Fortnightly review. Treatment of schizophrenia

Pilot Evaluation of a Communication Skills Training Program for Psychiatry Residents Using Standardized Patient Assessment

OBJECTIVE

Mental health clinicians can experience difficulties communicating diagnostic information to patients and their families/carers, especially about distressing psychiatric disorders such as schizophrenia. There is evidence for the effectiveness of communication skills training (CST) for improving diagnostic discussions, particularly in specialties such as oncology, but only limited evidence exists about CST for psychiatry. This study evaluated a CST program specifically developed for psychiatry residents called ComPsych that focuses on conveying diagnostic and prognostic information about schizophrenia.

METHOD

The ComPsych program consists of an introductory lecture, module booklets for trainees, and exemplary skills videos, followed by small group role-plays with simulated patients (SPs) led by a trained facilitator. A standardized patient assessment (SPA) was digitally recorded pre- and post-training with a SP using a standardized scenario in a time-limited (15 min) period. Recorded SPAs were independently rated using a validated coding system (ComSkil) to identify frequency of skills used in five skills categories (agenda setting, checking, questioning, information organization, and empathic communication).

RESULTS

Thirty trainees (15 males and 15 females; median age = 32) undertaking their vocational specialty training in psychiatry participated in ComPsych training and pre- and post-ComPsych SPAs. Skills increased post-training for agenda setting (d = -0.82), while questioning skills (d = 0.56) decreased. There were no significant differences in any other skills grouping, although checking, information organization, and empathic communication skills tended to increase post-training. A dose effect was observed for agenda setting, with trainees who attended more CST sessions outperforming those attending fewer.

CONCLUSION

Findings support the generalization and translation of ComPsych CST to psychiatry.

Caring for people with schizophrenia: family carers' involvement with medication

Objective

To investigate carers' experiences of medication, and their involvement in managing medication, when caring for an adult family member with schizophrenia.

Method

In-depth, semi-structured interviews were conducted with 14 family carers who were identified through voluntary care groups of the National Schizophrenia Fellowship (NSF). Interviews were audiotape recorded and transcribed. Data were analysed by comparing transcripts to generate descriptive themes.

Setting

All but one of the carers were interviewed in their homes; the remaining carer was interviewed in the researcher's home.

Key findings

Carers acknowledged the importance of medication in stabilising their care-recipients' illness. However, they had also observed their care-recipients experiencing unexpected adverse effects of medication. As a result of these observations, carers experienced feelings of guilt and fear for having encouraged medication compliance. Not all carers were involved with their care-recipients' medication but a number of roles were described: facilitator, monitor, advocate and interventionist. Direct involvement with managing medication was identified as a source of conflict between some carers and their adult care-recipients. All carers reported unmet needs for information and support concerning their care-recipients' medication.

Conclusion

In this study, the degree of involvement that carers had with their care-recipients' medication varied. Direct involvement with medication was identified as a source of conflict between some carers and care-recipients. All carers expressed the unmet need to discuss their care-recipients' medication with a professional. Health professionals need to consider effective methods for contributing to this gap in routine service provision.

Clozapine-induced interstitial nephritis - a rare but important complication: a case report

Introduction

Given the limited range of effective drug treatments for patients with schizophrenia, increasing numbers of patients, often termed 'treatment-resistant' are prescribed clozapine. While the induction of neutropenia or agranulocytosis by clozapine is well appreciated, other rare potentially fatal adverse reactions may also occur including acute interstitial nephritis as reported in this case.

Case presentation

A 57-year-old Caucasian woman with treatment-resistant chronic schizophrenia developed acute renal failure following initiation of treatment with clozapine. The adverse reaction occurred after only four doses of the drug had been administered (titrated from 12.5 to 25 mg per day). After clozapine had been withdrawn, the patient's renal function returned to normal with no other changes to medication. The patient had been exposed to clozapine about 4 years previously when she had developed a similar reaction.

Conclusion

Renal reactions to clozapine are extremely rare but, if not recognized promptly, may prove fatal. Psychiatrists need to be aware of this possible complication when clozapine is initiated.

