Five-year follow-up during antipsychotic treatment: efficacy, safety, functional and social outcome

Clinical validation of the Symptom Self-rating Scale for Schizophrenia (4S) among inpatients

PURPOSE

Self-reports of psychosis-related symptoms may be a valuable supplement to clinician-ratings, but more validation studies are required. The aim of this study was to conduct clinical validation for the Symptom Self-rating Scale for Schizophrenia (4S) in an inpatient setting.

MATERIALS AND METHODS

Inpatients diagnosed with schizophrenia were invited to participate in the study. The participants completed the 4S, the 5-item World Health Organization Wellbeing Index (WHO-5) and the Sheehan Disability Scale (SDS) at two time points. Trained raters assessed participants using the 6-item Positive And Negative Syndrome Scale (PANSS-6). The relationship between the 4S and PANSS-6, self-reported side effects, functioning and wellbeing was assessed using Spearman's correlation coefficient (rho).

RESULTS

Sixty-one participants completed the 4S at least once (yielding a total of 91 completed 4S questionnaires). The 4S total score was weakly correlated with the PANSS-6 total score (rho = 0.37, p < 0.001). The rho's for individual 4S and PANSS-6 subscales and item comparisons ranged from -0.24 (thought disorder) to 0.69 (hallucinations). Finally, the 4S hallucination subscale was also sensitive to change. The 4S was strongly inversely correlated with wellbeing (WHO-5) and moderately inversely correlated with functioning (SDS total score).

CONCLUSION

The 4S holds promise as a valid self-report of core schizophrenia symptoms among inpatients. While the hallucination subscale seems superior to existing scales, the thought disorder subscale needs to be re-developed.

Patient versus rater evaluation of symptom severity in treatment resistant schizophrenia receiving clozapine

Patient input as part of health care has taken on increased importance recently. To look at whether patients with treatment resistant schizophrenia (TRS) are able to provide a valid self-assessment of symptoms, the present study investigated patient versus rater evaluation of clinical symptoms. Ninety-three patients diagnosed with TRS and treated with clozapine were recruited. Both patients and raters completed the 7-point Clinical Global Impression - Schizophrenia Version (CGI-SCH) scale, thereby providing evaluations for positive, negative, depressive, and cognitive symptoms as well as overall illness severity. Patients rated their clinical symptoms significantly lower than raters. A positive correlation was found between patients and raters for all symptom domains, while the strength of correlation varied. Age, gender and years of education did not impact the relationship between patient and rater scores. The conclusion is that patients provided valid information in self-assessments of symptoms when compared to raters, and this was consistent over time. In addition, the greatest heterogeneity between rater and patient ratings occurred with regard to cognitive symptoms. Patient assessments may help further engage individuals in their care and permit clinicians to identify where discrepancies exist. Addressing these issues offers opportunities for improved therapeutic alliance, education, and shared decision-making within treatment.

FAST-O works well for characterization and monitoring of sheltered housing schizophrenia patients

OBJECTIVE

The de-institutionalizing process came to an end before the millennium shift by closing mental hospitals. After that some of the most ill patients are cared for in sheltered housing (SH). There is no in-house psychiatric competence and the staff on the floor usually lacks such knowledge and training. Observation instruments may improve this by making it possible to assess and monitor patients.

METHOD

FAST-O is a simple twelve-item observation scale. Staff at eight SH units were trained in using the instrument and then assessed a total of 67 patients once, twice or three times at monthly intervals.

RESULTS

Ten items formed two highly homogenous subscales reflecting Social skills (Soc) and Excitation/Aggression (E/A). Depression and Clinical Global Impression (CGI) items were considered separately. The correlation pattern suggested that the ratings had construct validity. A cluster analysis identified three patient subgroups, of which one had very high E/A scores. Comparisons with reference data suggested that the average symptom level was on par with acutely admitted in-patients for this subgroup. In all groups, E/A symptoms varied considerably over time, the other symptoms were more stable. There were marked differences among the eight SH units with respect to the level of patient problems.

