The Brief Psychiatric Rating Scale. Dimension of schizophrenia--reliability and construct validity

Effect of Repeated Intravenous Esketamine on Adolescents With Major Depressive Disorder and Suicidal Ideation: A Randomized Active-Placebo-Controlled Trial

OBJECTIVE

Suicide is a major cause of death in adolescents with limited treatment options. Ketamine and its enantiomers have shown rapid anti-suicidal effects in adults with major depressive disorder (MDD), but their efficacy in adolescents is unknown. We conducted an active, placebo-controlled trial to determine the safety and efficacy of intravenous esketamine in this population.

METHOD

A total of 54 adolescents (aged 13-18 years) with MDD and suicidal ideation were included from an inpatient setting and randomly assigned (1:1) to receive 3 infusions of esketamine (0.25 mg/kg) or midazolam (0.02mg/kg) over 5 days, with routine inpatient care and treatment. Changes from baseline to 24 hours after the final infusion (day 6) in the scores of the Columbia Suicide Severity Rating Scale (C-SSRS) Ideation and Intensity (primary outcome) and the Montgomery-Åsberg Depression Rating Scale (MADRS, key secondary outcome) were analyzed using linear mixed models. In addition, the 4-week clinical treatment response was a key secondary outcome.

RESULTS

The mean changes in C-SSRS Ideation and Intensity scores from baseline to day 6 were significantly greater in the esketamine group than in the midazolam group (Ideation, -2.6 [SD = 2.0] vs -1.7 [SD = 2.2], p = .007; Intensity, -10.6 [SD = 8.4] vs -5.0 [SD = 7.4], p = .002), and the changes in MADRS scores from baseline to day 6 were significantly greater in the esketamine group than in the midazolam group (-15.3 [SD = 11.2] vs -8.8 [SD = 9.4], p = .004). The rates of antisuicidal and antidepressant responses at 4 weeks posttreatment were 69.2% and 61.5% after esketamine, and were 52.5% and 52.5% after midazolam, respectively. The most common adverse events in the esketamine group were nausea, dissociation, dry mouth, sedation, headache, and dizziness.

CONCLUSION

These preliminary findings indicate that 3-dose intravenous esketamine, added to routine inpatient care and treatment, was an effective and well-tolerated therapy for treating adolescents with MDD and suicidal ideation.

CLINICAL TRIAL REGISTRATION INFORMATION

A study to evaluate the efficacy and safety of Esketamine combined with oral antidepressants in the treatment of major depressive disorder with suicidal ideation; http://www.chictr.org.cn; ChiCTR2000041232.

DIVERSITY & INCLUSION STATEMENT

We worked to ensure that the study questionnaires were prepared in an inclusive way. The author list of this paper includes contributors from the location and/or community where the research was conducted who participated in the data collection, design, analysis, and/or interpretation of the work. We actively worked to promote sex and gender balance in our author group.

Functional network interactions in patients with schizophrenia with persistent auditory verbal hallucinations: A multimodal MRI fusion approach using three-way pICA

Over the last decade, there have been an increasing number of functional magnetic resonance imaging (fMRI) studies examining brain activity in schizophrenia (SZ) patients with persistent auditory verbal hallucinations (AVH) using either task-based or resting-state fMRI (rs-fMRI) paradigms. Such data have been conventionally collected and analyzed as distinct modalities, disregarding putative crossmodal interactions. Recently, it has become possible to incorporate two or more modalities in one comprehensive analysis to uncover hidden patterns of neural dysfunction not sufficiently captured by separate analysis. A novel multivariate fusion approach to multimodal data analysis, i.e., parallel independent component analysis (pICA), has been previously shown to be a powerful tool in this regard. We utilized three-way pICA to study covarying components among fractional amplitude of low-frequency fluctuations (fALFF) for rs-MRI and task-based activation computed from an alertness and a working memory (WM) paradigm of 15 SZ patients with AVH, 16 non-hallucinating SZ patients (nAVH), and 19 healthy controls (HC). The strongest connected triplet (false discovery rate (FDR)-corrected pairwise correlations) comprised a frontostriatal/temporal network (fALFF), a temporal/sensorimotor network (alertness task), and a frontoparietal network (WM task). Frontoparietal and frontostriatal/temporal network strength significantly differed between AVH patients and HC. Phenomenological features such as omnipotence and malevolence of AVH were associated with temporal/sensorimotor and frontoparietal network strength. The transmodal data confirm a complex interplay of neural systems subserving attentional processes and cognitive control interacting with speech and language processing networks. In addition, the data emphasize the importance of sensorimotor regions modulating specific symptom dimensions of AVH.

Family Psycho-Social Involvement Intervention for severe mental illness in Uganda

Background

Treatment rates for severe mental illness (SMI) are low in low- and middle-income countries because of limited resources. Enlisting family support could be effective and low cost in improving patient outcomes.

Aim

The article assess the feasibility, acceptability and estimates of efficacy of Family Psychosocial Involvement Intervention (FAPII) for patients with SMI.

Setting

Masaka Regional Referral Hospital and Mityana District Hospital in Uganda.

Methods

This was a controlled pilot study with two sites randomly assigned as intervention and control. Thirty patients each with one or two family members and six mental health professionals were recruited at the intervention site. Five patients, their family members and two mental health professionals met monthly for 6 months to discuss pre-agreed mental health topics. Patient outcomes were assessed at baseline, 6- and 12-months and analysed using paired t-tests. The trial was prospectively registered (ISRCTN25146122).

Results

At 6 and 12 months, there was significant improvement in the QoL in the intervention group compared to the control (p = 0.001). There was significant symptom reduction in the intervention group at 6 and 12 months (p < 0.001). Family Psychosocial Involvement Intervention affected better treatment adherence at 6 and 12 months (p = 0.035 and p < 0.001, respectively) compared to the control arm.

Conclusion

Family Psychosocial Involvement Intervention improved QoL, medication adherence, reduced stigma and symptoms among patients with SMI. The authors recommend involving families in the care of patients with SMI in Uganda, with FAPII employing culturally sensitive psychotherapy.

Contribution

The results support involvement of family in the care of patients with SMI.

Effects of Ziprasidone or Haloperidol on Theory of Mind in Patients With Schizophrenia: A 16-week Pilot Trial

OBJECTIVES

Schizophrenia is associated with impairment in theory of mind (ToM), which is defined as the ability to make judgments about mental states and is related to medial prefrontal cortical activity. Ziprasidone, but not haloperidol, is known to have a protective effect in the medial prefrontal cortex. Thus, we hypothesized that these 2 drugs would have different efficacy in improving ToM task performance in patients with schizophrenia.

METHODS

Patients with a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnosis of schizophrenia matched for sex, duration of illness, and education were randomized to receive ziprasidone (n=30) or haloperidol (n=30). All patients were assessed using the Positive and Negative Syndrome Scale and the Personal and Social Functioning Scale. ToM was assessed using a first-order false belief task, a second-order false belief task, the faux-pas task, and the Reading the Mind in the Eyes Task, in order of developmental complexity and difficulty. The primary outcome was change in ToM performance from baseline to 16 weeks of treatment.

RESULTS

For the first-order false belief task, there were no significant differences between the groups (P>0.05). For the second-order false belief task, the interaction effect was significant (P<0.05), and the simple effect of time showed a significant difference only in the ziprasidone group (P<0.001). For the faux-pas task, the interaction effect was not significant (P>0.05). For the Reading the Mind in the Eyes Task, the interaction effect was significant (P<0.05), and the simple effect of time showed a significant difference only in the ziprasidone group (P<0.001). The Positive and Negative Syndrome Scale results were similar between the groups. The ziprasidone group performed better than the haloperidol group on the Personal and Social Functioning Scale. There were no major safety concerns or adverse events.

