our results, to improve the quality of life of patients with schizophrenia in primary care, we should pay more attention to the treatment of depression, negative and insomnia symptoms of schizophrenia, the choice and dosage of antipsychotic medication and improvement in the treatment compliance. The combined use of educational and behavioral strategies may improve treatment adherence.

Second-Generation Antipsychotics' Effectiveness and Tolerability: A Review of Real-World Studies in Patients with Schizophrenia and Related Disorders

Despite methodological limitations, real-world studies might support clinicians by broadening the knowledge of antipsychotics' (APs) effectiveness and tolerability in different clinical scenarios and complement clinical trials. We conducted an extensive literature search in the PubMed database to evaluate the effectiveness and tolerability profiles of second-generation antipsychotics (SGAs) from real-world studies to aid clinicians and researchers in selecting the proper treatment for patients with schizophrenia and related disorders. The present review evidenced that SGAs demonstrated superior effectiveness over first-generation antipsychotics (FGAs) in relapse-free survival and psychiatric hospitalization rate and for treating negative symptoms. Persistence and adherence to therapy were higher in SGAs than FGAs. Most studies concluded that switching to long-acting injectables (LAIs) was significantly associated with a lower treatment failure rate than monotherapy with oral SGAs. Considerable improvements in general functionality, subjective well-being, and total score on global satisfaction tests, besides improved personal and social performance, were reported in some studies on patients treated with LAI SGAs. Clozapine was also associated with the lowest rates of treatment failure and greater effectiveness over the other SGAs, although with more severe side effects. Effectiveness on primary negative symptoms and cognitive deficits was rarely measured in these studies. Based on the data analyzed in the present review, new treatments are needed with better tolerability and improved effectiveness for negative, affective, and cognitive symptoms.

The feeling, embodiment and emotion of hallucinations in first episode psychosis: A prospective phenomenological visual-ecological study using novel multimodal unusual sensory experience (MUSE) maps

BACKGROUND

Research and practice typically focus upon unimodal hallucinations, especially auditory verbal hallucinations. Contemporary research has however indicated that voice-hearing may co-occur within a broader milieu of feelings, and multimodal hallucinations may be more common than previously thought.

METHODS

An observational design asked participants to prospectively document the feeling and modality of hallucinations for one week prior to an interview. Novel visual diary methods involving drawing, writing and body-mapping generated 42 MUSE maps (multimodal unusual sensory experience), analysed with a participatory qualitative method. Twelve people took part: all experiencing hallucinations daily, accessing early intervention in psychosis services, given psychotic-spectrum diagnoses, and living in the community. The study took place during a seven-month period in 2018 at Leicestershire and Rutland's Psychosis Intervention and Early Recovery service (UK).

FINDINGS

All documented hallucinations co-occurred with bodily feelings. Feelings were localised to specific body areas, generalised across the body and extended beyond the body into peripersonal space. Co-occurring emotional feelings most commonly related to confusion, fear and frustration.

INTERPRETATION

Hallucinations were characterised by numerous feelings arising at once, often including multimodal, emotional, and embodied features. Within this study, the immediate feeling of hallucination experiences were readily communicated through prospective, visual, and ecological information gathering methods and particularly those which offer multiple modes of communication (e.g. body-map, visual, written, oral). Uptake of visual, ecological and prospective methods may enhance understandings of lived experiences of hallucinations.Funding: University of Leicester.

Multidimensional and intergenerational impact of Severe Mental Disorders

BACKGROUND

Severe Mental Disorders (SMDs) affect multiple generations although this is poorly studied. The aim of this study was to investigate the intergenerational and multidimensional impacts of SMD in rural Ethiopia.

METHODS

This comparative study was nested within an existing population-based cohort study. We collected data from a total 5762 family members of 532 households (266 households with at least one family member with SMD and 266 sex and age matched mentally well controls from the neighborhood) in 2019. The main outcomes were multidimensional poverty, mortality, food insecurity, and family satisfaction.

FINDINGS

Multidimensional poverty Index was higher in the households of persons with SMD (74·44%) than the comparison households (38·35%). School attendance was lower in children of people with SMD (63·28%) than children of the comparisons (78·08%). The median years of schooling was also lower among children of people with SMD than the controls. This lower attendance was also true among siblings of people with SMD (35·52%) than the comparisons (49·33%). Over the course of 20 years, family members who have a person with SMD in their household had 23% increased risk of death compared to family members who did not have a person with SMD in their household. Severe food insecurity was also higher in the SMD households (20·68%) than the comparison (13·53%) while family satisfaction was lower.

INTERPRETATION

Families of people with SMD experience pervasive multidimensional and intergenerational impacts. Interventions should consider the broader family social and healthcare needs of the broader family.

Satisfaction with antipsychotics as a medication: the role of therapeutic alliance and patient-perceived participation in decision making in patients with schizophrenia spectrum disorder

OBJECTIVES

The aim of this study was to identify independent predictors of satisfaction with antipsychotics in patients with schizophrenia spectrum disorders treated in a mental health catchment area.

METHODS

Observational analytical study of patients (n = 150) recruited through a convenience sampling method from five mental health units. Satisfaction with the antipsychotic as a medication was evaluated using the Treatment Satisfaction Questionnaire for Medication (TSQM). Therapeutic alliance was assessed by the Working Alliance Inventory Short Form (WAI-S). Patient-perceived participation in decision-making was assessed using COMRADE (Combined Outcome Measure for Risk communication And treatment Decision making Effectiveness). A multiple linear regression analysis was performed to identify variables independently associated with the TSQM 'Global Satisfaction' total score.

RESULTS

Two variables - age and higher level of self-perceived participation in treatment decision-making - were directly, significantly, and independently associated (β coefficient values: 0.209 and 0.432, respectively) with a higher TSQM Global satisfaction score. In addition, the severity of psychotic symptoms was inversely associated with satisfaction (β coefficient value: -0.205) (R² = 0.355; R² adj. = 0.291; F(13) = 5.554; p < 0.01).

CONCLUSIONS

These findings suggest that involving the patient in treatment decision-making and optimising the treatment to reduce symptoms, especially in younger patients, could increase satisfaction with antipsychotic treatment.Key PointsPatient involvement in shared decision-making is relevant for treatment satisfaction.Current evidence suggests that improving the doctor-patient relationship optimises antipsychotics outcomes.Self-perceived participation in decision-making predicts satisfaction with antipsychotic medication.Types of antipsychotics do not determine consistent differences in satisfaction.

Structural brain volumes of individuals at clinical high risk for psychosis: a meta-analysis

Background

Structural magnetic resonance imaging studies in individuals at clinical high risk (CHR) for psychosis have yielded conflicting results.

Methods

The aims of this study were to compare intracranial and structural brain volumes and variability of CHR individuals with those of healthy control (HC) subjects and to investigate brain volume differences and variability in CHR subjects with and without transition to psychosis. The PubMed and Embase databases were searched for relevant studies published before June 1, 2020.

Results

A total of 34 studies were deemed eligible, which included baseline data of 2111 CHR and 1472 HC participants. In addition, data were included for 401 CHR subjects who subsequently transitioned to psychosis and 1023 nontransitioned CHR participants. Whole-brain and left, right, and bilateral hippocampal volume were significantly smaller in CHR subjects than in HC subjects. Cerebrospinal fluid and lateral ventricle volumes were significantly larger in CHR subjects than in HC subjects. Variability was not significantly different in CHR subjects compared with HC subjects. CHR individuals with and without subsequent transition to psychosis did not show significant differences in any of the volumetric assessments or in variability.