CONCLUSIONS

The SH staff was able to produce valid FAST-O assessments. There are reference data which makes it possible to characterize individual patients as well as SH units with respect to treatment needs and safety aspects (for instance risk of violence).

Predicting real-world functional milestones in schizophrenia

Schizophrenia is a severe disorder that often causes impairments in major areas of functioning, and most patients do not achieve expected real-world functional milestones. The aim of this study was to identify which variables of demography, illness activity, and functional capacity predict patients' ability to attain real-world functional milestones. Participants were 235 outpatients, 149 men and 86 women, diagnosed with schizophrenia spectrum disorder. Our results showed that younger patients managed to achieve a higher level of functioning in educational level, marital status, and social contacts. Patients' functional capacity was primarily associated with educational level and housing situation. We also found that women needed less support regarding housing and obtained a higher level of marital status as compared with men. Our findings demonstrate the importance of considering current symptoms, especially negative symptoms, and remission stability over time, together with age, duration of illness, gender, educational level, and current functional capacity, when predicting patients' future real-world functioning. We also conclude that there is an advantage in exploring symptoms divided into positive, negative, and general domains considering their probable impact on functional achievements.

Pharmacoeconomics of depot antipsychotics for treating chronic schizophrenia in Sweden

AIMS

To determine the cost-effectiveness of long-acting injectable (LAI) antipsychotics for chronic schizophrenia in Sweden.

METHODS

A 1-year decision tree was developed for Sweden using published data and expert opinion. Five treatment strategies lasting 1 year were compared: paliperidone palmitate (PP-LAI), olanzapine pamoate (OLZ-LAI), risperidone (RIS-LAI), haloperidol decanoate (HAL-LAI) and olanzapine tablets (oral-OLZ). Patients intolerant/failing drugs switched to another depot; subsequent failures received clozapine. Resources and employment time lost (indirect costs) were costed in 2011 Swedish kroner (SEK), from standard government lists. The model calculated the average cost/patient and quality-adjusted life-years (QALYs), which were combined into incremental cost-effectiveness ratios. Multivariate and 1-way sensitivity analyses tested model stability.

RESULTS

PP-LAI followed by OLZ-LAI had the lowest cost/patient (189,696 SEK) and highest QALYs (0.817), dominating in the base case. OLZ-LAI followed by PP-LAI cost 229,775 SEK (0.812 QALY), RIS-LAI followed by HAL-LAI cost 221,062 SEK (0.804 QALY), HAL-LAI followed by oral-OLZ cost 243,411 SEK (0.776 QALY), and oral-OLZ followed by HAL-LAI cost 249,422 SEK (0.773 QALY). The greatest proportions of costs (52.5-83.8%) were for institutional care; indirect costs were minor (2.4-3.8%). RESULTS were sensitive to adherence and hospitalization rates, but not drug cost. PP-LAI followed by OLZ-LAI dominated OLZ-LAI followed by PP-LAI in 59.4% of simulations, RIS-LAI followed by HAL-LAI in 65.8%, HAL-LAI followed by oral-OLZ in 94.0% and oral-OLZ followed by HAL-LAI in 95.9%; PP-LAI followed by OLZ-LAI was dominated in 1.1% of the 40,000 iterations.

CONCLUSION

PP-LAI followed by OLZ-LAI was cost-effective in Sweden for chronic schizophrenia and cost-saving overall to the healthcare system.

Prevalence and risk factors associated with tardive dyskinesia among Indian patients with schizophrenia

BACKGROUND

Tardive dyskinesia (TD) is one of the most distressing side effects of antipsychotic treatment. As prevalence studies of TD in Asian population are scarce, a cross-sectional study was performed to assess the frequency of TD in Indian patients with schizophrenia and risk factors of TD.

METHOD

Cross-sectional study of 160 Indian patients fulfilling the DSM-IV TR criteria for schizophrenia and who received antipsychotics for at least one year, were examined with two validated scales for TD. Logistic regression analyses were used to examine the relationship between TD and clinical risk factors.