CONCLUSIONS

The findings of this study suggest that ziprasidone could improve ToM and might be superior to haloperidol for improving complex ToM as well as personal and social functioning in patients with schizophrenia.

TRIAL REGISTRATION CHINESE CLINICAL TRIAL REGISTER

ChiCTR2200060542.

Attenuated niacin response is associated with a subtype of first-episode drug-naïve psychosis characterized as serious negative symptoms

Although the phenomenon of attenuated niacin response (ANR) has been widely replicated in some patients with first-episode psychosis (FEP), its relevance to the negative symptoms (NS) of psychosis remains unclear. Total of 240 patients with drug-naïve FEP and 101 healthy controls (HCs) were recruited, and 209 were followed up for 1 year. Psychotic symptoms were assessed using the Positive and Negative Syndrome Scale (PANSS), and niacin-induced responses were measured using laser Doppler flowmetry. We calculated the log-transform EC50 [concentration of methyl nicotinate required to elicit a half-maximal blood flow (MBF) response] and MBF values. Core-NS was generated by factor analysis of the PANSS-NS subscale and cluster analysis to produce subtypes. Significant differences were found in the log10 (EC50) values between the FEP and HC groups (p < 0.001), supporting the ANR in patients with FEP. A higher NS severity was found in the ANR subgroup than that in other patients. Factor analysis determined that a two-dimensional model included core NS and rigidity of thinking. The log10 (EC50) value was significantly associated with only the core NS. Cluster analysis revealed three subtypes-36.7% (cluster-1, n = 88), 16.7% (cluster-2, n = 40), and 46.7% (cluster-3, n = 112). Cluster-2 characterized by extensive NS appeared to have a more remarkable ANR and less symptomatic improvement than those with other clusters during follow-up. No significant changes were found in the niacin response trajectories between the baseline and follow-up. Our findings indicate a significant correlation between ANR and core NS in patients with FEP. ANR may be a potential biomarker for certain subtypes with NS-dominated characteristics and poor symptomatic remission.

Replication of the abnormal niacin response in first episode psychosis measured using laser Doppler flowmeter

INTRODUCTION

Impaired sensitivity of the skin flush response to niacin is found in approximately 30% of patients with schizophrenia. Although the niacin response abnormality (NRA) may serve as a useful endophenotype for schizophrenia, few studies have directly replicated NRA in patients with first-episode psychosis (FEP).

METHODS

In total, 204 patients with FEP, 16 with psychotic mood disorder (PMD), and 68 healthy controls (HC) were included. The log₁₀ (EC₅₀ ) values represent the concentration of methyl nicotinate required to elicit a half-maximal blood flow (MBF) response, and the MBF value was calculated. The NRA was defined as having log₁₀ (EC₅₀ ) molar value above the 90% and an MBF value below the 60% of those in the HC group.

RESULTS

In total, 13.7% of the FEP, 12.5% of the PMD, and 7.4% of the HC group met the definition of NRA. Significant differences were found in the log₁₀ (EC₅₀ ) values between the FEP and HC groups (p = .014) and in the MBF between the FEP and PMD groups (p = .011). Patients with FEP and NRA had more severe negative symptoms than those with a normal niacin response.

DISCUSSION

These data represent the NRA in patients with FEP, defining a small subgroup of patients with early-phase psychosis possessing a clinically significant phospholipid-signaling defect.

Using Computational Modeling to Capture Schizophrenia-Specific Reinforcement Learning Differences and Their Implications on Patient Classification

BACKGROUND

Psychiatric diagnosis and treatment have historically taken a symptom-based approach, with less attention on identifying underlying symptom-producing mechanisms. Recent efforts have illuminated the extent to which different underlying circuitry can produce phenotypically similar symptomatology (e.g., psychosis in bipolar disorder vs. schizophrenia). Computational modeling makes it possible to identify and mathematically differentiate behaviorally unobservable, specific reinforcement learning differences in patients with schizophrenia versus other disorders, likely owing to a higher reliance on prediction error-driven learning associated with basal ganglia and underreliance on explicit value representations associated with orbitofrontal cortex.

METHODS

We used a well-established probabilistic reinforcement learning task to replicate those findings in individuals with schizophrenia both on (n = 120) and off (n = 44) antipsychotic medications and included a patient comparison group of bipolar patients with psychosis (n = 60) and healthy control subjects (n = 72).

RESULTS

Using accuracy, there was a main effect of group (F3,279 = 7.87, p < .001), such that all patient groups were less accurate than control subjects. Using computationally derived parameters, both medicated and unmediated individuals with schizophrenia, but not patients with bipolar disorder, demonstrated a reduced mixing parameter (F3,295 = 13.91, p < .001), indicating less dependence on learning explicit value representations as well as greater learning decay between training and test (F1,289 = 12.81, p < .001). Unmedicated patients with schizophrenia also showed greater decision noise (F3,295 = 2.67, p = .04).

CONCLUSIONS

Both medicated and unmedicated patients showed overreliance on prediction error-driven learning as well as significantly higher noise and value-related memory decay, compared with the healthy control subjects and the patients with bipolar disorder. Additionally, the computational model parameters capturing these processes can significantly improve patient/control classification, potentially providing useful diagnosis insight.

Vitamin D Deficiency and Risk Factors Related to Acute Psychiatric Relapses in Patients with Severe Mental Disorders: A Preliminary Study

Previous studies have indicated that vitamin (Vit) D deficiency is frequent in psychiatric patients, regardless of diagnostic category. We aimed to assess whether acute psychiatric relapses in inpatients was associated with Vit D deficiency compared to stabilized outpatients. The cohort (152 total patients, 75 males and 77 females) had a mean age of 47.3 ± 14.4 years at admission and was grouped according to psychiatric diagnosis. Psychopathological symptom severity was assessed by the Brief Psychiatric Rating Scale (BPRS), a multidimensional symptom inventory. Total calcium serum levels were measured using standard laboratory methods, while plasma levels of 25-OH-Vit D and parathyroid hormone (PTH) were measured by automated chemiluminescence immunoassays. The psychiatric inpatient subgroup showed a significant difference in serum levels of 25-OH-Vit D and PTH (p < 0.001). Correlation analysis between serum levels of 25-OH-Vit D and BPRS total and subitem scores indicated a significantly negative relationship. In addition, linear regression analysis evidenced that the inpatient condition might predict low PTH and 25-OH-Vit D serum levels. Hospitalized psychiatric patients are at increased risk for Vit D deficiency regardless of their diagnostic categories. The mechanism underlying the association between acute psychiatric relapses and Vit D deficiency remains unclear. Therefore, screening for Vit D deficiency should pertain to the health assessment of patients with major psychiatric disorders.

Intestinal Microbes in Patients With Schizophrenia Undergoing Short-Term Treatment: Core Species Identification Based on Co-Occurrence Networks and Regression Analysis

Schizophrenia, a common mental disorder, has a tremendous impact on the health and economy of people worldwide. Evidence suggests that the microbial-gut-brain axis is an important pathway for the interaction between the gut microbiome and the development of schizophrenia. What is not clear is how changes in the gut microbiota composition and structure during antipsychotic treatment improve the symptoms of schizophrenia. In this study, 25 patients with schizophrenia were recruited. Their fecal samples were collected before and after hospital treatment for 14–19 days. The composition and structure of the intestinal microbiota were evaluated by 16S rRNA sequencing analysis, and the results showed significant differences in fecal microbiota before and after treatment. Firmicutes (relative abundances of 82.60 and 86.64%) and Gemminger (relative abundances of 14.17 and 13.57%) were the first dominant species at the phylum and genus levels, respectively. The random forest algorithm and co-occurrence network analysis demonstrated that intestinal flora (especially the core species ASV57) could be used as biomarkers to distinguish different clinical states and match treatment regimens accordingly. In addition, after fecal microbiota transplantation, antibiotic-treated recipient mice showed multiple behavioral improvements. These included decreased psychomotor hyperactivity, increased social interaction, and memory. In conclusion, this study suggests that differences in the composition and structure of gut microbiota after treatment are associated with the development and severity of schizophrenia. Results may provide a potential target for the treatment of this disorder.