Conclusions

This meta-analysis demonstrates reduced whole-brain and hippocampal volumes and increased cerebrospinal fluid and lateral ventricle volumes in CHR individuals. However, no significant differences were observed in any of the volumetric assessments between CHR individuals with and without subsequent transition to psychosis. These findings suggest that although structural brain alterations are present before the onset of the disorder, they may not significantly contribute to the identification of CHR individuals at the highest risk for the development of psychosis.

Identifying determinants of diabetes risk and outcomes for people with severe mental illness: a mixed-methods study

Background

People with severe mental illness experience poorer health outcomes than the general population. Diabetes contributes significantly to this health gap.

Objectives

The objectives were to identify the determinants of diabetes and to explore variation in diabetes outcomes for people with severe mental illness.

Design

Under a social inequalities framework, a concurrent mixed-methods design combined analysis of linked primary care records with qualitative interviews.

Setting

The quantitative study was carried out in general practices in England (2000–16). The qualitative study was a community study (undertaken in the North West and in Yorkshire and the Humber).

Participants

The quantitative study used the longitudinal health records of 32,781 people with severe mental illness (a subset of 3448 people had diabetes) and 9551 ‘controls’ (with diabetes but no severe mental illness), matched on age, sex and practice, from the Clinical Practice Research Datalink (GOLD version). The qualitative study participants comprised 39 adults with diabetes and severe mental illness, nine family members and 30 health-care staff.

Data sources

The Clinical Practice Research Datalink (GOLD) individual patient data were linked to Hospital Episode Statistics, Office for National Statistics mortality data and the Index of Multiple Deprivation.

Results

People with severe mental illness were more likely to have diabetes if they were taking atypical antipsychotics, were living in areas of social deprivation, or were of Asian or black ethnicity. A substantial minority developed diabetes prior to severe mental illness. Compared with people with diabetes alone, people with both severe mental illness and diabetes received more frequent physical checks, maintained tighter glycaemic and blood pressure control, and had fewer recorded physical comorbidities and elective admissions, on average. However, they had more emergency admissions (incidence rate ratio 1.14, 95% confidence interval 0.96 to 1.36) and a significantly higher risk of all-cause mortality than people with diabetes but no severe mental illness (hazard ratio 1.89, 95% confidence interval 1.59 to 2.26). These paradoxical results may be explained by other findings. For example, people with severe mental illness and diabetes were more likely to live in socially deprived areas, which is associated with reduced frequency of health checks, poorer health outcomes and higher mortality risk. In interviews, participants frequently described prioritising their mental illness over their diabetes (e.g. tolerating antipsychotic side effects, despite awareness of harmful impacts on diabetes control) and feeling overwhelmed by competing treatment demands from multiple morbidities. Both service users and practitioners acknowledged misattributing physical symptoms to poor mental health (‘diagnostic overshadowing’).

Limitations

Data may not be nationally representative for all relevant covariates, and the completeness of recording varied across practices.

Conclusions

People with severe mental illness and diabetes experience poorer health outcomes than, and deficiencies in some aspects of health care compared with, people with diabetes alone.

Future work

These findings can inform the development of targeted interventions aimed at addressing inequalities in this population.

Study registration

National Institute for Health Research (NIHR) Central Portfolio Management System (37024); and ClinicalTrials.gov NCT03534921.

Funding

This project was funded by the NIHR Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 10. See the NIHR Journals Library website for further project information.

Network meta-analysis on the comparative efficacy of family interventions for psychotic disorders: a protocol

INTRODUCTION

Family interventions are effective and are strongly recommended for psychotic disorders. However, there is a variety of intervention types, and their differential efficacy is widely unclear. The aim of the planned network meta-analysis (NMA) is to compare the efficacy of family interventions that differ in content (eg, psychoeducation, mutual support, skills training) and format (eg, number of sessions, inclusion of patients, form of delivery).

METHODS AND ANALYSIS

We will include randomised controlled trials comparing psychosocial interventions directed at the adult relatives, friends or non-professional carers of people with a diagnosis of a psychotic disorder (schizophrenia spectrum) to any kind of control condition. The main outcomes will be global clinical state for the patients and coping with psychosis as well as attitudes towards psychosis for the relatives. Additional outcomes will be severity of symptoms, functioning, burden and compliance/drop-out. We conducted a comprehensive search of Cochrane Central Register of Controlled Trials, MEDLINE(R), PsycINFO, Cumulative Index to Nursing & Allied Health Literature (8 August 2019) and reference lists of review articles. Full-text assessment of eligibility, data extraction and risk-of-bias assessment will be done by two independent reviewers. An NMA will be conducted for any of the planned outcomes and intervention characteristics for which sufficient and appropriate data are available. The analyses will make use of a random effects model within a frequentist framework. Estimates for all pairwise treatment effects will be obtained using standardised mean differences for continuous outcomes and risk ratios for dichotomous outcomes. Interventions will be ranked according to their relative efficacy. We will address the assumption of transitivity, heterogeneity and inconsistency using theoretical and statistical approaches. The possibility of publication bias and the strength of evidence will also be examined.

ETHICS AND DISSEMINATION

There are no ethical concerns. Results will be published in peer-reviewed journals and presented at practitioners' conferences.

PROSPERO REGISTRATION NUMBER

CRD42020148728.

Examining the relationship between community mobility and participation using GPS and self-report data

Higher levels of community mobility have been shown to be associated with better physical health, mental health, and quality of life. The ability to move about one's community is also expected to facilitate community participation, which is an aspect of health functioning. This study uses Global Positioning Systems (GPS) technology to track various dimensions of community mobility, such as destinations, time outside the home, and distance traveled, and examine the relationship between these variables and community participation in a sample of individuals with serious mental illnesses (SMI). This population was selected because they are known to have diminished health functioning in terms of their community participation, and the goal is to explore the extent to which mobility limitations may account for this. A total of 103 individuals with serious mental illnesses were recruited from mental health agencies and consented to having their mobility tracked using GPS for 13 days and answering questions about their community-based activities. Greater amount of participation was associated with having more destinations and spending more time out of the house, but not with traveling larger distances and having a greater activity space. None of the mobility variables were related to the number of important participation areas or sufficiency of participation. The findings support the hypothesis that greater mobility is related to more participation, although satisfaction with the degree to which one participates does not appear to be impacted, suggesting that other factors need to be accounted for. Health policymakers and providers should pay attention to community mobility as a factor that affects health outcomes such as participation, in individuals with serious mental illnesses, and other populations. In particular, attending to access to personal transport, public transportation, and other mobility options appears to be important, as well as interventions aimed at encouraging greater community mobility.