A mentally retarded patient with schizophrenia

Schizophrenia is one of the most incapacitating forms of mental disorder that runs a chronic and relapsing course. It typically starts in adolescence or early adulthood and can be life-long. It is more common in people with learning disabilities than in the general population. Its prodromal features include depression, anxiety, suspiciousness, social isolation and bizarre behaviour. It may result in significant functional, social and economic impairments. The care of patients with schizophrenia places a considerable burden on all carers including patient's family, health and social services. Treatment includes pharmacotherapy and psychosocial interventions. In this case report we describe a thirteen-year-old patient with schizophrenia who has a background history of mental retardation.

The clinical use of plasma clozapine levels in a maximum security setting

Background. Research suggests a correlation between clozapine dose, plasma level and therapeutic response. Plasma clozapine levels may, therefore, be useful in practice. Little evidence exists, however, on the indications for, and outcome of, levels being undertaken or their use in maximum security settings. Objective. To determine if plasma clozapine levels are useful in clinical practice by analysing their use at the maximum-security State Hospital, Carstairs. Methods. All plasma clozapine levels (until March 2004) undertaken at the State Hospital, clinical indication and outcome were analysed by retrospective case note analysis. These results were compared with the published literature. Results. A total of 140 plasma clozapine levels were analysed. The average level was 0.61 mg/l and dose was 622.9 mg/day. The indications for and consequences of levels are demonstrated. A positive correlation of 0.217 was calculated. Conclusion. This paper shows that plasma clozapine levels are most useful in managing side effects and suspected non-compliance. Plasma clozapine levels are, therefore, useful in clinical practice.

The European sertindole safety and exposure survey: a follow-up study of 8600 patients

BACKGROUND

A regulatory signal suggested that sertindole was associated with a 10-fold increased risk of death. This observational study aimed to identify deaths and their causes in patients treated with sertindole.

METHODS

Sertindole-treated patients in Germany, Austria, Belgium, Hungary, The Netherlands and the United Kingdom were identified and their vital status ascertained. Eventual cause of death and patient and treatment characteristics were ascertained. A nested case-control study compared on-treatment cardiac or unexplained deaths with randomly selected survivors matched on age and gender for potential risk factors.

RESULTS

Eight thousand six hundred eight patients were identified as having initiated treatment with sertindole, for a total 3819 person-years exposure. Thirty-five had died since (all-cause mortality rate 0.92 per 100 person-years exposed). Of these, 15 (43%) had been previously reported to the regulatory authorities. Eight deaths were suicides, of which 2 (25%) had been previously reported; 11 were cardiac deaths, of which 8 (73%) had been reported. On average, patients who died because of cardiac disorders were older, and patients who committed suicide were younger than the other patients who died. The nested case-control study revealed that patients receiving sertindole were at a higher risk of premature cardiac or unexplained death if they had hypertension or other cardiovascular disorders associated with diabetes or metabolic disorder.

CONCLUSION

Overall and cardiovascular death rates were similar or lower than those observed in premarketing clinical trials. There was a very high reporting rate of all-cause and cardiovascular deaths that could have contributed to the regulatory alert.

Effects of risperidone and quetiapine on cognition in patients with schizophrenia and predominantly negative symptoms

