Achieving symptomatic remission in out-patients with schizophrenia--a naturalistic study with quetiapine

Symptomatic Remission Determines Functional Improvement and Quality of Life in Schizophrenia

INTRODUCTION

Schizophrenia is a chronic illness that negatively affects the quality of life and psychosocial functions. Defined criteria to assess remission in schizophrenia are considered to be useful in the long-term follow-up of patients and in discriminating diagnostic factors. This study investigated the quality of life and functionality in schizophrenia patients in symptomatic remission (R-Sch) and not in remission (Non-R-Sch).

METHODS

Sociodemographic data were collected for 40 R-Sch and 40 Non-R-Sch patients, and the following scales were administered: the Clinical Global Impression-Severity (CGI-S) Scale; Positive and Negative Syndrome Scale (PANSS), World Health Organization Quality of Life Questionnaire-Short Form, Turkish Version (WHOQOL-BREF-TR), Quality of Life Scale for Schizophrenia Patients (QLS), and Global Assessment of Functioning Scale (GAF).

RESULTS

The total and all subscale scores of PANSS and the CGI-S score were significantly lower in the R-Sch group than in the Non-R-Sch group, whereas the GAF scores and all subscales of QLS and WHOQOL-BREF-TR were significantly higher.

CONCLUSION

This study demonstrates that improvement in symptoms in schizophrenia patients improves quality and functionality in all areas of life, suggesting that an improvement in symptoms is the most important determinant of functional recovery in the treatment of schizophrenia.

Design and validation of standardized clinical and functional remission criteria in schizophrenia

BACKGROUND

International Remission Criteria (IRC) for schizophrenia were developed recently by a group of internationally known experts. The IRC detect only 10%-30% of cases and do not cover the diversity of forms and social functioning. Our aim was to design a more applicable tool and validate its use - the Standardized Clinical and Functional Remission Criteria (SCFRC).

METHODS

We used a 6-month follow-up study of 203 outpatients from two Moscow centers and another further sample of stable patients from a 1-year controlled trial of atypical versus typical medication. Diagnosis was confirmed by International Classification of Diseases Version 10 (ICD10) criteria and the Mini-International Neuropsychiatric Interview (MINI). Patients were assessed by the Positive and Negative Syndrome Scale, including intensity threshold, and further classified using the Russian domestic remission criteria and the level of social and personal functioning, according to the Personal and Social Performance Scale (PSP). The SCFRC were formulated and were validated by a data reanalysis on the first population sample and on a second independent sample (104 patients) and in an open-label prospective randomized 12-month comparative study of risperidone long-acting injectable (RLAI) versus olanzapine.

RESULTS

Only 64 of the 203 outpatients (31.5%) initially met the IRC, and 53 patients (26.1%) met the IRC after 6 months, without a change in treatment. Patients who were in remission had episodic and progressive deficit (39.6%), or remittent (15%) paranoid schizophrenia, or schizoaffective disorder (17%). In addition, 105 patients of 139 (51.7%), who did not meet symptomatic IRC, remained stable within the period. Reanalysis of data revealed that 65.5% of the patients met the SCFRC. In the controlled trial, 70% of patients in the RLAI group met the SCFRC and only 19% the IRC. In the routine treatment group, 55.9% met the SCFRC and only 5.7% the IRC. Results of the further independent sample demonstrated that 35% met the IRC, 65% the SCFRC, and 56% of patients met both the symptomatic and functional criteria. In the controlled trial of RLAI and olanzapine, 40% and 35% of patients, respectively, met the IRC, while 70% and 55%, respectively, met the SCFRC.

CONCLUSION

In schizophrenia outpatients, a greater proportion of stable cases is detected in remission by SCFRC in comparison with IRC. The SCFRC were more sensitive to the full spectrum of schizophrenia. The SCFRC appear to be valid as a tool and clinically useful as they produce a comprehensive assessment of treatment effectiveness for a wide range of patients.

Predictors of symptomatic remission in first-episode psychosis outpatients treated with quetiapine: a naturalistic study

OBJECTIVES

The aim of this naturalistic study was to assess course and predictors of symptomatic remission in outpatients with first-episode psychosis during quetiapine monotherapy.

METHODS

In 131 outpatients presenting with first-episode psychosis, socio-demographic and clinical variables including PANSS-8 and CGI-S scores were compared at baseline and follow-up between the subgroups with and without symptomatic remission during 12 weeks of flexible-dose treatment with quetiapine.

RESULTS

Logistic regression revealed a low degree of negative symptoms at baseline, younger age, shorter duration of psychotic episode, early treatment response, and the absence of concomitant diseases as predictors for symptomatic remission whereas general disease severity, PANSS-8 total score, gender, alcohol or substance abuse had no predictive value.

CONCLUSIONS

Our study underlines the predictive value of early treatment response and a low degree of negative symptoms in outpatients with first-episode psychosis. It also confirms the usability of the symptomatic remission criterion as a cross-sectional threshold criterion in clinical practice.