RESULTS

The frequency of probable TD in the total sample was 26.4%. The logistic regression yielded significant odds ratios between TD and age, intermittent treatment, and total cumulative antipsychotic dose. The difference of TD between SGA and FGA disappeared after adjusting for important co-variables in regression analysis.

CONCLUSION

Indian patients with schizophrenia and long-term antipsychotic treatment have a high risk of TD, and TD is associated with older age, intermittent antipsychotic treatment, and a high total cumulative antipsychotic dose. Our study findings suggest that there is no significant difference between SGAs with regards to the risk of causing TD as compared to FGAs.

Psychopathological long-term outcome of schizophrenia -- a review

OBJECTIVE

In the past, the comparability of empirical studies that examined the course and outcome of schizophrenia was limited by their use of different diagnostic systems. Focussing on the psychopathological long-term outcome, the present article aims to review follow-up studies that used modern operationalized diagnostic criteria for schizophrenia (DSM-III, DSM-III-R, DSM-IV and ICD-10).

METHOD

We searched MEDLINE, the Cochrane Central Register of Controlled Trials, EMBASE, PsycINFO and PSYNDEX for relevant studies up to the year 2011. Twenty-one studies were included in the final analysis.

RESULTS

The long-term outcome of schizophrenia was heterogeneous and included full remissions as well as severe chronic states. Schizophrenia, however, showed a considerably more unfavourable outcome than other diagnostic groups such as schizoaffective or affective disorders. Psychopathological symptoms remained relatively stable in the course of illness. Several predictors for a poor outcome were identified, such as male gender or pronounced negative symptoms.

CONCLUSION

Recent studies using modern diagnostic systems largely confirm the results of earlier studies. Current diagnostic criteria for schizophrenia identify a heterogeneous sample of patients. The influence of therapeutic interventions on long-term outcome remains unclear.

DAI-10 is as good as DAI-30 in schizophrenia

Drug attitude inventory (DAI-30) is considered to be the best predictor of poor adherence in first-episode schizophrenia. We compared the short version (DAI-10) with DAI-30 in long-term schizophrenia, documented if DAI was associated with poor insight, PANSS and GAF and constructed DAI-10 percentiles. DAI-30 and DAI-10 were homogenous (r = 0.82 and 0.72, respectively) with good test-retest reliability (0.79). The correlation between the DAI versions was high (0.94). Percentile scores of DAI-10 were computed. DAI is an easy-to-use self-report instrument seemingly assessing a unique clinical dimension relevant to non-adherence. DAI-10 might be preferred for its simplicity and good psychometric properties.

One-year functional outcomes of naturalistically treated patients with schizophrenia

Against the background of the growing evidence that the patient's functioning significantly influences the course and outcome of schizophrenia, the aims of this analysis were to examine what proportion of patients achieve functional outcome criteria after 1 year, and to identify clinical and sociodemographic predictive factors for functional remission. Patients with the diagnosis of schizophrenia who were treated as inpatients at the beginning of the study were examined within a naturalistic follow-up trial. The present study reports on the time frame from admission to discharge of an inpatient treatment period and the 1-year follow-up assessment. The Global Assessment of Functioning (GAF) Scale and Social and Occupational Functioning Assessment Scale (SOFAS) were evaluated with respect to functional outcome, whereas Positive and Negative Syndrome Scale (PANSS) scores were rated as psychopathological outcome measures. Functional remission thresholds were defined according to a GAF score of ≥61 points and a SOFAS score ≥61 points. Symptomatic remission criteria were applied according to the remission criteria of the Schizophrenia Working Group. The Strauss-Carpenter Prognostic Scale (SCPS), the Phillips Premorbid Adjustment Scale, medical history, sociodemographic and psychopathologic parameters were evaluated in order to find valuable predictors for functional remission. One year after discharge from inpatient treatment, 211 out of 474 patients were available for analysis according to both rating scales used to assess functional remission (GAF and SOFAS). Forty-seven percent of patients fulfilled criteria for functional remission (GAF and SOFAS) at discharge and 51% of patients at the 1-year follow-up visit. With regard to symptomatic remission criteria, the corresponding remitter rates were 61% of patients at discharge and 54% at the 1-year follow-up visit. Forty-two percent of patients fulfilled both remission criteria at discharge and 37% at the 1-year follow-up visit. A significant association was found between functional and symptomatic remission at discharge and at the 1-year follow-up visit. The strongest predictors for functional remission at the 1-year follow-up visit were: a higher SCPS total score at admission, a lower number of previous hospitalizations, a status of employment, lower scores in all PANSS subscales at discharge, a better premorbid social adjustment, the occurrence of a first psychotic episode, a younger age, a lower PANSS negative subscore at admission, a status of being an early responder, a shorter duration of inpatient treatment, a later age of onset, and female gender.