Advancing the Science of Recovery: The Utility of the Recovery Assessment Scale in the Prediction of Self-Directed Health and Wellness Outcomes in Adults with a Diagnosis of a Serious Mental Illness

Adults with serious mental illness commonly experience comorbid chronic physical conditions and experience a reduced life expectancy of 10-25 years compared to the general population (Saha et al. in Arch Gen Psychiatry 64(10):1123-31.  2007; Hayes et al. in Acta Psychiatr Scand 131(6):417-25. 2015; Walker et al. in JAMA Psychiatry 72(4):334-41. 2015). Dimensions of personal recovery may have real-world implications that extend beyond functional and mental health outcomes to impact the self-directed health and wellness of adults with serious mental illness. This study examined the predictive utility of the Recovery Assessment Scale with respect to medical self-efficacy, self-management, psychiatric symptoms, and community functioning for adults with serious mental illness. Data were derived from a secondary analysis of baseline and 10-month data collected from a randomized control trial with adults aged 18 years and older with a diagnosis of bipolar disorder, schizoaffective disorder, schizophrenia, or major depressive disorder (N=56). A linear regression was conducted to examine the predictive value of total baseline RAS scores on self-efficacy at 10 months while controlling for study group. This model significantly predicted self-efficacy (F (2, 53) = 13.28, p < .001) and accounted for 36.1% of the variance. Total baseline RAS scores significantly predicted self-efficacy (β = 059, p < .001); specifically, higher baseline RAS scores were associated with greater self-efficacy. A greater degree of recovery may facilitate greater medical self-efficacy in managing chronic disease in people diagnosed with a serious mental illness. Future intervention approaches may consider recovery-focused therapeutic targets such as peer support to promote self-efficacy to manage chronic diseases in people with serious mental illness.

The effect on relapse rate and psychiatric symptomatology: Switching a combination of first- and second-generation antipsychotic polypharmacy to antipsychotic monotherapy in long-term inpatients with schizophrenia and related disorders. A pragmatic randomized open-label trial (SwAP trial)

BACKGROUND

There is little evidence to support the use of antipsychotic polypharmacy, and there are concerns about safety and side effects. Nonetheless, it is commonly used in the treatment of long-term inpatients with schizophrenia. This study investigated the effects of switching from a combination of first- and second-generation antipsychotics (FGA and SGA) to monotherapy (FGA or SGA) on relapse rates and psychiatric symptomatology.

METHODS

Institutionalized patients with chronic psychotic disorders using a combination of SGA and FGA (n = 136) participated in a randomized open-label trial. The SWITCH group discontinued either FGA or SGA, the STAY group continued combination treatment. Relapse and psychotic symptoms were measured at baseline and during follow-up at 3, 6, and 9 months. Psychiatric symptomatology was measured using the Brief Psychiatric Rating Scale (BPRS). Relapse was defined as (i) an increase in BPRS score of at least 2 points on any item, or (ii) an increase of at least 4 points in total BPRS score and an adjustment of antipsychotics.

RESULTS

A logistic regression model, corrected for sex, showed that the probability of relapse was significantly lower in the SWITCH group: 0.29 (95% CI 0.13-0.62). The protective effect of switching to monotherapy was attributable to patients continuing clozapine as monotherapy. For patients who did not experience a relapse nor dropped out, BPRS total scores decreased significantly more in the SWITCH group (p = 0.0001).

CONCLUSION

Switching from a combination of FGA and SGA to monotherapy in long-term inpatients does not increase the relapse rate and may even reduce it.

A Pilot Study of Switching Electroconvulsive Therapy for Patients With Treatment Resistant Schizophrenia or Mood Disorder

OBJECTIVES

Switching of ECT electrode modality is commonly done in clinical practice but outcomes are unclear. We aimed to compare the clinical outcomes between ECT modality switchers and nonswitchers in a large tertiary psychiatric institution over 1 year.

METHODS

Brief Psychiatric Rating Scale (BPRS), Montgomery-Åsberg Depression Rating Scale (MADRS) and Montreal Cognitive Assessment (MoCA) were used to assess symptoms and cognition. General linear regression was utilized to compare the change of BPRS or MADRS and MoCA score among switchers vs nonswitchers.

RESULTS

21.5% of 209 patients switched ECT. Baseline BPRS scores were lower among nonswitchers. Response rate in schizophrenia, depression and mania were higher for nonswitchers (69.6%, 81.35% and 84.8% respectively / 9.2 (SD 3.3) sessions) compared to switchers (53.8%, 0% and 66.7% respectively / 10.6 (SD 4.5) sessions). Most common ECT switches were Bifrontal (BF) to Bitemporal (BT) (schizophrenia), UB RUL (ultrabrief right unilateral) to BT (depression), and UB RUL to BT / BF (mania). There was no significant difference in the change of BPRS and MoCA scores between nonswitchers and switchers. However, there was significantly more improvement of MADRS scores among nonswitchers [adjusted mean ± SE: (-26.4 ± 2.8)] compared with switchers (-10.6) ±6.6).

CONCLUSIONS

ECT switching was commonly done and may result in better or worse outcomes than not switching depending on diagnosis. Controlled trials are required to address this urgent clinical issue.

Associations between symptom severity and well-being among Thai patients with schizophrenia: a cross-sectional analytical study

BACKGROUND

Severity of symptoms in patients with schizophrenia is a determinant of patient's well-being, but evidence in low- and middle-income countries is limited. We aimed to measure the symptom severity using objective measurements, the Brief Psychiatric Rating Scale (BPRS) and Clinical Global Impression-Severity scale (CGI-S), and their associations with well-being in patients with schizophrenia.

METHODS

Patients with schizophrenia aged ≥18 years, without active psychosis including no history of hospitalization within the last 6 months, were included. Symptom severity was measured by the clinicians using BPRS and CGI-S. The patients' well-being was assessed by self-report using the Subjective Well-being under Neuroleptic treatment scale (SWN) as continuous and binary outcomes (categorized into adequate or poor well-being). Correlations between symptom severity (BPRS and CGI-S scores) and well-being (SWN score) were analyzed using Pearson's correlation. Association between well-being status and BPRS was analyzed using multivariate logistic regression.

RESULTS

Of 150 patients, BPRS and CGI-S were inversely correlated with SWN score (r = - 0.47; p < 0.001 and - 0.21; p < 0.01, respectively). BPRS Affect domain had the highest correlation with SWN (r = - 0.51, p < 0.001). In multivariate logistic regression, BPRS score and being unemployed were associated with poor well-being status (adjusted OR 1.08; 95%CI 1.02-1.14; p = 0.006, and 4.01; 95%CI 1.38-11.7; p = 0.011, respectively).

CONCLUSION

Inverse relationships between symptom severity and well-being score were found. Higher BPRS Affect domain was significantly associated with lower patients' well-being. The use of BPRS tool into routine clinical practice could serve as an adjunct to physician's clinical evaluation of patients' symptoms and may help improve patient's well-being. Further research on negative symptoms associated with well-being is required.

A Test-Retest Reliability Generalization Meta-Analysis of Judgments Via the Policy-Capturing Technique

Policy capturing is a widely used technique, but the temporal stability of policy-capturing judgments has long been a cause for concern. This article emphasizes the importance of reporting reliability, and in particular test-retest reliability, estimates in policy-capturing studies. We found that only 164 of 955 policy-capturing studies (i.e., 17.17%) reported a test-retest reliability estimate. We then conducted a reliability generalization meta-analysis on policy-capturing studies that did report test-retest reliability estimates—and we obtained an average reliability estimate of .78. We additionally examined 16 potential methodological and substantive antecedents to test-retest reliability (equivalent to moderators in validity generalization studies). We found that test-retest reliability was robust to variation in 14 of the 16 factors examined but that reliability was higher in paper-and-pencil studies than in web-based studies and was higher for behavioral intention judgments than for other (e.g., attitudinal and perceptual) judgments. We provide an agenda for future research. Finally, we provide several best-practice recommendations for researchers (and journal reviewers) with regard to (a) reporting test-retest reliability, (b) designing policy-capturing studies for appropriate reportage, and (c) properly interpreting test-retest reliability in policy-capturing studies.