Premorbid Social Functioning and Affective Symptoms Predict Subjective Outcome Among Outpatients With Schizophrenia

Improving the subjective outcome of patients is an important target in the treatment of schizophrenia. Accordingly, the aim of the present study was to examine the association of factors deemed relevant in this context, i.e., premorbid functioning, residual symptoms, and side effects of antipsychotic medication, with subjective outcome. To this end, 70 clinically stable outpatients with schizophrenia were included into a cross-sectional study. Premorbid functioning, psychopathology, and side effects were assessed by using the Premorbid Adjustment Scale, the Positive and Negative Syndrome Scale, and the Udvalg for Kliniske Undersogelser Side Effect Rating Scale, respectively. Subjective outcome was measured in terms of life satisfaction (Life Satisfaction Questionnaire), self-esteem (Index of Self-Esteem), and needs for care (Berliner Bedürfnisinventar). Both premorbid social functioning and affective symptoms predicted life satisfaction, self-esteem, and patients' basic needs, whereas positive and negative symptoms predicted needs in the health, social, and functional domains. Concerning side effects, parkinsonism and akathisia showed a significant negative correlation with self-esteem. These findings highlight the complex nature of subjective outcome in patients suffering from schizophrenia. Evidently, premorbid social functioning plays a prominent role in the experienced subjective outcome during the course of the illness. Furthermore, these preliminary findings underscore that constant efforts are essential to treat residual symptoms of the disorder and to avoid extrapyramidal motor side effects of antipsychotic medication. Longitudinal studies are needed to investigate this latter point in more detail.

Sexuality and intimacy among people with serious mental illness: a qualitative systematic review

OBJECTIVE

The aim of this systematic review was to synthesize the best available qualitative evidence on the experiences and support needs of people with serious mental illness (SMI) regarding sexuality and intimacy within hospital and community settings. The objectives were to explore intimate relationship experiences of people with SMI, to uncover potential obstacles to the expression of sexuality and to present recommendations for mental health policy, education, research and practice.

INTRODUCTION

Mental health services worldwide have seen major transformations in recent years through deinstitutionalization programs and more enlightened ways of organizing and providing mental health care. However, in terms of social and emotional wellbeing, issues persist for people with SMI, particularly relating to intimacy and the expression of sexuality. This systematic review may assist service providers to determine ways that they may better support people in establishing and maintaining satisfying intimate relationships and the full expression of their sexuality.

INCLUSION CRITERIA

This review explored the intimacy and sexuality experiences, perceptions and concerns of people over the age of 18 years who were living with a SMI in hospital or community settings. This review considered studies that focused on qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research and feminist research.

METHODS

The databases MEDLINE, CINAHL, PsycINFO, Embase and Web of Science were utilised in the review. The search included studies published from 1995 up to and including February 6, 2018 and were limited to those in the English language. Each paper was assessed by two independent reviewers for methodological quality using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Qualitative Research. Any disagreements that arose between the reviewers were resolved through discussion. Data extraction was conducted by two independent reviewers using the standardized qualitative data extraction tool from JBI. The qualitative research findings were pooled using JBI methodology. The JBI process of meta-aggregation was used to identify categories and synthesized findings.

RESULTS

Based on the thematic findings from the 21 studies, three synthesized findings were extracted from 10 categories and 83 findings: 1) the complexity of individual sexual experiences, 2) the clinical constructs of sexuality and 3) family and partner involvement.

CONCLUSIONS

Having fulfilling and satisfying sexual and relationship experiences is a fundamental human right that can enhance an individual's quality of life. Being aware of the potential stresses and challenges that having a SMI can have on a relationship and involving partners in the treatment, may help to promote intimacy and recovery. Practitioners can use these findings to guide future policy, education and developments in practice. Further research is required to develop and evaluate interventions that target the identified barriers and help people with SMI to fulfil their unmet sexuality and intimacy needs.

Patient outcomes in schizophrenia I: correlates with sociodemographic variables, psychopathology, and side effects

Objective

The present cross-sectional study examined the relationships of psychopathology, side effects, and sociodemographic factors with treatment outcomes in terms of patients' quality of life (QOL), functioning, and needs for care.

Method

Sixty outpatients with chronic schizophrenia who had been treated with either clozapine or olanzapine for at least 6 months were investigated.

Results

Most psychopathological symptoms as well as psychic side effects, weight gain, and female sex were associated with lower QOL, while cognitive symptoms correlated with better QOL. Female sex, cognitive symptoms, and parkinsonism negatively influenced occupational functioning, and negative symptoms determined a lesser likelihood of living independently. Age, education, depression/anxiety, negative symptoms, and psychic side effects were predictors of patients' needs for care.

Conclusion

Our results highlight the complex nature of patient outcomes in schizophrenia. They reemphasize the need of targeting effectiveness, i.e. both symptomatic improvement as well as drug safety, in such patients.

Multidimensional impact of severe mental illness on family members: systematic review

OBJECTIVE

The impact of severe mental illnesses (SMIs) is not limited to the person with the illness but extends to their family members and the community where the patient comes from. In this review, we systematically analyse the available evidence of impacts of SMI on family members, including parents, grandparents, siblings, spouses and children.

DATA SOURCES

PubMed, PsycINFO, Embase and Global Index Medicus were searched from the inception of each database up to 9 November 2019. We also did manual searches of grey literature.

ELIGIBILITY CRITERIA

We included studies that assessed the impacts of SMI on any family member. We excluded studies in admitted clinics and acute wards to rule out the acute effect of hospitalisation.

DATA EXTRACTION

Two reviewers extracted data independently using the Cochrane handbook guideline for systematic reviews and agreed on the final inclusion of identified studies.

RISK OF BIAS

The quality of the included studies was assessed using effective public health practice project quality assessment tool for quantitative studies.The review protocol was registered in the PROSPERO database.

RESULTS

We screened a total of 12 107 duplicate free articles and included 39 articles in the review. The multidimensional impact of SMI included physical health problems (sleeplessness, headache and extreme tiredness.), psychological difficulties (depression and other psychological problems) and socioeconomic drift (less likely to marry and higher divorce rate and greater food insecurity). Impacts on children included higher mortality, poor school performance and nutritional problems. However, the quality of one in five studies was considered weak.

CONCLUSIONS

Our review indicated a high level of multidimensional impact across multiple generations. The serious nature of the impact calls for interventions to address the multidimensional and multigenerational impact of SMI, particularly in low/middle-income countries. Given the relatively high number of studies rated methodologically weak, more robust studies are indicated.

PROSPERO REGISTRATION NUMBER

CRD42018064123.

Care-giving by people with psychotic disorders in the second Australian prevalence study of psychosis

Increasing numbers of people living with psychosis are providing care for others, although the associated benefits and impacts are poorly understood. This innovative quantitative study investigated this life role using a population-based framework aiming to compare the mental health and functioning of those providing care to and/or receiving care from others. Care-giving provided by people with psychosis was examined using data from the second Australian prevalence survey of psychosis. This epidemiologically based sample (n = 1,822) was divided into four subgroups based on providing and/or receiving care from others. Independent functioning, cognitive functioning, social functioning, social connection and mental health were compared between the four subgroups. One in seven participants were providing care to others. The majority of carers were female and half were living with the care recipients. Caregivers were more likely to experience better illness course and were more commonly diagnosed with bipolar disorder. Almost one-third of caregivers reported that caring adversely affected their lives a great deal. Functioning and social connection were better in caregivers compared to non-caregivers, although cognitive functioning did not differ. People with psychosis who were neither providing nor receiving care were more likely to be single and perceive less warmth in their relationships. As expected, those only in receipt of care were living with greater disability and poorer illness course. It is relatively common to encounter people with psychosis who provide care to others in clinical settings, and women in particular combine care-giving with multiple other roles. Despite most experiencing some negative emotional impact, care-giving is associated with enhanced social relationships which may provide meaning and purpose for recovery. Care-giving roles should be addressed in recovery and care planning so as to provide people with psychosis with adequate information and support to fulfil these potentially important life roles.