Effects of sertindole on cognition in clozapine-treated schizophrenia patients

OBJECTIVE

To assess the cognitive effects of sertindole augmentation in clozapine-treated patients diagnosed with schizophrenia. Cognition is secondary outcome of the trial.

METHOD

A 12-week, double-blinded, randomized, placebo-controlled, augmentation study of patients treated with clozapine. Participants were randomized 1:1 to receive 16 mg of sertindole or placebo as adjunctive treatment to clozapine.

RESULTS

Participants displayed substantial cognitive deficits, ranging from 1.6 standard deviation below norms at baseline to more than three standard deviations on tests of response readiness and focused attention. There were no significant differences between sertindole augmentation and placebo groups at study end. Correlation analysis of Positive and Negative Syndrome (PANSS) subscales, Global Assessment of Functioning subscale (GAF-F) and Clinical Global Impression (CGI) with 20 neurocognitive indices was conducted, but no significant correlations were found. Second, we tested change from baseline to endpoint for the PANSS, GAF-F, and CGI, vs. the concomitant changes in cognitive test performance, and found no significant correlations.

CONCLUSION

The clozapine-treated patients displayed marked cognitive deficits at baseline. Adding sertindole did not improve or worsen cognitive functioning, which is in line with previous negative studies of the effect on cognition of augmenting clozapine treatment with another antipsychotic drug.

Development and validation of the Fast Assessment in Acute Treatment of Psychosis-Observation Rating Scale (FAST-O)

OBJECTIVES

There is a need for an observation scale for assessment and monitoring of acutely psychotic patients. Milestones based on such ratings should be defined, similar to the PANSS-based Remission criteria. FAST-O is such an instrument (11 items and a CGI rating).

METHODS

Reliability, validity and factor structure were analyzed in four separate studies--most importantly in one study of 33 chronic forensic in-patients rated concurrently by three independent raters, and another study of 91 Psychiatric Intensive Care Units patients and 20 newly admitted forensic patients, rated twice, each time by two independent raters.

RESULTS

The factor structure was simple, two factors and an orphan item (Depression). Reliability was adequate on item (>0.75) as well as scale (>0.85) level. There was no bias related to the rater's professional background. The instrument was sensitive to change. Percentile-based algorithms allow characterization of patients and groups. Tentative treatment milestones are defined; a clinical state "half-way" between the acute state and remission.

CONCLUSIONS

FAST-O is a reliable, valid and easy to implement observation scale for patients with a psychotic illness, which can be used without bias by all staff.

Use of antipsychotics - an analysis of lifetime treatment in 66 patients with psychoses

Only a minority of patients treated with antipsychotics in clinical studies continue their treatments throughout a longer study period. Few studies address this issue from a lifetime perspective. In this naturalistic study, we aimed at analysing the prescription pattern of antipsychotic drugs among a sample of Swedish patients with a diagnosis of psychotic illness, from the first contact with psychiatry (typically between 1973 and 1997) until the last written note in the case history documents. A retrospective descriptive analysis was performed of all case history data of 66 patients diagnosed with schizophrenia or related psychotic disorders. Patients with schizophrenia were prescribed antipsychotic medication more than 90% of the time. Each patient generally had been prescribed several (up to 16) different antipsychotic drugs and a quarter of the patients had been prescribed two or more antipsychotics for a third of their prescription time. Patients with psychosis were exposed to a cumulatively growing number of antipsychotics. Various factors, including clinician and patient expectations, and specific strengths and limitations of available antipsychotics may account for frequent medication changes over time.