Candidate Factors Maintaining Social Anxiety in the Context of Psychotic Experiences: A Systematic Review

Social anxiety is common in psychosis and associated with impaired functioning, poorer quality of life, and higher symptom severity. This study systematically reviewed factors maintaining social anxiety in people with attenuated, transient, or persistent psychotic experiences. Other correlates of social anxiety were also examined. MEDLINE, Embase, CENTRAL, and PsycINFO were searched for relevant literature up to October 19, 2020. Forty-eight articles were eligible for narrative synthesis: 38 cross-sectional studies, 8 prospective studies, 1 uncontrolled trial, and 1 qualitative study. From 12060 participants, the majority was general population (n = 8771), followed by psychosis samples (n = 2532) and those at high risk of psychosis (n = 757). The methodological quality and risk of bias were assessed using the Mixed Methods Appraisal Tool. Ninety percent of studies were rated as high to very-high quality. Poorer quality studies typically failed to adequately control for confounds and provided insufficient information on the measurement validity and reliability. Prominent psychological factors maintaining social anxiety included self-perceptions of stigma and shame. Common correlates of social anxiety included poorer functioning and lower quality of life. In conclusion, stigma and shame could be targeted as a causal mechanism in future interventional studies. The integration of findings from this review lead us to propose a new theoretical model to guide future intervention research.

Predicting individual improvement in schizophrenia symptom severity at 1-year follow-up: Comparison of connectomic, structural, and clinical predictors

In a machine learning setting, this study aims to compare the prognostic utility of connectomic, brain structural, and clinical/demographic predictors of individual change in symptom severity in individuals with schizophrenia. Symptom severity at baseline and 1-year follow-up was assessed in 30 individuals with a schizophrenia-spectrum disorder using the Brief Psychiatric Rating Scale. Structural and functional neuroimaging was acquired in all individuals at baseline. Machine learning classifiers were trained to predict whether individuals improved or worsened with respect to positive, negative, and overall symptom severity. Classifiers were trained using various combinations of predictors, including regional cortical thickness and gray matter volume, static and dynamic resting-state connectivity, and/or baseline clinical and demographic variables. Relative change in overall symptom severity between baseline and 1-year follow-up varied markedly among individuals (interquartile range: 55%). Dynamic resting-state connectivity measured within the default-mode network was the most accurate single predictor of change in positive (accuracy: 87%), negative (83%), and overall symptom severity (77%) at follow-up. Incorporating predictors based on regional cortical thickness, gray matter volume, and baseline clinical variables did not markedly improve prediction accuracy and the prognostic utility of these predictors in isolation was moderate (<70%). Worsening negative symptoms at 1-year follow-up were predicted by hyper-connectivity and hypo-dynamism within the default-mode network at baseline assessment, while hypo-connectivity and hyper-dynamism predicted worsening positive symptoms. Given the modest sample size investigated, we recommend giving precedence to the relative ranking of the predictors investigated in this study, rather than the prediction accuracy estimates.

The influence of temperament and character on functioning and aspects of psychological health among people with schizophrenia

Research findings that link personality factors to functioning and symptoms in schizophrenia are inconsistent, and further studies are needed within the area. The purpose of this study was to investigate how personality, as measured by the Temperament and Character Inventory (TCI), was related to demographic factors, subtypes of diagnoses, level of functioning, and aspects of psychological health, including sense of coherence, perceived control, and self-esteem, among people with schizophrenia. Subjects were 104 individuals, aged 20–55 years, in psychiatric outpatient care. The results indicated that personality was not related to subtypes of diagnoses or demographic characteristics of the respondents, but to level of functioning and all aspects of psychological health. Especially self-directedness distinguished three groups of functioning and was highly correlated with the different aspects of psychological health. The article discusses how knowledge of schizophrenic patients’ personality structure might be used for tailoring psychiatric treatments.

Clinical target syndromes in psychiatry: latent structure analysis versus factor analysis

The algorithms for the demonstration of shared phenomenology of psychiatric syndromes in DSM-III are resistant to quantification. In contrast, the rating scale approach quantifies clinical target syndromes in psychiatry. The two most useful statistical models for quantifying shared phenomenology by symptom rating scales have been reviewed; namely factor analysis and latent structure analysis. Results have shown that factor analysis has demonstrated dimensions of dementia, delirium, schizophrenia, mania, outward aggression, depression and anxiety. Latent structure analysis has confirmed that the items of brief rating scales (such as the Melancholia Scale) are additively related implying that their total scores are sufficient statistics for the measurement of these factors or dimensions. Latent structure analysis should be considered as a psychometric “glasnost” compared to algorithm-resistant logic of quantification in DSM-III.

Structure/function interrelationships in patients with schizophrenia who have persistent auditory verbal hallucinations: A multimodal MRI study using parallel ICA

There is accumulating neuroimaging evidence for both structural and functional abnormalities in schizophrenia patients with persistent auditory verbal hallucinations (AVH). So far, the direct interrelationships between altered structural and functional changes underlying AVH are unknown. Recently, it has become possible to reveal hidden patterns of neural dysfunction not sufficiently captured by separate analysis of these two modalities. A data-driven fusion method called parallel independent component analysis (p-ICA) is able to identify maximally independent components of each imaging modality as well as the link between them. In the present study, we utilized p-ICA to study covarying components among gray matter volume maps computed from structural MRI (sMRI) and fractional amplitude of low-frequency fluctuations (fALFF) maps computed from resting-state functional MRI (rs-fMRI) data of 15 schizophrenia patients with AVH, 16 non-hallucinating schizophrenia patients (nAVH), and 19 healthy controls (HC). We found a significant correlation (r = 0.548, n = 50, p < .001) between a sMRI component and a rs-fMRI component, which was significantly different between the AVH and non AVH group (nAVH). The rs-fMRI component comprised temporal cortex and cortical midline regions, the sMRI component included predominantly fronto-temporo-parietal regions. Distinct clinical features, as measured by the Psychotic Symptoms Rating Scale (PSYRATS), were associated with two different modality specific rs-fMRI components. There was a significant correlation between a predominantly parietal resting-state network and the physical dimension of PSYRATS and the posterior cingulate/temporal cortex network and the emotional dimension of PSYRATS. These data suggest AVH-specific interrelationships between intrinsic network activity and GMV, together with modality-specific associations with distinct symptom dimensions of AVH.

Dying Too Soon: Excess Mortality in Severe Mental Illness

Aims: We aimed to identify baseline predictors of mortality in patients with a severe mental illness (SMI) over a 6-year period and to describe mortality rates as standardised mortality ratios (SMRs). We hypothesised that cardiovascular diseases, older age, cigarette smoking, more severe psychiatric symptoms and more severe psychotropic side effects, and alcohol or drug use were independent risk factors for mortality. Method: Medical examinations were conducted at baseline in a cohort of 322 SMI patients. SMRs were estimated after 6 years and an evaluation was made of the impact of a wide range of variables on survival time. Results: Almost 11% of the SMI patients had died at the end of the study period. All-cause SMRs were 4.51 (95% CI 3.07-5.95) for all SMI patients (4.89, 95% CI 2.97-6.80 for men, and 3.94, 95% CI 1.78-6.10 for women). Natural causes accounted for 86% of excess mortality and unnatural causes for 14%. Cardiovascular disease was a major contributor to this excess mortality. Multivariate Cox regression analyses showed that premature death was associated with a longer history of tobacco use (HR: 1.03, 95% CI 1.02-1.03) and more severe symptoms of disorganisation (HR: 2.36, 95% CI 2.21-2.52). Conclusions: The high SMR and the incidence of cardiovascular disease-related death in SMI patients in our study justify concern. This study underscores the urgent need for interventions to reduce excess mortality in patients with SMI.