Epigenetic Factors in Schizophrenia: Mechanisms and Experimental Approaches

Schizophrenia is a chronic mental disorder that is still poorly understood despite decades of study. Many factors have been found to contribute to the pathogenesis, including neurodevelopmental disturbance, genetic risk, and environmental insult, but no single root cause has emerged. While evidence from twin studies suggests a strong heritable component, few individual loci have been identified in genomewide screens, suggesting a role for epigenetic effects. Rather, large numbers of weakly acting loci may cumulatively increase disease risk, including several mapping to epigenetic pathways. In this review, we discuss mechanisms of epigenetic regulation and evidence for an epigenetic contribution to disease phenotype. We further describe the range of experimental tools currently available to study epigenetic effects associated with the disease.

Trends in Subjective Quality of Life Among Patients With First Episode Psychosis-A 1 Year Longitudinal Study

Quality of life (QoL) is often used as an outcome assessment in programs treating patients with first-episode psychosis (FEP). The aim of this study was to examine the longitudinal trend of subjective QoL among patients with FEP and identify the potential influence of patients' social-demographic/lifestyle factors on the trend of QoL. Two hundred and eighty subjects participated in the study. Patient's demographics and subjective QoL were collected at baseline, 6 months and 1 year follow-up. Data were analyzed with a fixed-effect general linear regression model. Subjective QoL demonstrated significant trends of improvement in all four subdomains (physical health, psychological health, social relationships, and environment). Compared with unemployed participants, employed participants were significantly associated with better social relationships (p = 0.005) and environment (p = 0.029) after adjusting for age and gender. Moderation analysis demonstrated a significant improvement of physical health, social relationships, and environment for participants with a higher level of educational achievement, but not for participants with a lower level of educational achievement. Our results indicate that patients with FEP experienced significant improvement in subjective QoL over a 1 year period. Being employed was associated with overall better social relationships and environment among patients with FEP and higher educational achievement was associated with improvement of physical health, social relationship, and environment. Hence, educational achievement and employment could be considered for future optimization of early psychosis intervention programs.

Employment-Related Factors of Forensic Psychiatric Outpatients with Psychotic Disorders

PURPOSE

Employment is important for forensic psychiatric patients with psychotic disorders, in terms of reduction in symptoms, improving the quality of life, and preventing re-offenses. However, few detailed studies on employment status in such patients exist. We aimed to determine the employment rate among forensic psychiatric outpatients with psychotic disorders and identify the factors associated with employment.

PATIENTS AND METHODS

The study population comprised 406 patients with psychotic disorders who completed a forensic outpatient treatment order, were aged <65 years at discharge from a forensic psychiatric ward and provided written informed consent. Psychotic disorders were defined as psychiatric disorders classified into F2 in the International Statistical Classification of Diseases and Related Health Problems, 10th edition. Demographic data were collected from the medical records of the inpatient treatment period. Prognostic data during the outpatient treatment order period was provided by the reintegration coordinators responsible for coordinating the patients' social environment during this period. Exploratory univariate and multivariable logistic regression analyses identified the factors associated with employment.

RESULTS

The mean age at discharge was 44.4±10.8 years. The mean follow-up period was 2.69±1.01 years. There were 4.6 times more men (n=334) than women (n=72). During the outpatient treatment order period, 56 of 406 participants achieved employment (13.8%). Participants who committed serious crime, including homicide, arson, robbery, and sexual assault, had a lower employment rate compared to participants who committed bodily injury crimes (multivariable odds ratio, 0.421; 95% confidence interval, 0.220-0.807). History of substance use and living with family after discharge from a forensic psychiatric ward positively contributed to employment.

CONCLUSION

The employment rate among forensic psychiatric outpatients with psychotic disorders was low and was similar to that reported in previous studies on general psychiatric patients with schizophrenia. Furthermore, serious criminal behavior negatively impacted employment.

The influence of clerkship on students' stigma towards mental illness: a meta-analysis

CONTEXT

In university programmes preparing students to work with patients with mental illness, clerkship is proposed as a component that may contribute to the battle against stigma, through bringing students into contact with the patients' reality. Yet, the precise contribution of clerkship remains unclear, perhaps because of the variety of university programmes, clerkship characteristics or types of stigma explored. This is the first systematic meta-analysis of available evidence determining the precise effect size of the influence of clerkship on stigma and the potential moderators.

METHODS

We carried out a systematic literature review in Eric, PsycINFO, Pubmed, Scopus, UMI and Proquest dissertations, aiming to identify all the studies exploring health care students' stigma of mental illness (measured as overall stigma or as attitudes, affect and behavioural intentions) before and after a clerkship from 2000 to 2017. Twenty-two studies were included in the meta-analysis, providing data from 22 independent samples. The total sample consisted of 3161 students. The effects of programme (medicine, nursing, occupational therapy, and their combination), study design (paired-unpaired samples), publication year, sex, age and clerkship context, and inclusion of theoretical training and duration, were examined as potential moderators.

RESULTS

Our analyses yielded a highly significant medium effect size for overall stigma (Hedge's g = 0.35; p < 0.001; 95% confidence interval [CI], 0.20, 0.42), attitudes (Hedge's g = 0.308; p = 0.003; 95% CI, 0.10, 0.51) and behavioural intentions (Hedge's g = 0.247; p < 0.001; 95% CI, 0.17, 0.33), indicating a considerable change, whereas there was no significant change in the students' affect. Moderator analyses provided evidence for the distinct nature of each stigma outcome, as they were influenced by different clerkship and student characteristics such as clerkship context, theoretical training, age and sex.

CONCLUSIONS

The robust effect of clerkship on students' stigma of mental illness established by the present meta-analysis highlights its role as a crucial curriculum component for experiential learning and as a necessary agent for the battle against stigma.

The development and evaluation of a computerized decision aid for the treatment of psychotic disorders

BACKGROUND

Routinely monitoring of symptoms and medical needs can improve the diagnostics and treatment of medical problems, including psychiatric. However, several studies show that few clinicians use Routine Outcome Monitoring (ROM) in their daily work. We describe the development and first evaluation of a ROM based computerized clinical decision aid, Treatment-E-Assist (TREAT) for the treatment of psychotic disorders. The goal is to generate personalized treatment recommendations, based on international guidelines combined with outcomes of mental and physical health acquired through ROM. We present a pilot study aimed to assess the feasibility of this computerized clinical decision aid in daily clinical practice by evaluating clinicians' experiences with the system.

METHODS

Clinical decision algorithms were developed based on international schizophrenia treatment guidelines and the input of multidisciplinary expert panels from multiple psychiatric institutes. Yearly obtained diagnostic (ROM) information of patients was presented to treating clinicians combined with treatment suggestions generated by the algorithms of TREAT. In this pilot study 6 clinicians and 16 patients of Lentis Psychiatric Institute used the application. Clinicians were interviewed and asked to fill out self-report questionnaires evaluating their opinions about ROM and the effectiveness of TREAT.

RESULTS

Six clinicians and 16 patients with psychotic disorders participated in the pilot study. The clinicians were psychiatrists, physicians and nurse-practitioners which all worked at least 8 years in mental health care of which at least 3 years treating patients with psychotic illnesses. All Clinicians found TREAT easy to use and would like to continue using the application. They reported that TREAT offered support in using diagnostic ROM information when drafting the treatment plans, by creating more awareness of current treatment options.