Quetiapine and norquetiapine in plasma and cerebrospinal fluid of schizophrenic patients treated with quetiapine: correlations to clinical outcome and HVA, 5-HIAA, and MHPG in CSF

This study investigated concentrations of quetiapine and norquetiapine in plasma and cerebrospinal fluid (CSF) in 22 schizophrenic patients after 4-week treatment with quetiapine (600 mg/d), which was preceded by a 3-week washout period. Blood and CSF samples were obtained on days 1 and 28, and CSF levels of homovanillic acid (HVA), 5-hydroxyindoleacetic acid (5-HIAA), and 3-methoxy-4-hydroxyphenylglycol (MHPG) concentrations were measured at baseline and after 4 weeks of quetiapine, allowing calculations of differences in HVA (ΔHVA), 5-HIAA (Δ5-HIAA), and MHPG (ΔMHPG) concentrations. Patients were assessed clinically, using the Positive and Negative Syndrome Scale (PANSS) and Clinical Global Impression Scale at baseline and then at weekly intervals. Plasma levels of quetiapine and norquetiapine were 1110 ± 608 and 444 ± 226 ng/mL, and the corresponding CSF levels were 29 ± 18 and 5 ± 2 ng/mL, respectively. After the treatment, the levels of HVA, 5-HIAA, and MHPG were increased by 33%, 35%, and 33%, respectively (P < 0.001). A negative correlation was found between the decrease in PANSS positive subscale scores and CSF ΔHVA (r(rho) = -0.690, P < 0.01), and the decrease in PANSS negative subscale scores both with CSF Δ5-HIAA (r(rho) = -0.619, P = 0.02) and ΔMHPG (r(rho) = -0.484, P = 0.038). Because, unfortunately, schizophrenic patients experience relapses even with the best available treatments, monitoring of CSF drug and metabolite levels might prove to be useful in tailoring individually adjusted treatments.

The Munich 15-year follow-up study (MUFUSSAD) on first-hospitalized patients with schizophrenic or affective disorders: comparison of psychopathological and psychosocial course and outcome and prediction of chronicity

Given the limited explanatory power of the available neurobiological findings, results of long-term follow-up studies should still be considered as one criterion among others in the development of psychiatric classification systems regarding schizophrenia and affective disorders. A total of 323 first hospitalized inpatients of the Psychiatric Department of the University Munich were recruited at index time and followed up after 15 years. The full follow-up evaluation including several standardized assessment procedures (AMDP, PANSS, SANS, DAS, GAS) could be performed in 197 patients. The patients originally diagnosed according to ICD-9 were re-diagnosed according to ICD-10 and DSM-IV, using SCID among others. Schizophrenic patients had a much poorer outcome than affective or schizoaffective patients in terms of negative syndrome, deficit syndrome, psychosocial impairments and GAS results, and a higher prevalence of a chronic course. The logistic regression analyses performed to find optimized predictor combinations for the prognosis of a chronic course found, for example, the total Strauss-Carpenter Scale score, male gender and several other psychopathological syndromes to be relevant predictors. The findings reflect some long-term related validity for the differentiation between schizophrenia and affective disorders. The Strauss-Carpenter Scale, male gender as well as several psychopathological syndromes are the most relevant predictors for chronicity.

The abilities of improved schizophrenia patients to work and live independently in the community: a 10-year long-term outcome study from Mumbai, India

BACKGROUND

The outcome of first episode schizophrenia has several determinants. Socioecological factors, particularly living conditions, migration, community and culture, not only affect the level of risk but also the outcome. Mega cities around the world show a unique socioecological condition that has several challenges for mental health. The present study reports on the long-term status of patients with schizophrenia in such a mega city: Mumbai, India.