Evidence suggests that neurocognitive impairment is a key factor in the pathology of schizophrenia and is linked with the negative symptoms of the disease. In this study the effects of the atypical antipsychotics quetiapine and risperidone on cognitive function in patients with schizophrenia and with predominantly negative symptoms were compared. Patients were randomly assigned to double-blind treatment with quetiapine or risperidone for 12 weeks. Cognitive function was assessed at baseline, Week 6 and Week 12. Efficacy was assessed using the Positive and Negative Syndrome Scale (PANSS) and the Scale for the Assessment of Negative Symptoms (SANS) at baseline, Week 6 and Week 12. Extrapyramidal side-effects were assessed each week using the Simpson-Angus Scale (SAS), adverse events were recorded as additional indicators of tolerability throughout the trial. In total, 44 patients were enrolled in the study. Data from the 34 patients who completed cognitive assessments at two or more time points out of three (baseline, Week 6 and Week 12) are analysed here. Quetiapine improved significantly global cognitive index z-scores at both Week 6 (p<0.001 vs. baseline) and Week 12 (p<0.01 vs. baseline), whereas risperidone improved significantly global cognitive index z-scores at Week 12 (p<0.05). Between-group comparisons at Week 6 showed significantly greater improvements in working memory and verbal memory with quetiapine than risperidone (p<0.05) and a significantly greater improvement in reaction quality/attention with quetiapine than risperidone at Week 12 (p<0.05). Quetiapine and risperidone produced significant improvements from baseline in PANSS total (p<0.001) and subscale scores at Week 12. Significant improvements in SANS total score were also seen in both the quetiapine (p<0.001) and risperidone (p<0.01) groups at Week 12 compared with baseline. SAS scores, measuring the incidence of extrapyramidal side-effects, were higher in patients receiving risperidone compared with those receiving quetiapine, and significant differences were seen at Weeks 3, 4, 5 and 7. Both quetiapine and risperidone improved cognition according to changes in cognitive index scores from baseline to Week 12. These results suggest that quetiapine and risperidone provide valuable treatment options for patients with schizophrenia with predominantly negative symptoms. Also, the improvements in cognition following treatment with quetiapine and risperidone may enhance long-term outcomes for these patients.

Rising mental health costs: what are we getting for our money?

This synthesis of recent epidemiological and service use data concludes that, in aggregate, rising mental health spending since the early 1990s appear to be purchasing improvements in access to care and to represent a good value for society. However, there is also evidence of continuing waste and quality deficits. Although mental health faces some unique challenges, these patterns are more similar to than different from those seen in all of health care. These parallels suggest the importance of learning from and working with the broader health care system in improving the returns on U.S. mental health spending.

Ziprasidone therapy in elderly patients with psychotic mood disorders and Parkinson's disease

OBJECTIVE

To illustrate and discuss issues relevant to treatment of four elderly psychotic patients with multiple comorbidities, including a history of mood disorder and some level of movement disorder.

PARTICIPANTS

Four patients diagnosed with a major mood disorder and comorbid Parkinson's disease were treated successfully with adjunctive ziprasidone at doses of 80 to 160mg/d. Two of the patients had major depressive disorder, recurrent, with psychotic features (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition [DSM-IV] DSM-IV 296.34) and two had bipolar disorder, not otherwise specified (DSM-IV 296.8) and presented with psychotic and manic features. In three of the four patients, prior treatment with olanzapine or risperidone or both had failed to adequately control psychotic or manic symptoms; in some cases, the treatment worsened the Parkinson's symptoms.

RESULTS

In all four patients, ziprasidone greatly improved psychosis and mood disturbances within days. All of the patients were also treated with other medications for comorbidities; these included one or more antiparkinsonian drugs, antidepressants, and, in one case, quetiapine for insomnia. There were no observed serious adverse events, extrapyramidal side effects, or worsening of movement disorder symptoms with the administration of ziprasidone in these patients. All patients remained stable on ziprasidone combination therapy for as long as they were followed, which ranged from several months to three years.

CONCLUSION

These results indicate that ziprasidone may be an efficacious and well tolerated therapy in patients with comorbid Parkinson's disease and psychiatric illness.

Selective prescribing of atypical antipsychotics

PURPOSE

The aim of the study was to investigate whether the most recent introduced atypical antipsychotics olanzapine and risperidone were preferentially prescribed to patients susceptible to develop extrapyramidal side effects (EPS) and those not responding adequately to typical antipsychotics.

METHODS

Data were obtained from the Dutch PHARMO system that includes complete medication and hospital admission records of 675 000 residents of 14 Dutch cities. A total number of 129 new users of olanzapine and 142 new users of risperidone as well as 507 new users of typical antipsychotic drugs were identified from our database in the period of 1996-1998. The prevalence of markers of EPS, therapy resistance and therapy non-compliance were assessed in the period of 1 year prior to a new start of an antipsychotic.