CONCLUSION

This article presents a pilot study on the implementation of a computerized clinical decision aid linking routine outcome monitoring to clinical guidelines in order to generate personalized treatment advice. TREAT was found to be feasible for daily clinical practice and effective based on this first evaluation by clinicians. However, adjustments have to be made to the system and algorithms of the application. The ultimate goal is to provide appropriate evidence based care for patients with severe mental illnesses.

Antipsychotic medication non-adherence among schizophrenia patients in Central Ethiopia

Background

Despite the fact that adherence to antipsychotic medications is the cornerstone in the treatment and prevention of relapse of the disease, non-adherence is a major problem among schizophrenia patients. The purpose of this study was to assess the magnitude and factors associated with antipsychotic medication non-adherence among schizophrenia patients in Amanuel Mental Specialized Hospital.

Method

An institution-based cross-sectional study was conducted among 412 people with schizophrenia at Amanuel Mental Specialized Hospital from April to May 2014. Non-adherence was assessed using the questionnaire of Morisky medication adherence rating scale and semi-structured questions for assessment of associated factors. Logistic regression analysis was used to assess predictors of non-adherence.

Results

Prevalence of non-adherence was 41.0% among schizophrenia patients. Living in rural areas (adjusted odds ratio [AOR] = 2.07; 95% confidence interval [CI]: 1.31, 3.28), current substance use (AOR = 1.67; 95% CI: 1.09, 2.56), long duration of treatment (AOR = 2.07; 95% CI: 1.22, 3.50) and polypharmacy (AOR = 2.13; 95% CI: 1.34, 3.40) were found to be significantly associated with non-adherence.

Conclusion

The results indicate that non-adherence to antipsychotic medication was a major problem among patients with schizophrenia. Reducing the number of antipsychotic medications and availing drugs in rural areas may decrease the level of non-adherence.

Needs of Patients with Schizophrenia Among an Ethnic Minority Group in Latin America

The aim of the study is to describe the need profile of outpatients with schizophrenia belonging to an Aymara ethnic group in Latin-America and to compare that profile to non-Aymara patients. A sample of 253 patients were evaluated with the Two-Way Communication Checklist (2-COM Checklist) measuring the needs and satisfaction of the patient; Positive and Negative Syndrome scale for Schizophrenia (PANSS) and Attitude to the Drugs (DAI-10). No significant differences were found between Aymara and non-Aymara, either in the total number of needs or in the subscales of satisfaction or in the types of needs. After adjustment for socio-demographic and clinical factors, patients with higher severity (PANSS) had higher number of needs and lower level of satisfaction. Higher score on DAI-10 is related to a higher total number of needs and better satisfaction with medication. Age, sex, ethnicity and employment were also associated with specific needs. The profile of the needs of schizophrenic Aymara patients does not differ from that of non-Aymara patients, and that in both groups it is necessary that the treatment primarily address symptom management and the subjective aspects of quality of life.

Increasing the employment rate for people with longer-term mental health problems

Aims and method

To examine the effects of implementing the individual placement and support (IPS) approach within four community mental health teams (CMHTs). Demographic, clinical and vocational data were collected through a repeated cross-sectional survey. Additionally, a service user experience survey was conducted.

Results

The IPS approach appears to have a significant effect on the employment rates of service users; a higher proportion felt able to return to employment and a smaller proportion believed they were unable to work because of their mental health problems. Employment rates for service users appear to be independent of general employment rates.

Clinical implications

Implementing IPS appears to increase the employment rates in CMHTs resulting in increased service user expectations of being able to return to work.

Discrimination against people with mental illness: what can psychiatrists do?

This article discusses the evidence that experiences of stigmatisation and discrimination among people with mental illnesses are common and may be severe. Furthermore, there are growing concerns that people with mental illness receive second-class physical healthcare. Beyond this, some aspects of psychiatric practice are reported as being insensitive, disrespectful or even disabling. We consider whether such claims are justified and what psychiatrists can do, directly and indirectly, to reduce stigma and discrimination and improve our practice.

Effect of an art brut therapy program called go beyond the schizophrenia (GBTS) on prison inmates with schizophrenia in mainland China-A randomized, longitudinal, and controlled trial

Creative arts therapies are proven to promote an interconnection between body and mind, but there are major obstacles for providing therapeutic services in prisons due to inmates' inherent mistrust for verbal disclosure and rigid self-defenses, especially among inmates with schizophrenia. Thus, we developed a structured and quantitative art brut therapy program called go beyond the schizophrenia to actually measure the benefits of art therapy on prison inmates in mainland China. Upon completion of the program, the intervention group reported a decrease in anxiety, depression, anger, and negative psychiatric symptoms and showed better compliance with rules, socialization with peers, compliance with medications, and regular sleeping patterns after 16 weekly sessions of go beyond the schizophrenia. This article concludes that the art brut therapy was effective for the inmates with schizophrenia in mainland China and provides encouraging data on how to enhance mental health for inmates with schizophrenia.

KEY PRACTITIONER MESSAGE

Art brut therapy can reduce emotional distress and negative psychiatric symptoms among Chinese inmates. Arts brut therapy can enhance Chinese inmates' compliance with rules, socialization with peers, compliance with medicines, and regular sleeping patterns. Arts brut therapy in conjunction with medication is highly recommended for recovery of Chinese inmates with schizophrenia, especially for patients with negative symptoms.

Relationship between response to aripiprazole once-monthly and paliperidone palmitate on work readiness and functioning in schizophrenia: A post-hoc analysis of the QUALIFY study

Schizophrenia is a chronic disease with negative impact on patients' employment status and quality of life. This post-hoc analysis uses data from the QUALIFY study to elucidate the relationship between work readiness and health-related quality of life and functioning. QUALIFY was a 28-week, randomized study (NCT01795547) comparing the treatment effectiveness of aripiprazole once-monthly 400 mg and paliperidone palmitate once-monthly using the Heinrichs-Carpenter Quality-of-Life Scale as the primary endpoint. Also, patients' capacity to work and work readiness (Yes/No) was assessed with the Work Readiness Questionnaire. We categorized patients, irrespective of treatment, by work readiness at baseline and week 28: No to Yes (n = 41), Yes to Yes (n = 49), or No at week 28 (n = 118). Quality-of-Life Scale total, domains, and item scores were assessed with a mixed model of repeated measures. Patients who shifted from No to Yes in work readiness showed robust improvements on Quality-of-Life Scale total scores, significantly greater than patients not ready to work at week 28 (least squares mean difference: 11.6±2.6, p<0.0001). Scores on Quality-of-Life Scale instrumental role domain and items therein-occupational role, work functioning, work levels, work satisfaction-significantly improved in patients shifting from No to Yes in work readiness (vs patients No at Week 28). Quality-of-Life Scale total scores also significantly predicted work readiness at week 28. Overall, these results highlight a strong association between improvements in health-related quality of life and work readiness, and suggest that increasing patients' capacity to work is an achievable and meaningful goal in the treatment of impaired functioning in schizophrenia.

A randomized controlled trial comparing self-referral to inpatient treatment and treatment as usual in patients with severe mental disorders

BACKGROUND

There has been a call for increased patient autonomy and participation in psychiatry. Some Community Mental Health Centres (CMHC) have implemented services called 'self-referral to inpatient treatment' (SRIT) for patients with severe mental disorders.