AIM

This study aims to reveal the long-term outcome of patients suffering from schizophrenia with special reference to clinical symptoms and social functioning.

METHODS

The cohort for this study was drawn from a 10-year follow-up of first episode schizophrenia. Patients having completed 10 years of consistent treatment after first hospitalisation were assessed on psychopathological and recovery criteria. Clinical as well as social parameters of recovery were evaluated. Descriptive statistics with 95% confidence intervals are provided.

RESULTS

Of 200 patients recruited at the beginning of this study, 122 patients (61%) were present in the city of Mumbai at the end of 10-year follow-up study period. Among 122 available patients, 101 patients (50.5%) were included in the assessment at the end of 10-year follow-up study period, 6 patients (3.0%) were excluded from the study due to changed diagnosis, and 15 patients (7.5%) were excluded due to admission into long-term care facilities. This indicates that 107 out of 122 available patients (87.7%) were living in the community with their families. Out of 101 (50.5%) patients assessed at the end of 10 years, 61 patients (30.5%) showed improved recovery on the Clinical Global Impression Scale, 40 patients (20%) revealed no improvement in the recovery, 43 patients (72.9%) were able to live independently, and 24 patients (40%) were able to find employment.

CONCLUSION

With 10 years of treatment, the recovery rate among schizophrenia patients in Mumbai was 30.5%. Among the patients, 87.7% of patients lived in the community, 72.9% of patients lived independently, and 40% of patients obtained employment. However, 60% of patients were unable to return to work, which highlights the need for continued monitoring and support to prevent the deterioration of health in these patients. It is likely that socioecological factors have played a role in this outcome.

Defining and predicting functional outcome in schizophrenia and schizophrenia spectrum disorders

BACKGROUND

To assess criteria and to identify predictive factors for functional outcome. The criteria should cover all domains proposed by the Remission in Schizophrenia Working Group.

METHOD

PANSS ratings were used to evaluate the symptomatic treatment outcome of 262 inpatients with schizophrenia spectrum disorders within a naturalistic multicenter trial. Functional remission was defined as a GAF score >61 (Global Assessment of Functioning Scale), SOFAS score >61 (Social and Occupational Functioning Scale) and a SF-36 mental health subscore >40 (Medical Outcomes Study-Short Form Health Survey). Multivariate logistic regression and CART analyses were used to determine valid clinical and sociodemographic predictors.

RESULTS

In total, 52 patients (20%) fulfilled the criteria for functional remission, 125 patients (48%) achieved symptomatic resolution and when criteria for functional remission and symptomatic resolution were combined 33 patients (13%) achieved complete remission. Younger age, employment, a shorter duration of illness, a shorter length of current episode, less suicidality, and a lower PANSS negative and global subscore at admission were predictive of functional remission. The regression model showed a predictive value of more than 80%.

CONCLUSIONS

A significant association was found between functional remission and symptomatic resolution, indicating reasonable validity of the proposed definition for functional outcome. The revealed predictors for functional treatment outcome emphasize the need for psychosocial and vocational rehabilitation in schizophrenic patients.

Remission in schizophrenia: analysis in a naturalistic setting

OBJECTIVE

To investigate the recently defined Positive and Negative Syndrome Scale for Schizophrenia remission criteria in a naturalistic setting of psychotic patients; to identify causal factors that change remission status; and to validate the criteria against global indices of illness, cognitive functions, and social outcome.

METHODS

This was a longitudinal naturalistic study of 162 patients, diagnosed with schizophrenia or schizophrenia-related psychotic disorders (mean illness duration, 11 years) and treated with risperidone at study entry. Symptoms, drug treatment, cognitive function, and social outcome were measured at baseline and annually for 5 years. Remission was constructed retrospectively with only indirect data on stability over time.

RESULTS

At study entry, 40% of the patients with schizophrenia were in symptomatic remission, stabilizing between 55% and 60% after a few years. The need for hospitalization became less frequent over time; initially 31%, dropping to 7% by years 4 and 5. Many patients went in and out of remission. Remission was strongly associated with global indices of illness, with intact insight and with social outcome (except work/studies) but not with cognition or medication.