Effect of aripiprazole on verbal memory and fluency in schizophrenic patients : results from the ESCAPE study

BACKGROUND

Second-generation antipsychotics have gradually replaced first-generation antipsychotics as first-line treatment for patients with schizophrenia. Some positive effects on verbal cognition have been shown for the second-generation antipsychotics, but most studies are based on relatively small numbers of patients.

OBJECTIVE

In the frame of the prospective, multi-centre, open-label study ESCAPE (A Prospective, Multicenter, Open-Label Study to Evaluate the Effectiveness and the Effect on Cognitive Function of a Treatment With Aripiprazole in a Broad Range of Schizophrenic Patients; clinicaltrials.gov identifier NCT00329810) evaluating the effectiveness and effect on cognitive functioning of aripiprazole in schizophrenic patients, we conducted a post hoc analysis to examine changes in verbal cognition and investigate the predictive value of a cognitive improvement on quality of life.

STUDY DESIGN

This was a prospective, multi-centre, non-comparative, open-label study of aripiprazole in schizophrenic patients. At study enrolment, these patients were being treated with various first- or second-generation antipsychotics or were without previous antipsychotic treatment. On entering the study, all patients were treated with aripiprazole (Abilify(®); Otsuka, Tokyo, Japan) monotherapy; those patients who had received prior treatment with antipsychotics had their current drug(s) tapered off over a 2-week period. A post hoc analysis of the effect of aripiprazole on two verbal cognitive measures and their correlation with efficacy measures and quality of life was conducted.

SETTING

Patients with schizophrenia were recruited in 56 psychiatric hospitals.

PATIENTS

A total of 361 patients with schizophrenia, ranging from 18 to 65 years, entered the study.

INTERVENTION

Patients were treated with aripiprazole monotherapy at a dosage of 10-30 mg/day. Those who were receiving first- or second-generation antipsychotics at enrolment were switched to aripiprazole monotherapy by tapering off their current drug(s) over a 2-week period.

MAIN OUTCOME MEASURE

Physician- and patient-rated parameters were measured to gain a complete view of the effectiveness of aripiprazole on the Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q) at baseline and at weeks 4, 8 and 12 and on the Clinical Global Impression-Severity of Illness (CGI-S) scale at baseline and at weeks 1, 2, 4, 8 and 12. A secondary endpoint of verbal cognitive function was measured by the California Verbal Learning Test (CVLT) and the Verbal Fluency (VF) test at baseline and at weeks 4 and 12. The hypothesis of an improvement in verbal cognition and its predictive value on the quality of life was formulated during data collection.

RESULTS

238 patients completed the study. A significant improvement in verbal cognition was observed from week 4 with the long term free recall (LTFR) in the CVLT over the scheduled visits in the trial (F(2,519) = 29.67, p < 0.0001). For the phonemic (letter) subtest of the VF test, patients scored significantly better at week 12 in comparison with baseline (F(2,519) = 3.57, p = 0.0289). There was no significant effect on the semantic (categories) subtest of the VF test (F(2,518) = 0.57, p = 0.5614). Improvement in CGI-S scores at a particular moment in time predicted improvement in LTFR scores at that same moment (F(1,519) = 38.38, p < 0.0001) and in the phonemic (F(1,519) = 42.77, p < 0.0001) and semantic (F(1,518) = 67.43, p < 0.0001) subtests of the VF test. Similarly, CGI-S score improvement globally predicted quality-of-life improvement over visits. The Q-LES-Q scales leisure (F(1,144) = 14.03, p < 0.0001) and social relations (F(1,469) = 5.28, p = 0.0220) also directly correlated with verbal cognition.

CONCLUSION

The findings suggest that switching to, or initiating aripiprazole in schizophrenic patients results in improvement in verbal cognitive functioning. The observed improvement on quality of life is explained by the effect of aripiprazole on the CGI-S score, though the leisure and social relations scales of the Q-LES-Q also independently correlated with verbal fluency. Randomized, controlled, clinical trials of this effect of aripiprazole for selected patients are needed.

Remission and recovery and their predictors in schizophrenia spectrum disorder: results from a 1-year follow-up naturalistic trial

Remission and recovery are major outcome goals in schizophrenia yet their predictors have not been studied in detail. Therefore, 186 patients were examined regarding remission and recovery including their potential sociodemographic and clinical predictors 1 year after discharge. Remission was defined according to the consensus remission criteria and recovery following the definition by Liberman et al. (2002). Of the 186 patients 54% achieved remission and 26% recovery at the 1-year follow-up. The remission status at discharge was found to significantly influence remission and recovery at follow-up. A higher SOFAS score (P = 0.0002) as well as a positive attitude towards treatment at discharge (P = 0.0038) were identified to be significant predictors of remission at 1-year follow-up. Having a job (P = <0.0001) and being without pharmacological treatment at follow-up (P = 0.0113) were found to be significantly predictive of recovery. Our results underline the need to implement more specific treatment strategies to improve long-term outcome.