AIMS

To investigate whether SRIT could yield better outcomes after 12 months in use of mental health services for people with severe mental disorders than Treatment As Usual (TAU).

METHODS

This was a randomized controlled trial at a CMHC in Norway comparing SRIT and TAU in 12 months. Fifty-four patients with severe mental disorders were included. The patients in the SRIT group could admit themselves as inpatients for up to 5 days for each admission with at least a 2 weeks pause between the admittances.

RESULTS

Twenty out of 26 participants (77%) in the SRIT group used the SRIT for a median of 1.5 admissions and 5 inpatient days. With the exception of a somewhat larger number of admissions at the CMHC in the SRIT group, no significant differences were found between the two groups in days as inpatients, admissions, outpatient contacts or coercion. Both groups reduced their inpatients days by 40%.

CONCLUSIONS

Both the SRIT and the TAU groups reduced their use of services during the 12 months intervention period. Giving patients with severe mental disorders the possibility to self-refer did not change the use of services.

CLINICAL IMPLICATIONS

Self-referral to inpatient treatment for patients with severe mental disorders might increase patient autonomy, but does not seem to save use of inpatient services.

Cardiometabolic comorbidities, readmission, and costs in schizophrenia and bipolar disorder: a real-world analysis

BACKGROUND

Serious mental illnesses are associated with increased risk of cardiometabolic comorbidities. The objective of this study was to evaluate the prevalence of cardiometabolic comorbidity and its association with hospitalization outcomes and costs among inpatients with schizophrenia or bipolar disorder.

METHODS

This retrospective database analysis reviewed patients with an inpatient diagnosis of schizophrenia or bipolar disorder from the Premier Perspective® Database (4/1/2010-6/30/2012). Patients were categorized into 4 cohorts based on the number of ICD-9-CM cardiometabolic comorbidities (i.e., 0, 1, 2, or 3+). Outcomes included length of stay, mortality during the index hospitalization, healthcare costs, and 30-day all-cause readmission rates.

RESULTS

Of 57,506 patients with schizophrenia, 66.1% had at least one cardiometabolic comorbidity; 39.3% had two or more comorbidities. Of 124,803 patients with bipolar disorder, 60.5% had at least one cardiometabolic comorbidity; 33.4% had two or more. Average length of stay was 8.5 (for patients with schizophrenia) and 5.2 (for patients with bipolar disorder) days. Each additional cardiometabolic comorbidity was associated with an increase in length of stay for patients with bipolar disorder (p < .001) but not for patients with schizophrenia. Mortality rates during the index hospitalization were 1.2% (schizophrenia) and .7% (bipolar disorder). Each additional cardiometabolic comorbidity was associated with a significant increase in mortality for patients with bipolar disorder (OR 1.218, p < .001), and a numerical increase in mortality for patients with schizophrenia (OR 1.014, p = .727). Patients with more cardiometabolic comorbidities were more likely to have a 30-day readmission (schizophrenia = 9-13%; bipolar disorder = 7-12%), and to incur higher costs (schizophrenia = $10,606-15,355; bipolar disorder = $7126-13,523) (all p < .01).

CONCLUSIONS

Over 60% of inpatients with schizophrenia or bipolar disorder had cardiometabolic comorbidities. Greater cardiometabolic comorbidity burden was associated with an increased likelihood of readmission and higher costs among patients with schizophrenia or bipolar disorder, and an increase in length of stay and mortality for patients with bipolar disorder.

Art therapy for people with psychosis: a narrative review of the literature

Art therapy enables individuals to use art to creatively express themselves and communicate differently with themselves, others, and their reality. The National Institute for Health and Clinical Excellence guidelines for psychosis and schizophrenia suggest that arts therapies, which include art therapy, are considered to improve negative symptoms of psychosis. We examined the effectiveness of art therapy for people with psychosis and explored whether art therapy is a meaningful and acceptable intervention in this Review. Seven electronic databases were searched for empirical papers that concerned the use of art therapy for adults with psychosis that were published from 2007 onwards. The search identified 18 papers. High-quality quantitative articles provided inconclusive evidence for the effectiveness of art therapy in adults with psychosis. However, high-quality qualitative articles indicated that therapists and clients considered art therapy to be a beneficial, meaningful, and acceptable intervention, although this conclusion was based on a small number of studies. In this Review, we discuss the theoretical, clinical, and methodological issues in light of the development of more robust research, which is needed to corroborate individuals' experiences and guide evidence-based practice.

Cost-Utility Analysis of Lurasidone Versus Aripiprazole in Adults with Schizophrenia

BACKGROUND

In 2014, lurasidone, an atypical antipsychotic, was approved for the treatment of schizophrenia in adults. It is an alternative treatment option to aripiprazole, and when compared with aripiprazole, lurasidone was associated with improved symptom reduction and reduced risk of weight gain and relapse. We conducted a cost-utility analysis of lurasidone versus aripiprazole from the perspective of healthcare services, using Scotland and Wales as specific case studies.

METHODS

A 10-year Markov model, incorporating a 6-week acute phase and a maintenance phase across three health states (discontinuation, relapse, death) was constructed. Six-week probabilities of discontinuation and adverse events were based on a published independent mixed-treatment comparison; long-term risks of relapse and discontinuation were from an indirect comparison. Costs included drug therapy, relapse, and outpatient, primary and residential care. Costs and benefits were discounted at 3.5 %. Utility estimates were taken from published literature, and cost effectiveness was expressed as total 10-year incremental costs and quality-adjusted life-years (QALYs).

RESULTS

Lurasidone yielded a cost saving of £3383 and an improvement of 0.005 QALYs versus aripiprazole, in Scotland. Deterministic sensitivity analysis demonstrated that results were sensitive to relapse rates, while probabilistic sensitivity analysis suggested that lurasidone had the highest expected net benefit at willingness-to-pay thresholds of £20,000-30,000 per QALY. The probability that lurasidone was a cost-effective treatment strategy was approximately 75 % at all willingness-to-pay thresholds, with similar results being obtained for the Welsh analysis.

CONCLUSIONS

Our analysis suggests that lurasidone would provide an effective, cost-saving alternative for the healthcare service in the treatment of adult patients with schizophrenia.

Clinical utility of the Multiple Errands Test in schizophrenia: A preliminary assessment

Schizophrenia (SZ) is a chronic, severe disease, which results in misperception of reality, major social withdrawal, and cognitive disturbances. One type of cognitive disturbance, known as executive dysfunction, is widely considered as a primary determinant of functional outcome. However, classic neuropsychological measures of executive functioning (EF) poorly represent patients' functional outcome, and thus seem inappropriate for evaluating the real-world functional impact of diseases such as SZ. We hypothesized that the Multiple Errands Test (MET), an ecological assessment of executive function would show greater ability to measure everyday adaptive functioning SZ, compared to conventional EF assessment methods. 100 clinically stable SZ patients were administered the MET, Wisconsin Card Sorting Test - 64 and a paper version of MET. Correlation analyses were performed between each EF measure and functional outcome, as measured by the Social Autonomy Scale (SAS). After adjusting for age, education, IQ and illness duration, SAS was significantly predicted by MET global score. No other EF measure correlated with SAS. Results from this study suggest that MET offers a valuable prediction of daily life functional outcome in this large sample of SZ patients. Therefore, it could be used as a complementary measure to improve the identification of executive dysfunctions prior to psychosocial interventions.