CONCLUSIONS

In spite of certain weaknesses of the study, we may conclude that current definition of remission is primarily a symptomatic measure, covering a subset of symptoms, some of which are not schizophrenia-specific. Although the definition may be clinically relevant, we must be aware of the risk that the connotation of the word could induce too much focus on symptom control.

Psychopathology and cognition in divergent functional outcomes in schizophrenia

Cognitive performance rather than symptoms, especially positive symptoms, is regarded as the primary predictor of functional outcome in schizophrenia. However, contradictory evidence exists and many studies fail to sample from the extremes of outcome measures. This study tested whether the differential importance assigned to symptoms and cognitive impairment is supportable in patients with high and low levels of community independence. Schizophrenia patients with highly unfavorable (n=24) and highly favorable (n=28) functional outcomes as defined by community support requirements were studied. Standard cognitive and psychopathology measures were analyzed using independent groups comparisons and outcome prediction with logistic regression methods. Symptom severity and cognitive data separately accounted for significant amounts of variance in community independence. Positive as well as negative symptoms, non-psychotic psychopathology and cognition generated large effect sizes between highly unfavorable and favorable outcome groups. The conditional validity of both overall psychopathology and positive symptoms was significant over and above the contribution of cognition to outcome prediction. Results suggest researchers may have underestimated the role of psychopathology in general and positive symptoms in particular as potential determinants of functional status in schizophrenia.

Do patients improve in general psychiatric outpatient care? Problem severity among patients and the effectiveness of a psychiatric outpatient unit

This study evaluated a routine psychiatric outpatient unit that admitted a variety of diagnoses and was staffed with a multi-professional team. The aim was to describe the problem severity among patients of a routine psychiatric outpatient unit in Sweden and to evaluate the statistical and clinical effectiveness of routine care assessed at the termination of treatment. Newly admitted patients were diagnosed according to the ICD-10 and completed questionnaires at the beginning and end of their treatment regarding symptoms (Brief Symptom Inventory) and interpersonal problems (Inventory of Interpersonal Problems); 98.6% of the patients belonged to the dysfunctional group at pre-treatment, showing that there were considerable sufferings among new patients. There were significant improvements in most of the variables. The effect size regarding symptoms (Global Severity Index) was d=0.76 and 0.43 in the interpersonal total score. No difference between different diagnostic groups was found. As for the clinical significant change, the results showed that 64.5% of the patients were improved regarding symptom remission but also that a considerable number of patients (60.5%) still belonged to the dysfunctional group after the treatment. The study indicates that the effectiveness of a routine psychiatric outpatient practice seems to be similar to results obtained from speciality research clinics and randomized controlled trial studies. However, the results also show that there is a considerable amount of patients still in the dysfunctional group after the treatment, a fact that implies that further improvements of the treatment could be made.

A symptom self-rating scale for schizophrenia (4S): psychometric properties, reliability and validity

The objective of the study was to validate a self-administrated symptom rating scale for use in patients with schizophrenia spectrum disorders by item analysis, exploration of factor structure, and analyses of reliability and validity. Data on 151 patients, initially treated by risperidone, obtained within the framework of a naturalistic Phase IV longitudinal study, were analysed by comparing patient and clinician ratings of symptoms, side-effects and global indices of illness. The Symptom Self-rating Scale for Schizophrenia (4S) is psychometrically adequate (item analysis, internal consistency, factor structure). Side-effect ratings were reliable. Symptom ratings displayed consistent associations with clinicians' ratings of corresponding symptom dimensions, suggesting construct validity. Patients had most difficulties assessing negative symptom items. Patients were well able to assess their own symptoms and drug side-effects. The factor structure of symptom ratings differs between patients and clinicians as well as how they construe global indices of illness. Clinicians focus on psychotic, patients on affective symptoms. Use of symptom self-ratings is one way to improve communication and thereby strengthen the therapeutic alliance and increase treatment adherence.