Resting-state functional brain networks in first-episode psychosis: A 12-month follow-up study

INTRODUCTION

Schizophrenia is increasingly conceived as a disorder of brain network connectivity and organization. However, reports of network abnormalities during the early illness stage of psychosis are mixed. This study adopted a data-driven whole-brain approach to investigate functional connectivity and network architecture in a first-episode psychosis cohort relative to healthy controls and whether functional network properties changed abnormally over a 12-month period in first-episode psychosis.

METHODS

Resting-state functional connectivity was performed at two time points. At baseline, 29 first-episode psychosis individuals and 30 healthy controls were assessed, and at 12 months, 14 first-episode psychosis individuals and 20 healthy controls completed follow-up. Whole-brain resting-state functional connectivity networks were mapped for each individual and analyzed using graph theory to investigate whether network abnormalities associated with first-episode psychosis were evident and whether functional network properties changed abnormally over 12 months relative to controls.

RESULTS

This study found no evidence of abnormal resting-state functional connectivity or topology in first-episode psychosis individuals relative to healthy controls at baseline or at 12-months follow-up. Furthermore, longitudinal changes in network properties over a 12-month period did not significantly differ between first-episode psychosis individuals and healthy control. Network measures did not significantly correlate with symptomatology, duration of illness or antipsychotic medication.

CONCLUSIONS

This is the first study to show unaffected resting-state functional connectivity and topology in the early psychosis stage of illness. In light of previous literature, this suggests that a subgroup of first-episode psychosis individuals who have a neurotypical resting-state functional connectivity and topology may exist. Our preliminary longitudinal analyses indicate that there also does not appear to be deterioration in these network properties over a 12-month period. Future research in a larger sample is necessary to confirm our longitudinal findings.

Social inclusion and relationship satisfaction of patients with a severe mental illness

BACKGROUND

Research suggests that patients with a severe mental illness (SMI) are among the most social excluded in society. However, comparisons of social network composition and relationship satisfaction between SMI patients and a control group are rare.

AIMS

Our aim was to compare differences in size, satisfaction and composition of the social network between patients with SMI and a control group. Potential sociodemographic and clinical risk factors in relation to social network size in SMI patients were explored.

METHODS

The sample consisted of a control group ( N = 949) and SMI patients ( N = 211) who were under treatment in Dutch mental health care institutions. In these groups, network size, relationship satisfaction, sociodemographic and clinical (patients only) characteristics were assessed.

RESULTS

Social network size was 2.5 times lower in SMI patients, which was also reflected in a lower relationship satisfaction. The composition of the social network of SMI patients differs from that of controls: patients' network seems to consist of a smaller part of friends. Different risk factors were associated with the impoverishment of the social network of family, friends and acquaintances of patients with SMI.

CONCLUSION

SMI patients have very small networks compared to controls. This may be a problem, given the ongoing emphasis on outpatient treatment of SMI patients and self-dependence. This outcome advocates for more attention to social isolation of SMI patients and involvement of family in the treatment and aftercare of SMI patients.

Repetitive TMS on Left Cerebellum Affects Impulsivity in Borderline Personality Disorder: A Pilot Study

The borderline personality disorder (BPD) is characterized by a severe pattern of instability in emotional regulation, interpersonal relationships, identity and impulse control. These functions are related to the prefrontal cortex (PFC), and since PFC shows a rich anatomical connectivity with the cerebellum, the functionality of the cerebellar-PFC axis may impact on BPD. In this study, we investigated the potential involvement of cerebello-thalamo-cortical connections in impulsive reactions through a pre/post stimulation design. BPD patients (n = 8) and healthy controls (HC; n = 9) performed an Affective Go/No-Go task (AGN) assessing information processing biases for positive and negative stimuli before and after repetitive transcranial magnetic stimulation (rTMS; 1 Hz/10 min, 80% resting motor threshold (RMT) over the left lateral cerebellum. The AGN task consisted of four blocks requiring associative capacities of increasing complexity. BPD patients performed significantly worse than the HC, especially when cognitive demands were high (third and fourth block), but their performance approached that of HC after rTMS (rTMS was almost ineffective in HC). The more evident effect of rTMS in complex associative tasks might have occurred since the cerebellum is deeply involved in integration and coordination of different stimuli. We hypothesize that in BPD patients, cerebello-thalamo-cortical communication is altered, resulting in emotional dysregulation and disturbed impulse control. The rTMS over the left cerebellum might have interfered with existing functional connections exerting a facilitating effect on PFC control.

Homesick: residential and care patterns in patients with severe mental illness

BACKGROUND

Changes in the residential and care settings of patients with severe mental illness (SMI) are a concern because of the large variety of possible negative consequences. This study describes patterns of changes in the residential and care settings of SMI patients and explores associations between these changes, sociodemographics, and clinical characteristics.

METHODS

From January 2006 to January 2012, all data relating to changes in residential and/or care setting by SMI patients (N = 262) were collected from electronic case files. Data covering psychopathology, substance use, and medication adherence were assessed in 2006.

RESULTS

There were more changes in the residential than in the care setting. In 6 years, only 22% of our sample did not move, 23% changed residence once, 19% twice, 10% three times, and 26% four or more times. Substance use predicted changes of care and/or residential setting and rehospitalisation. The severity of negative symptoms predicted rehospitalisation and duration of hospitalisation. Disorganisation symptoms predicted the duration of hospitalisation.

CONCLUSIONS

A majority of patients with SMI changed residential and/or care settings several times in 6 years. Patients with substance use or severe negative and disorganisation symptoms may need more intensive and customised treatment. Further research is needed to investigate prevention programmes for highly-frequent movers.

Auditory P300 event related potentials in acute and transient psychosis-Comparison with schizophrenia

BACKGROUND

Limited biological research data are available on acute and transient psychotic disorder (ATPD) vis-à-vis schizophrenia. P300 event related potentials (ERP) have been extensively studied as an important neurophysiological parameter in schizophrenia. However, no P300 ERP studies comparing the two disorders are available. We compared auditory P300 ERP in patients remitted from ATPD with schizophrenia in remission and biologically unrelated healthy controls.

METHODS

In this case-control study design, 25 subjects remitted from ATPD were age-/gender-matched with healthy controls and patients with schizophrenia in remission. Clinical assessment and auditory P300 ERP (amplitude and latencies at central and parietal sites, reaction time) were recorded. The ERP parameters were compared across the three groups.

RESULTS

All three groups showed significant differences in P300 amplitudes and latencies at central and parietal sites. Schizophrenia group differed significantly (p<0.001) from the ATPD group in all the P300 parameters. The ATPD group was found to have lower Pz latency (p<0.05) and lower mean reaction time (p<0.001) as compared to healthy controls.

CONCLUSION

The results suggest that P300 could easily distinguish between ATPD and schizophrenia in remission, thus neurophysiologically differentiating the two disorders. Lower P300 latency and reaction time, which indicate hyper-arousability, distinguished ATPD from normal controls, with implications for a better understanding of ATPD.