Do routine outcome monitoring results translate to clinical practice? A cross-sectional study in patients with a psychotic disorder

BACKGROUND

The use of Routine Outcome Monitoring (ROM) in mental health care has increased widely during the past decade. Little is known, however, on the implementation and applicability of ROM outcome in daily clinical practice. In the Netherlands, an extensive ROM-protocol for patients with psychotic disorders has been implemented over the last years (ROM-Phamous). The current study investigated to what extent ROM results translate to daily clinical practice. Therefore, we investigated whether clinical problems as identified with ROM were detected and used in the treatment of patients with psychotic disorders.

METHODS

Out of the ROM database of 2010 (n = 1040), a random sample of 100 patients diagnosed with a psychotic disorder was drawn. ROM-data used in this study included a physical examination, laboratory tests, interviews and self-report questionnaires. Based on these data, the prevalence of positive and negative symptoms, psychosocial problems and cardiovascular risk factors was determined. Next, we investigated whether these problems, as identified with ROM, were reflected in the treatment plans of patients, as an indication of the use of ROM in clinical practice.

RESULTS

The sample consisted of 63 males and 37 females. The mean age was 44 and the mean duration of illness was 17.7 years. The prevalence of positive and negative symptoms, psychosocial problems and cardiovascular risk factors ranged from 11 to 86 %. In the majority of cases, problems as identified with ROM were not reflected in the treatment plans of patients.

CONCLUSIONS

We found a substantial discrepancy between the ROM measurements and the treatment plans, i.e. low rates of detection of symptoms, psychosocial problems and cardiovascular risk factors in the treatment plans, even though these problems were identified with ROM. The opposite occurred as well, where problems were reflected in the treatment plans but not identified with ROM. Thus, ROM and daily clinical practice appear to be two separate processes, whereas ideally they should be integrated. Strong efforts should be made to integrate ROM and consequent treatment activities. Such integration may help to provide patients with adequate and customized care and simultaneously minimize under- and over-treatment.

Psychometric evaluation of the Work Readiness Questionnaire in schizophrenia

OBJECTIVE/INTRODUCTION

Unemployment can negatively impact quality of life among patients with schizophrenia. Employment status depends on ability, opportunity, education, and cultural influences. A clinician-rated scale of work readiness, independent of current work status, can be a valuable assessment tool. A series of studies were conducted to create and validate a Work Readiness Questionnaire (WoRQ) for clinicians to assess patient ability to engage in socially useful activity, independent of work availability.

METHODS

Content validity, test-retest and inter-rater reliability, and construct validity were evaluated in three separate studies.

RESULTS

Content validity was supported. Cronbach's α was 0.91, in the excellent range. Clinicians endorsed WoRQ concepts, including treatment adherence, physical appearance, social competence, and symptom control. The final readiness decision showed good test-retest reliability and moderate inter-rater reliability. Work readiness was associated with higher function and lower levels of negative symptoms. Low positive and high negative predictive values confirmed the concept validity.

DISCUSSION

The WoRQ has suitable psychometric properties for use in a clinical trial for patients with a broad range of symptom severity. The scale may be applicable to assess therapeutic interventions. It is not intended to assess eligibility for supported work interventions.

CONCLUSIONS

The WoRQ is suitable for use in schizophrenia clinical trials to assess patient work functional potential.

Subjective distress in a representative sample of outpatients with psychotic disorders

BACKGROUND

The affective burden of psychotic disorder has been increasingly recognised. However, subjective reports of distress and its covariates, especially those related to service use, remain under-investigated in patients with psychosis.

METHODS

This study investigated subjective distress and its covariates in a representative sample of 401 outpatients with a confirmed diagnosis of psychotic disorders in Brazil. Distress was assessed using the corresponding domain of a standardised measure of need - the Camberwell Assessment of Need.

RESULTS

Distress was reported as a need by 165 (41%) patients, being met in 78 (20%) and unmet in 87 (22%). Hierarchical logistic regression showed that the presence of distress as a need was predicted by attendance at psychotherapy (OR=3.49, CI=1.62-7.53), presence of suicidal ideation (OR=2.89, CI=1.75-4.79), non-attendance at psychosocial rehabilitation (OR=2.84, CI=1.31-6.19), and higher psychopathology (OR=1.09, CI=1.06-1.12). An unmet need was predicted by family not accompanying patients to treatment (OR=2.60, CI=1.05-6.44) and higher psychopathology (OR=1.05, CI=1.02-1.09).

LIMITATION

The use of a cross-sectional design and a single questionnaire domain to evaluate distress are the main limitations.

CONCLUSIONS

Subjective distress is a common unmet need in psychosis, and can be treated. The main clinical implication is that subjective distress in psychosis may be impacted on by family engagement and psychosocial interventions.

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

AIM

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

Associations of Quality of Life with Service Satisfaction in Psychotic Patients: A Meta-Analysis

BACKGROUND

Quality of life (QoL) has gained increasing attention as a desired outcome of psychosocial treatments targeting psychotic patients. Yet, the relationship between the patients' satisfaction with services and QoL has not been clearly established, perhaps due to the multidimensionality of the QoL concept and the variability in its assessment.

AIM

This is the first systematic meta-analysis of all available evidence assessing the relationship between QoL and service satisfaction.

METHODS

In all, 19 studies reporting data of 21 independent samples (N = 5,337) were included in the present meta-analysis. In moderator analyses, effects of age, sex, diagnoses (schizophrenia vs. other psychoses), treatment context (inpatients vs. outpatients), study design (cross-sectional vs. longitudinal), and QoL domain (subjective vs. health-related) were examined.

RESULTS

Analyses revealed a highly significant medium-sized effect (r = .30, p < .001) for the associations of QoL and service satisfaction. Effect sizes were significantly stronger for subjective than health-related quality of life (r = .35 vs. r = .14, respectively). Moreover, associations with subjective QoL remained largely robust when accounting for moderating variables, although there was a trend of stronger associations for outpatients compared to inpatients. In contrast, effect sizes for health-related QoL were small and only observable for samples with longitudinal designs.

CONCLUSION

Associations between QoL and service satisfaction appear to be robust but are differentiated in regard to QoL domain. Our findings suggest that agents responsible for service design and implementation need to take the patients' perception of the service adequacy for achieving QoL enhancement into account.

Combined intervention with education and progressive muscle relaxation on quality of life, functional disability, and positive symptoms in patients with acute schizophrenia

OBJECTIVES

To explore the effects of combined intervention with education and progressive muscle relaxation (PMR) on quality of life (QoL), functional disability, and positive symptoms of patients with acute schizophrenia.

METHODS

This randomized controlled study took place in an acute schizophrenia ward in Changsha, China. Sixty-four patients with acute schizophrenia were randomly assigned to four groups: control, education, PMR, and education plus PMR. QoL was assessed with the Quality of Life Enjoyment and Satisfaction Questionnaire Short Form. Functional disability was assessed with the Sheehan Disability Scale. Severity of positive schizophrenia symptoms was assessed with the Scale for the Assessment of Positive Symptoms. All patients were evaluated at baseline (within 72 hours before the interventions) and at the end of weeks 5 (when the interventions ended) and week 15 (a 10-week follow-up after the interventions).