[Response and remission in schizophrenic subjects]

BACKGROUND

This naturalistic study investigates in detail symptom reduction during acute inpatient treatment (response), long-term symptom improvement in the post-acute phase (remission) and the rate of re-hospitalisations.

MATERIAL AND METHODS

A total of 183 patients were enrolled. Criteria for response were PANSS total score and syndrome reductions of 20, 30, 40 and 50%. Remission criteria employed were based on recommendations from Andreasen et al.

RESULTS

The average length of stay was 45.6 days (SD 42.7). PANSS total score response rates were found to be 63.9% for the 20% level and were reduced in the following consecutive levels by approximately 15%. Only 10.3% of the patients remitted during a 1-year follow-up period. At least one re-hospitalisation was reported for 43.9% of the subjects.

CONCLUSION

Compared to previous randomised and controlled trials, the rates of response and remission are significantly lower. In daily inpatient care, the chronic course of schizophrenia is far commoner than expected from previous reports.

Remission in schizophrenia: results of cross-sectional with 6-month follow-up period and 1-year observational therapeutic studies in an outpatient population

BACKGROUND

A standardized definition of remission criteria in schizophrenia was proposed by the International group of NC Andreasen in 2005 (low symptom threshold for the eight core Positive and Negative Syndrome Scale (PANSS) symptoms for at least 6 consecutive months).

METHODS

A cross-sectional study of remission rate, using a 6-month follow-up to assess symptomatic stability, was conducted in two healthcare districts (first and second) of an outpatient psychiatric service in Moscow. The key inclusion criteria were outpatients with an International Classification of Diseases, 10th edition (ICD-10) diagnosis of schizophrenia or schizoaffective disorder. Remission was assessed using modern criteria (severity and time criteria), PANSS and Global Assessment of Functioning (GAF). Patients who were stable but did not satisfied the symptomatic criteria were included in a further 1-year observational study, with the first group (first district) receiving risperidone (long-acting, injectable) (RLAI) and the second group (second district) continuing to receiving routine treatment. Symptoms were assessed with PANSS, social functioning with the personal and social performance scale, compliance with rating of medication influences scale, and extrapyramidal side effects with the Simpson-Angus scale.

RESULTS

Only 64 (31.5%) of 203 outpatients met the criteria for symptomatic remission in the cross-sectional study, but at the end of the 6-month follow-up period, 158 (77.8%) were stable (irrespective of remission status). Among these only 53 (26.1%) patients fulfilled the remission criteria. The observational study had 42 stable patients in the RLAI group and 35 in the routine treatment group: 19.0% in the RLAI group and 5.7% in the control group met remission criteria after 12 months of therapy. Furthermore, reduction of PANSS total and subscale scores, as well as improvement in social functioning, was more significant in the first group.

CONCLUSIONS

Only around one-quarter of our outpatient schizophrenic population met full remission criteria. Use of RLAI gave a better remission rate than achieved in standard care with routine treatment. Criteria for remission should take into account clinical course and functioning to support clinical care.

Differential effects of childhood abuse and neglect: mediation by posttraumatic distress in neurotic disorder and negative symptoms in schizophrenia?

Dissociation, though understood as a response to trauma, lacks a proven etiology. The assumption of a dose-response relationship between trauma, dissociation and Schneiderian symptoms led to the proposal of a dissociative subtype of schizophrenia characterized by severe child maltreatment, dissociation and psychosis. Child maltreatment and dissociation are common features of neurotic disorders as well, and the link between trauma, dissociation, and hallucinations is not specific for schizophrenia. This study compares childhood abuse and neglect, posttraumatic distress and adult dissociation in patients with psychotic vs. non-psychotic disorder. Thirty-five participants with non-psychotic disorder and twenty-five with schizophrenia were analyzed using the Scale for the Assessment of Positive Symptoms (SAPS), the Scale for the Assessment of Negative Symptoms (SANS), the Montgomery-Åsberg Depression Rating Scale (MADRS), the Posttraumatic Stress Diagnostic Scale PDS (PDS), the Childhood Trauma Questionnaire (CTO) and the Arbeitsgemeinschaft Methodik und Dokumentation in der Psychiatrie (AMDP)-module on dissociation. Trauma and clinical syndromes were compared by means of T-testing and logistic regression between 1) the diagnoses and 2) groups with and without post-traumatic stress disorder (PTSD), marked dissociation and psychotic symptoms. While non-psychotic disorder was related to abuse, schizophrenia showed an association with neglect. Childhood trauma predicted posttraumatic symptomatology and negative symptoms. Childhood abuse and neglect may effectuate different outcomes in neurotic and psychotic disorder. The underlying mechanisms, including dissociation, dovetail with cognitive, emotional and behavioural changes involved in depression, posttraumatic distress and chronic schizophrenia symptoms rather than being directly linked to trauma.