Relationships between Occupational Factors and Health and Well-Being in Individuals with Persistent Mental Illness Living in the Community

Purpose. This study identified relationships between occupational factors and health and well-being among individuals with persistent mental illness. Methods. There were 103 subjects assessed in regards to time spent in different occupations, activity level, satisfaction with daily occupations, and experienced occupational value. The health-related variables were self-rated health, quality of life, self-esteem, sense of coherence, self-mastery, psychosocial functioning, and psychiatric symptoms. Results. Subjective perceptions of occupational performance were consistently related to both self-rated and interviewer-rated aspects of health and functioning. While variables pertaining to actual doing showed weak or no associations with self-rated health-related variables, they exhibited moderate relationships to interviewer-rated health and functioning. Implications. The health-promoting ingredients in occupations were determined by the way occupations were perceived, rather than the doing per se. The findings indicate that perceived meaning and satisfaction ought to be prioritized when setting goals in occupational therapy practice, and, besides, that existing occupational therapy theory needs to be updated.

Measuring negative symptoms in patients with schizophrenia: reliability and validity of the Korean version of the Motivation and Pleasure Scale-Self-Report

BACKGROUND

The Clinical Assessment Interview for Negative Symptoms (CAINS) is one of the validated interview measures of negative symptoms in psychotic disorders. The Motivation and Pleasure Scale-Self-Report (MPSR) is a self-report measure that assesses the motivation and pleasure domains of negative symptoms based on the CAINS. This study evaluated the reliability and validity of a Korean version of the MPSR.

METHODS

A total of 139 patients with schizophrenia completed the MPSR, CAINS, Scale for the Assessment of Negative Symptoms (SANS), Brief Psychiatric Rating Scales, Calgary Depression Scale for Schizophrenia, and other measures of trait and cognitive function.

RESULTS

The 15-item MPSR showed good internal consistency. In addition, it also had a good convergent validity with the Motivation and Pleasure subscale of the CAINS and the anhedonia/avolition subscale of the SANS. The scale was not associated with psychotic symptoms, agitation/mania, and depression/anxiety, and it showed good discriminant validity. MPSR scores were significantly correlated with Behavioral Activation System total score for trait measure.

CONCLUSION

The Korean version of the MPSR is a notable self-report method for examining the severity of negative symptoms in schizophrenia.

Victimisation in adults with severe mental illness: prevalence and risk factors

BACKGROUND

Patients with a severe mental illness (SMI) are more likely to experience victimisation than the general population.

AIMS

To examine the prevalence of victimisation in people with SMI, and the relationship between symptoms, treatment facility and indices of substance use/misuse and perpetration, in comparison with the general population.

METHOD

Victimisation was assessed among both randomly selected patients with SMI (n = 216) and the general population (n = 10 865).

RESULTS

Compared with the general population, a high prevalence of violent victimisation was found among the SMI group (22.7% v. 8.5%). Compared with out-patients and patients in a sheltered housing facility, in-patients were most often victimised (violent crimes: 35.3%; property crimes: 47.1%). Risk factors among the SMI group for violent victimisation included young age and disorganisation, and risk factors for property crimes included being an in-patient, disorganisation and cannabis use. The SMI group were most often assaulted by someone they knew.

CONCLUSIONS

Caregivers should be aware that patients with SMI are at risk of violent victimisation. Interventions need to be developed to reduce this vulnerability.

Clinical and Functional Outcome of Assertive Outreach for Patients With Schizophrenic Disorder: Results of a Quasi-Experimental Controlled Trial

Background

The majority of studies support modern assertive health service models. However, the evidence is limited for parts of continental Europe, as well as for the pharmacological adherence outcome parameter.

Method

We conducted a quasi-experimental controlled trial including adult patients with a schizophreniform disorder and a maximum of 60 points on the Global Assessment of Functioning Scale (GAF). Interventions (n = 176) and controls (TAU, n = 142) were assessed every six-month within one year in 17 study practices in rural areas. Mental and functional state were rated using the Brief Psychiatric Rating Scale (BPRS) and the GAF. Functional limitations and pharmacological adherence were patient-rated using the WHO-Disability Assessment Schedule II (WHODAS–II) and the Medication Adherence Report Scale (MARS). We computed multilevel mixed models.

Results

The GAF and BPRS of both groups improved significantly, yet the increase in the intervention group was significantly higher. In contrast, patient-rated variables – WHODAS–II and MARS – neither showed a stable temporal improvement nor a difference between groups.

Conclusion

Our findings only partly support the investigated AO intervention, because of conflicting results between clinician- and patient-ratings. Accordingly, the benefits of AO need to be further evaluated.

Social interaction among people with psychiatric disabilities--does attending a day centre matter?

BACKGROUND

Engaging in social interaction has, for people with psychiatric disabilities, been shown to enhance well-being and the experience of meaning and to generally prevent the worsening of mental illness.

AIM

The aim of the study was to investigate how day centre attendees differed from non-attendees regarding different aspects of social interaction and to investigate how occupational factors, including day centre attendance, and previously known predictors were related to social interaction in the study sample as a whole.

METHODS

A total of 93 day centre attendees and 82 non-attendees with psychiatric disabilities were examined regarding social interaction, subjective perception of occupation, activity level, sense of self-mastery and socio-demographic and clinical variables. Data were analysed with non-parametric statistics, mainly logistic regression.

RESULTS

Social support was mainly provided by informal caregivers such as family members. The day centre attendees had more social relations but did not experience better quality or closeness in their relationships than non-attendees. Important factors for social interaction were subjective perceptions of daily occupation, being married/cohabiting, self-mastery and severity of psychiatric symptoms.

CONCLUSION

Alternative ways of enhancing social interactions in the community is needed, targeting the group's feeling of satisfaction and value in daily life together with self-mastery.

Obsessive compulsive symptoms in patients with Schizophrenia on Clozapine and with Obsessive Compulsive disorder: a comparison study

Obsessive compulsive symptoms are commonly reported in those with schizophrenia. Clozapine has previously been reported to induce, aggravate and alleviate these symptoms. It is unclear if these are similar to the symptoms experienced by those with obsessive compulsive disorder. This study describes the obsessive compulsive symptom profile of a population of patients with schizophrenia treated with clozapine (n = 62) and compares this with patients with Obsessive Compulsive Disorder (n = 35). All participants were attending an outpatient community mental health service. The Obsessive Compulsive Inventory (which measures the frequency and associated distress of a range of "behavioural" and "cognitive" symptoms), the Hospital Anxiety and Depression Scale and a demographic questionnaire were completed. In addition the schizophrenia group treated with clozapine completed the Brief Psychiatric Rating Scale. The OCD group reported significantly more symptoms for all OCI subscales compared to the clozapine group. Overall fourteen (22%) of the schizophrenia treated with clozapine group had clinically significant total OCI scores. Two (3%) had documented OCS pre clozapine. De novo OCS was reported in twelve (19%) cases. Nine (11%) had documented OC symptoms pre-clozapine while only two (3%) had symptoms after clozapine was initiated. In terms of OC symptom profile, the clozapine group scored highest on the Doubting scale, a cognitive symptom whereas the OCD group scored highest on Washing, a behavioural symptom. Both groups reported greater distress with cognitive rather than behavioural symptoms. Medication including clozapine dose was not correlated with symptom severity. Anxiety correlated highly with obsessive compulsive symptoms in the Clozapine group but not the OCD group. Within the Clozapine group, Obsessing correlated highly with Unusual Thought Content. Findings suggest that obsessive compulsive symptoms in the Clozapine group may reflect a subtype of 'schizo-obsessive' disorder.

Does substance use disorder affect clinical expression in first-hospitalization patients with schizophrenia? Analysis of a prospective cohort

Although several papers reported a wide range of negative outcomes among patients with both schizophrenia and Substance Use Disorder (SUD), only a few studies evaluated the impact of SUD on psychopathology and thus on the length of first-hospitalization. The aim of the present study was to compare clinical expression of first-episode of schizophrenia between inpatients with and without SUD, giving close attention to the length of stay. One hundred and thirty inpatients at first-episode of schizophrenia were assigned to either SUD or not SUD group depending on SUD diagnosis and were assessed through BPRS at admission, during hospitalization and at discharge. Cross-sectional and longitudinal statistical analysis were performed to investigate differences between groups and also a linear regression was used to evaluate relationship between length of stay and BPRS scores. SUD group showed more disorganization at admission, less marked improvement of symptoms (disorganization, thought disturbance, anergia), and longer hospital stay than not SUD group. Moreover BPRS total score during hospitalization was a significant positive predictor for length of stay. Taken together, these findings suggest that SUD patients have a more severe and drug-resistant expression of schizophrenia, hence, they need longer treatment to achieve the overall symptoms improvement required for discharge.