RESULTS

The sociodemographic and clinical characteristics of all four study groups were similar at baseline. Repeated-measures analysis of variance showed significant differences among the interventions in improving QoL, functional disability, and positive symptoms over time in the patients. Education and PMR alone resulted in sustained improvement of QoL during the intervention period and a 10-week follow-up but had no significant effects on functional disability or positive schizophrenia symptoms. In contrast, combined intervention with education and PMR showed better effects on improving QoL than did education or PMR alone throughout the 15-week study. It also statistically significantly improved functional disability and positive schizophrenia symptoms during the intervention period and led to sustained improvement of functional disability during the 10-week follow-up.

CONCLUSIONS

A combined intervention with education and PMR is effective in improving QoL, functional disability, and positive symptoms in patients with acute schizophrenia. The combined intervention model could be a new paradigm of adjunctive treatment for acute schizophrenia.

Measuring the economic costs of discrimination experienced by people with mental health problems: development of the Costs of Discrimination Assessment (CODA)

PURPOSE

Stigma and discrimination are faced by many with mental health problems and this may affect the uptake of services and engagement in leisure and recreational activities. The aims of this study were to develop a schedule to measure the impact of stigma and discrimination on service use, employment and leisure activities and to estimate the value of such reductions.

METHODS

A questionnaire, the Cost of Discrimination Assessment, was developed and piloted in a sample people with mental health problems. Costs were calculated and test-retest reliability assessed.

RESULTS

Test-retest reliability was good for most items. A substantial proportion of the sample had experienced negative impacts on employment as a result of stigma and discrimination. Around one-fifth had reduced contacts with general practitioners in the previous 6 months due to stigma and discrimination and the leisure activity most affected was visiting pubs/restaurants/café.

CONCLUSIONS

In conclusion, stigma and discrimination result in reduced use of services and reduced engagement in leisure activities. This represents a welfare loss to individuals.

Employment and the associated impact on quality of life in people diagnosed with schizophrenia

A systematic review was conducted to assess the employment rate of people with schizophrenia. Additionally, information from the selected studies concerning factors associated with employment and health-related quality of life (HRQoL) was examined. Employment rates ranged from 4% to 50.4%. The studies differed considerably in design, patient settings, and methods of recruitment. The most frequently reported factors associated with employment were negative and cognitive symptoms, age of onset, and duration and course of the disease. Individual characteristics associated with unemployment were older age, lower education, and sex (female). Additionally, environmental factors, eg, the availability of welfare benefits and vocational support programs, seemed to play a role. Generally, being employed was positively associated with HRQoL. However, the causal direction of this association remained unclear, as studies on the bidirectional relationship between employment and HRQoL were lacking.

Internet delivered question and answer column for patients with schizophrenia

The purpose of this study was to describe the use of an Internet delivered question and answer column among patients with schizophrenia. The column was developed for research purposes. The study sample consisted of patients (N = 100) admitted to acute inpatient psychiatric care in two hospital districts. Descriptive data were collected from the column to which a nurse replied within 3 days and analysed using qualitative content analysis. The column had four to five questions weekly. The most common age of users was 18-24 years, and the gender distribution was almost equal. Column use was heaviest among students (44%) and least among unemployed people (19%). Out of 85 questions or comments sent to the column, 25 (29%) were related to program training and the remaining 60 (71%) were related to medication (31%), illness and tests (25%), other questions or comments (9%), daily life and coping with it (4%), and places to receive treatment (2%). An Internet delivered question and answer column can be included in the care of patients with schizophrenia. However, it requires a new type of basic and additional education in the field of mental health care in order for nurses to be able to provide nursing via the Internet forum.

Social and functional capacity of schizophrenia patients: A cross-sectional study

BACKGROUND

The chronic course of schizophrenia typically results in severe social, vocational and functional impairment, interferes with patients' autonomy, reduces quality of life and increases disability.

AIMS

The aim of our study was: (1) to assess social and functional impairment in schizophrenia outpatients from the Czech Republic and Slovakia; and (2) to examine a relationship between functioning and antipsychotic treatment and demographic variables.

METHODS

Schizophrenia outpatients in a stable phase of illness, treated with current antipsychotic medication for a minimum of one month, were enrolled for the study. Demographic and medication data were recorded. The Personal and Social Performance (PSP), Subjective Well-Being under Neuroleptics (SWN) and Clinical Global Impressions (CGI) scales were administered.

RESULTS

The total number of study subjects was 926. Most PSP values were within the interval of moderate impairment. Functional performance correlated positively with subjective satisfaction with medication and negatively with symptom severity. Higher education predicted better functioning on PSP. The best performance was associated with a stable relationship and a useful work role. Patients who showed the best level of functioning were more likely to be treated with antipsychotic monotherapy. No difference among drugs in monotherapy was found in subjective satisfaction.

CONCLUSIONS

The PSP values of stable schizophrenia outpatients indicated a moderate degree of impairment. Improvement of functional capacity remains one of the unmet needs of schizophrenia patients.

Beliefs of Vocational Rehabilitation Counselors About Competitive Employment for People With Severe Mental Illness in Belgium

Vocational rehabilitation (VR) counselors do not always focus on competitive employment for people with severe mental illness (SMI). Based on the Theory of Planned Behavior (TPB), this study examines how three types of VR counselors (i.e., gatekeepers, case managers, and specialists) vary in their underlying beliefs about competitive employment. VR counselors ( N = 286) from Belgium completed an online TPB survey measuring behavioral, normative, control, and self-efficacy beliefs. Differences in beliefs were analyzed by one-way ANOVAs and post hoc comparisons using Bonferroni correction. Results indicate that counselors differ in their beliefs regarding competitive employment for people with SMI. Specialized counselors are stronger convinced that competitive employment results in latent benefits (e.g., increased integration and self-confidence). In contrast, gatekeepers consider income as the most recurrent and positive effect. The more specialized VR counselors are, the more often they perceive significant others valuing competitive employment and the more often they may comply with these norms. Finally, specialized counselors experience fewer barriers, more control, and more self-efficacy in dealing with problems compared with less specialized counselors. The differences in beliefs determining the focus on competitive employment may result in a lack of an integrated approach. Training, outcome feedback, and intersectoral communication can enhance consistency between different VR services.

Evaluation of acetylcholinesterase activity and behavioural alterations induced by ketamine in an animal model of schizophrenia

OBJECTIVE

Cognitive deficits in schizophrenia play a crucial role in its clinical manifestation and seem to be related to changes in the cholinergic system, specifically the action of acetylcholinesterase (AChE). Considering this context, the aim of this study was to evaluate the chronic effects of ketamine in the activity of AChE, as well as in behavioural parameters involving learning and memory.

METHODS

The ketamine was administered for 7 days. A duration of 24 h after the last injection, the animals were submitted to behavioural tests. The activity of AChE in prefrontal cortex, hippocampus and striatum was measured at different times after the last injection (1, 3, 6 and 24 h).

RESULTS

The results indicate that ketamine did not affect locomotor activity and stereotypical movements. However, a cognitive deficit was observed in these animals by examining their behaviour in inhibitory avoidance. In addition, an increase in AChE activity was observed in all structures analysed 1, 3 and 6 h after the last injection. Differently, serum activity of AChE was similar between groups.

CONCLUSION

Chronic administration of ketamine in an animal model of schizophrenia generates increased AChE levels in different brain tissues of rats that lead to cognitive deficits. Therefore, further studies are needed to elucidate the complex mechanisms associated with schizophrenia.