Nicotine use and its correlates in patients with psychosis

OBJECTIVE

To examine nicotine use and its correlates among psychotic patients.

METHOD

Longitudinal naturalistic study of 176 patients, diagnosed with schizophrenia or schizophrenia-related psychotic disorders, and treated with risperidone at study entry. Levels of nicotine use (smoking, snuffing) were measured along with other relevant ratings and measurements (symptoms, drug treatment, side effects, weight, cognitive functions and outcome) at baseline and once yearly for 5 years.

RESULTS

Nicotine use was twice as common as in the general population. Only few nicotine users had started after onset of psychoses. We could not find any differences among nicotine users and non-users in diagnosis, symptoms, side effects, weight, cognitive functions, personality and outcome, cross-sectionally and longitudinally, ruling against the 'self-medication' hypothesis.

CONCLUSION

A parsimonious interpretation of the findings is that patients suffering from psychosis fail to desist from nicotine rather than experience significant positive effects of the usage.

Limitations of current therapies: why do patients switch therapies?

The results of recent studies, including the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study, the Cost Utility of the Latest Antipsychotic Drugs in Schizophrenia Study (CUtLASS), the European Schizophrenia Outpatient Health Outcome (SOHO), and the Spanish EFESO study have given some insight into why, in the course of real-world treatment, patients with schizophrenia discontinue or ask to be switched to other medications. Disappointingly, these studies consistently demonstrate that there is not one answer for these patients. The data from these studies indicate that an individual approach to treatment is required, and by doing this the need to adjust medications in advance of problems may be addressed. A combination of knowledge of the potential impact of each antipsychotic, typical or newer, alongside a more informed view of quality of life needs for these patients, might be useful to maximise treatment compliance of the currently available treatment options - with the potential for a not inconsiderable impact on efficacy in schizophrenia.

Costs of schizophrenia during 5 years

OBJECTIVE

To explore the direct and indirect costs in a cohort of 225 risperidone-treated patients with schizophrenia followed up annually during 5 years.

METHOD

Data on costs for medication, hospitalization, sheltered living and productivity losses, as well as degree of social isolation, were collected.

RESULTS

The direct costs were dominated by hospitalization and sheltered living expenses, while drug costs only represented 7% of the direct costs. Indirect costs represented 43% of the total costs during the 5 years. About 12% worked full-time, and 12% worked part-time, implying large productivity losses. As a consequence of the national mental health care reform, a substantial shift of costs from hospital care to sheltered living took place on the national level, but the reduction of hospital days for the study patients over time was much larger suggesting that the switch from first to second generation compounds was therapeutically successful. A high degree of social isolation was seen, with more than 20% being completely without social contacts and 30% seeing friends/relatives less often than once a week.

CONCLUSION

The economic costs of schizophrenia are high and driven by the need for assisted living and hospitalizations, together with productivity losses. In addition, the intangible costs, such as social contacts, are also high.

Clinical decision-making during 5 years of antipsychotic treatment

OBJECTIVE

Explore how clinicians select drug treatment based on symptoms, side effects and patient factors, including patient participation in the process, and the association between these factors and attitudes towards drugs.

METHOD

A cohort of 166 patients initially treated with risperidone was followed with yearly assessments over 5 years. At the end of the study, 101 patients were evaluated of whom 58 were still treated with risperidone.

RESULTS

More women than men remained in the study, and on the initial medication. The most common reason for medication switch was lack of efficacy. Clinicians and patients agreed well in their global ratings of medication effects and side effects. Robust associations between switch decisions and patient characteristics including symptoms and side effects could not be identified. The effects of switches were rated as better by the clinicians than by the patients. Negative drug attitudes were associated with pronounced positive symptoms (threshold effect), whereas the corresponding association with 'lack of judgment and insight' was linear over the whole range.

CONCLUSION

The decision-making process appears to have many unknown components, and may benefit from more active patient involvement by using structured clinician and patient rating scales for monitoring the treatment. Such shared decision-making may improve compliance.