The Motivation and Pleasure Scale-Self-Report (MAP-SR): reliability and validity of a self-report measure of negative symptoms

The Clinical Assessment Interview for Negative Symptoms (CAINS) is an empirically developed interview measure of negative symptoms. Building on prior work, this study examined the reliability and validity of a self-report measure based on the CAINS-the Motivation and Pleasure Scale-Self-Report (MAP-SR)-that assesses the motivation and pleasure domain of negative symptoms. Thirty-seven participants with schizophrenia or schizoaffective disorder completed the 18-item MAP-SR, the CAINS, and other measures of functional outcome. Item analyses revealed three items that performed poorly. The revised 15-item MAP-SR demonstrated good internal consistency and convergent validity with the clinician-rated Motivation and Pleasure scale of the CAINS, as well as good discriminant validity, with little association with psychotic symptoms or depression/anxiety. MAP-SR scores were related to social anhedonia, social closeness, and clinician-rated social functioning. The MAP-SR is a promising self-report measure of severity of negative symptoms.

Motivation and treatment engagement intervention trial (MotivaTe-IT): the effects of motivation feedback to clinicians on treatment engagement in patients with severe mental illness

BACKGROUND

Treatment disengagement and non-completion poses a major problem for the successful treatment of patients with severe mental illness. Motivation for treatment has long been proposed as a major determinant of treatment engagement, but exact mechanisms remain unclear. This current study serves three purposes: 1) to determine whether a feedback intervention based on the patients' motivation for treatment is effective at improving treatment engagement (TE) of severe mentally ill patients in outpatient psychiatric treatment, 2) to gather insight into motivational processes and possible mechanisms regarding treatment motivation (TM) and TE in this patient population and 3) to determine which of three theories of motivation is most plausible for the dynamics of TM and TE in this population.

METHODS/DESIGN

The Motivation and Treatment Engagement Intervention Trial (MotivaTe-IT) is a multi-center cluster randomized trial investigating the effectiveness of feedback generated by clinicians regarding their patients' treatment motivation upon the patients' TE. The primary outcome is the patients' TE. Secondary outcomes are TM, psychosocial functioning and quality of life. Patients whose clinicians generate monthly motivation feedback (additional to treatment as usual) will be compared to patients who receive treatment as usual. An estimated 350 patients, aged 18 to 65 years, with psychotic disorders and/or severe personality disorders will be recruited from outpatient community mental health care. The randomization will be performed by a computerized randomization program, with an allocation ratio of 1:1 (team vs. team or clinician vs. clinician) and patients, but not clinicians, will be blind to treatment allocation at baseline assessment. Due to the nature of the trial, follow-up assessment can not be blinded.

DISCUSSION

The current study can provide important insights regarding motivational processes and the way in which motivation influences the treatment engagement and clinical outcomes. The identification of possible mechanisms through which changes in the outcomes occur, offers a tool for the development of more effective future interventions to improve TM and TE.

TRIAL REGISTRATION

Current Controlled Trials NTR2968.

The life situation of people with persistent mental illness visiting day centers: a comparative study

This study compared the life situation of visitors of day centers (DC) for people with mental illness (N = 93) with a comparison group (N = 82) in respect of sociodemographic and clinical characteristics, care consumption, well-being and everyday activities. The response rate was 49%, and those who declined are believed to be those with the most severe psychiatric disabilities. Most individuals were single (81%/78%) and few had children (12%/18%). The DC group had less education than the comparison group but had a friend more often. Although having their need for daily activities met, the DC group had greater unmet needs in respect of daily living in general. They less frequently reported having a psychosis and had fewer negative and more depressive symptoms. They got more housing support and general outpatient care, while the comparison group used specialized psychiatric care more frequently. The samples were equally satisfied with their care, health and well-being and found their everyday activities equally meaningful. The DC visitors formed a vulnerable group, by living single, having a low level of education and having unmet needs, and were at risk of not getting specialized psychiatric care.

Dorsolateral prefrontal cortex and hippocampus sustain impulsivity and aggressiveness in borderline personality disorder

BACKGROUND

Borderline Personality Disorder (BPD) patients are characterized by increased levels of aggressivity and reduction of impulse control, which are behavioural dimensions mainly sustained by hippocampus and dorsolateral prefrontal cortex (DLPFC). In this study we aimed at investigating whether hippocampus and DLPFC anatomy may sustain impulsive and aggressive behaviours in BPD.

METHODS

Fifteen DSM-IV BPD patients (11 females, 4 males) and fifteen 1:1 matched healthy controls (11 females, 4 males) were studied with a 1.5T magnetic resonance imaging (MRI) and underwent a psychopathological assessment in order to measure the severity of aggressive and impulsive traits.

RESULTS

Right hippocampal volumes were significantly reduced in BPD patients compared to healthy subjects (p=0.027), particularly in those with a history of childhood abuse (p=0.01). Moreover, in patients but not in controls, right hippocampal volumes significantly inversely correlated with aggressiveness and DLPFC grey matter volumes significantly inversely associated with impulsiveness (p<0.05).

CONCLUSIONS

Our results provide evidence that hippocampus and DLPFC play a separate and unique role in sustaining the control of impulse and aggressive behaviours in BPD patients.

Achieving high research reporting quality through the use of computational ontologies

Systematic reviews and meta-analyses constitute one of the central pillars of evidence-based medicine. However, clinical trials are poorly reported which delays meta-analyses and consequently the translation of clinical research findings to clinical practice. We propose a Center of Excellence in Research Reporting in Neurosurgery (CERR-N) and the creation of a clinically significant computational ontology to encode Randomized Controlled Trials (RCT) studies in neurosurgery. A 128 element strong computational ontology was derived from the Trial Bank ontology by omitting classes which were not required to perform meta-analysis. Three researchers from our team tagged five randomly selected RCT's each, published in the last 5 years (2004-2008), in the Journal of Neurosurgery (JoN), Neurosurgery Journal (NJ) and Journal of Neurotrauma (JoNT). We evaluated inter and intra observer reliability for the ontology using percent agreement and kappa coefficient. The inter-observer agreement was 76.4%, 75.97% and 74.9% and intra-observer agreement was 89.8%, 80.8% and 86.56% for JoN, NJ and JoNT respectively. The inter-observer kappa coefficient was 0.60, 0.54 and 0.53 and the intra-observer kappa coefficient was 0.79, 0.82 and 0.79 for JoN, NJ and JoNT journals respectively. The high degree of inter and intra-observer agreement confirms tagging consistency in sections of a given scientific manuscript. Standardizing reporting for neurosurgery articles can be reliably achieved through the integration of a computational ontology within the context of a CERR-N. This approach holds potential for the overall improvement in the quality of reporting of RCTs in neurosurgery, ultimately streamlining the translation of clinical research findings to improvement in patient care.

Belonging and doing: important factors for satisfaction with sexual relations as perceived by people with persistent mental illness

BACKGROUND

It is increasingly acknowledged that satisfaction with sexual relations forms an important aspect of people's lives, but little is known of factors associated with this phenomenon among people with mental illness.

AIM

This study aimed to investigate how demographic, social, clinical, and health-related factors were related to satisfaction with sexual relations.

METHODS

Patients with persistent mental illness (N = 103), recruited from an outpatient unit, were assessed regarding the target variables.