RESULTS

New use of olanzapine and risperidone was significantly associated with previous use of other antipsychotics (odds ratio 4.0, 95%CI: 2.5-6.7 and odds ratio 3.0, 95%CI: 2.0-4.7, respectively). New use of olanzapine and risperidone was also associated with previous use of anticholinergic drugs compared to users of typical antipsychotics (over three and two times more, respectively). This effect diminished when adjusted for previous use of antipsychotics.

CONCLUSIONS

In particular olanzapine and also risperidone were selectively prescribed to patients formerly treated with other antipsychotics and to those susceptible for EPS. If not recognised or controlled for, observational studies comparing different antipsychotic drugs may produce biased results on efficacy or frequency of side effects for the different types of antipsychotics.

Risperidone in chronic schizophrenia: a detailed audit, open switch study and two-year follow-up of patients on depot medication

Little information exists on the medium- to long-term outcome of switching patients with schizophrenia from traditional depot to atypical oral antipsychotic agents. By detailed clinical audit, we identified a representative group of 102 patients of an Irish psychiatric service with DSM-IV chronic schizophrenia and on depot neuroleptics for a mean of 15 years. Of 69 eligible to participate, 33 entered a 6-month switch study of risperidone, with limited follow-up of consenters and non-consenters at 1 and 2 years. At 6 months, 23 of 33 were still on risperidone and had small significant improvements in clinical and extrapyramidal side effects, QOL and adjunct medication measures over baseline. At 12 months, 19 of 33 were still on risperidone, reducing to 13 of 33 at 2 years. At 2 years, of 32 surviving consenters to switch, 19 had suffered clinically detrimental events and were no longer on risperidone, compared to none of the 33 surviving non-consenters, who were all still on depot. These findings suggest that switching from depot to risperidone may encounter high rates of refusal and attrition subsequent to switch. While a majority of switched patients may improve to least 6 months, audit plus switch may have clinically unfavourable effects on others over a 2-year follow-up period [corrected].

Substance misuse in patients with schizophrenia: epidemiology and management

Substance misuse in individuals with schizophrenia is very common, especially in young men, in communities where use is frequent and in people receiving inpatient treatment. Problematic use occurs at very low intake levels, so that most affected people are not physically dependent (with the exception of nicotine). People with schizophrenia and substance misuse have poorer symptomatic and functional outcomes than those with schizophrenia alone. Unless there is routine screening, substance misuse is often missed in assessments. Service systems tend to be separated, with poor inter-communication, and affected patients are often excluded from services because of their comorbidity. However, effective management of these disorders requires a fully integrated approach because of the close inter-relationship of the disorders. Use of atypical antipsychotics may be especially important in this population because of growing evidence (especially on clozapine and risperidone) that nicotine smoking, alcohol misuse and possibly some other substance misuse is reduced. Several pharmacotherapies for substance misuse can be used safely in people with schizophrenia, but the evidence base is small and guidelines for their use are necessarily derived from experience in the general population.

Quetiapine: efficacy and tolerability in schizophrenia

Quetiapine, in common with clozapine, has a greater affinity for 5-HT(2) receptors than D(2) receptors and preclinical studies have consistently predicted efficacy against schizophrenia, with a low potential for causing extrapyramidal symptoms (EPS). In clinical trials, the efficacy of quetiapine was consistently superior to placebo and it was effective against both positive and negative symptoms. Quetiapine was also at least as effective as chlorpromazine or haloperidol in improving the symptoms of acute schizophrenia and moreover was associated with higher response rates. The consistent, placebo-level incidence of EPS associated with quetiapine in clinical trials was not seen with haloperidol. Thus, the combination of efficacy comparable to other antipsychotic agents, with an acceptable side effect and tolerability profile, provides support for the use of quetiapine as a first-line antipsychotic agent in the long-term treatment of schizophrenia.