RESULTS

No clinical variable, and only one demographic factor, namely being a cohabitant, was found to be important to satisfaction with sexual relations. Several social factors, pertaining to how everyday occupations were valued and how the social network was perceived, were shown to be of importance. General quality of life, but not self-rated health or interviewer-assessed psychopathology, was also important for satisfaction with sexual relations. A multivariate analysis showed that the most significant factor for satisfaction with sexual relations was how everyday activities were valued, and being a cohabitant explained some additional variation.

CONCLUSION

Previous research indicates that the mental health care services largely neglect sexual problems among people with mental illness, and the findings may provide additional knowledge that may be used in the support of this target group.

Applied psychometrics in clinical psychiatry: the pharmacopsychometric triangle

OBJECTIVE

To consider applied psychometrics in psychiatry as a discipline focusing on pharmacopsychology rather than psychopharmacology as illustrated by the pharmacopsychometric triangle.

METHOD

The pharmacopsychological dimensions of clinically valid effects of drugs (antianxiety, antidepressive, antimanic, and antipsychotic), of clinically unwanted effects of these drugs, and the patients' own subjective perception of the balance between wanted and unwanted effects are analysed using rating scales assessed by modern psychometric tests (item response theory models)

RESULTS

Symptom rating scales fulfilling the item response theory models have been shown to be psychometrically valid outcome scales as their total scores are sufficient statistics for demonstrating dose-response relationship within the various classes of antianxiety, antidepressive, antimanic or antipsychotic drugs. The total scores of side-effect rating scales are, however, not sufficient statistics, implying that each symptom has to be analysed individually. Self-rating scales with very few items appear to be sufficient statistics when measuring the patients' own perception of quality of life.

CONCLUSION

Applied psychometrics in psychiatry have been found to cover a pharmacopsychometric triangle illustrating the measurements of wanted and unwanted effects of pharmacotherapeutic drugs as well as health-related quality of life.

Cognitive memory control in borderline personality disorder patients

BACKGROUND

It has been demonstrated that the mechanism of cognitive memory control in humans is sustained by the hippocampus and prefrontal cortices, which have been found to be structurally and functionally abnormal in borderline personality disorder (BPD). We investigated whether the memory control mechanism is affected in BPD.

METHOD

Nineteen Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV BPD patients and 19 matched healthy controls (HC) performed a specific think/no-think paradigm exploring the capacity of remembering and suppressing pair of words previously learned. After the think-no think phase, the second member of each word pair has to be remembered either when subjects are presented with the cue word showed at the beginning of the test (Same Probe Test; SPT) or when they are presented with an extra-list categorical word (Independent Probe Test; IPT). We evaluated the effect of suppression and of retrieval activity on later retention of words.

RESULTS

Both on the SPT and on the IPT, HC showed the expected improvement of memory retrieval on to-be-remembered words, unlike BPD patients. On the SPT, HC, but not BPD patients, correctly recalled significantly more words among remembered words (RW) than among suppressed words (SW). Similarly to HC, subjects with BPD without a history of childhood abuse showed a significantly higher percentage of correctly recalled words among RW than among SW.

CONCLUSIONS

The mechanism of active retrieval of memories and of improvement through repetition is impaired in BPD, particularly in those who experienced traumatic experiences. This impairment might play an important role, possibly resulting in the emergence of unwanted memories and dissociative symptoms.

Schizophrenia: measurements of psychopathology

A key problem in schizophrenia research is how to assess the effects of treatment interventions given the spectrum of schizophrenia symptoms and patients' functioning. Measuring symptoms is complex, because these symptoms cover a wide variety of psychopathologic domains. The commonly recognized domains are the positive, negative, cognitive, excitement, and depression domains. This article critically reviews some of the available assessment tools of these domains together with other associated syndromes. The instruments discussed cover the broad range of psychopathology found in patients who have schizophrenia.

Usefulness of long-acting injectable risperidone during 12-month maintenance therapy of bipolar disorder

This study aimed to assess the safety, tolerability, efficacy, and compliance of a risperidone long-acting injection (RLAI) formulation for the maintenance treatment of stabilized bipolar patients. A prospective, open-label trial of RLAI was conducted for 12 months. Stable bipolar patients (n=11) were switched from their existing oral antipsychotic agents to RLAI, and injections were given every 2 weeks. The assessments were performed at baseline and at 6 and 12 months of treatment by using the Young Mania Rating Scale (YMRS), Clinical Global Impressions-Severity of Illness (CGI-S) scale, 17-item Hamilton Rating Scale for Depression (HAM-D), Brief Psychiatric Rating Scale (BPRS), and Extrapyramidal Symptom Rating Scale (ESRS). The satisfaction levels of subjects were evaluated at the end of the study period using a 10-point visual analog scale. Ten patients (90.9%) completed the trial, and no significant changes were seen in the YMRS, HAM-D, and BPRS scores throughout the study. CGI-S and ESRS scores were significantly decreased from the baseline to the post-12-month treatment score. Relapses were not reported by any of the participants. This result indicates that RLAI may be beneficial in the maintenance therapy of stable bipolar patients; however, an adequately powered, randomized, placebo-controlled trial is necessary to draw a definite conclusion about the role of RLAI in the maintenance treatment of bipolar patients.

Social network among people with persistent mental illness: associations with sociodemographic, clinical and health-related factors

BACKGROUND

Social interaction is crucial for whether a person will successfully accomplish important life tasks.

AIM AND METHOD

This study investigated the importance of sociodemographic, clinical and self-perceived health-related factors for social interaction among 103 individuals with persistent mental illness, mainly psychoses, visiting an outpatient unit.

RESULTS

Bivariate analyses pointed to several relationships, especially between the health-related variables and both quantitative and qualitative aspects of the social network. In multivariate analyses, higher levels of quality of life, self-esteem, being a cohabitant, and living in a house were related to higher ratings on different aspects of the social network. Older age was associated with fewer close relationships but more adequate social integration.

CONCLUSIONS

The social network appeared to be a function of both self-perceptions and sociodemographic influences. The influence is probably dynamic and, for example, just as a better quality of life may lead to more social interaction, a more developed social network probably promotes better quality of life. Therefore, interventions in mental health care that target social interaction constitute a powerful resource and should be part of the support for people with severe and persistent mental illness.

Clinical correlates of clozapine prescription for schizophrenia in China

AIMS

Few studies have investigated the prescription patterns of clozapine in outpatients with schizophrenia in China. It is an important issue due to clozapine's high efficacy and potentially fatal side effect profile. This study examined the use of clozapine and its correlates in China.

METHODS

Three hundred ninety-eight clinically stable outpatients with schizophrenia were randomly selected and interviewed in Hong Kong (HK) and Beijing (BJ). Assessment instruments included the Structured Clinical Interview for DSM-IV, Brief Psychiatric Rating Scale, Simpson and Angus Scale of Extrapyramidal Symptoms, Barnes Akathisia Rating Scale and the Hong Kong and Mainland China World Health Organization Quality of Life Schedule-Brief version. Assessments were performed by the same investigator in both sites.

RESULTS

Clozapine was prescribed to 15.6% of (n = 62) patients. There was a wide inter-site variation between HK and BJ. Use of clozapine was associated with age, age at onset, extrapyramidal side effects (EPS), having health insurance, use of depot and typical antipsychotic and anticholinergic drugs and benzodiazepines as well as history of suicidal attempts. On multiple logistic regression analysis, the number of hospitalizations, site (HK vs. BJ), use of typical antipsychotics, polypharmacy and co-prescription with anticholinergics were significantly associated with the prescription of clozapine. No significant differences were found between the clozapine and non-clozapine groups with regard to any of the quality of life domains.

CONCLUSION

A combination of economical and clinical factors, health policies and the characteristics of the treatment settings plays important roles in determining clozapine use. Clozapine appears to have little significant influence on quality of life in clinical stable Chinese patients with schizophrenia.