Depression and the reintegration phase of acute schizophrenia

Negative symptoms and their association with depressive symptoms in the long-term course of schizophrenia

Depressive symptoms abound in schizophrenia and even in subclinical states of the disorder. We studied the frequency of these symptoms and their relationship to negative symptoms from the first psychotic episode on over a long-term course of 134 months on data for 107 patients in our ABC Schizophrenia Study. Prevalence rates of 90 % for presenting at least one negative symptom and of 60 % for presenting at least one depressive symptom in the first psychotic episode illustrate the frequency of these syndromes. After the remission of psychosis the rates fell to 50 % (negative symptoms) and 40 % (depressive symptoms) over a period of 5 years, remaining stable thereafter. After we broke the negative syndrome down into (SANS) subsyndromes, a positive association emerged between anhedonia and depressive symptoms and remained stable over the entire period studied. In contrast, the association between abulia and depression grew increasingly pronounced over the illness course. However, a more detailed look revealed this to be the case in female patients only, whereas male patients showed no such association of these symptom dimensions. We have no explanation at hand for this sex difference yet.

Fluphenazine decanoate (depot) and enanthate for schizophrenia

BACKGROUND

Intramuscular injections (depot preparations) offer an advantage over oral medication for treating schizophrenia by reducing poor compliance. The benefits gained by long-acting preparations, however, may be offset by a higher incidence of adverse effects.

OBJECTIVES

To assess the effects of fluphenazine decanoate and enanthate versus oral anti-psychotics and other depot neuroleptic preparations for individuals with schizophrenia in terms of clinical, social and economic outcomes.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's Trials Register (February 2011 and October 16, 2013), which is based on regular searches of CINAHL, BIOSIS, AMED, EMBASE, PubMed, MEDLINE, PsycINFO, and registries of clinical trials.

SELECTION CRITERIA

We considered all relevant randomised controlled trials (RCTs) focusing on people with schizophrenia comparing fluphenazine decanoate or enanthate with placebo or oral anti-psychotics or other depot preparations.

DATA COLLECTION AND ANALYSIS

We reliably selected, assessed the quality, and extracted data of the included studies. For dichotomous data, we estimated risk ratio (RR) with 95% confidence intervals (CI). Analysis was by intention-to-treat. We used the mean difference (MD) for normal continuous data. We excluded continuous data if loss to follow-up was greater than 50%. Tests of heterogeneity and for publication bias were undertaken. We used a fixed-effect model for all analyses unless there was high heterogeneity. For this update. we assessed risk of bias of included studies and used the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach to create a 'Summary of findings' table.

MAIN RESULTS

This review now includes 73 randomised studies, with 4870 participants. Overall, the quality of the evidence is low to very low.Compared with placebo, use of fluphenazine decanoate does not result in any significant differences in death, nor does it reduce relapse over six months to one year, but one longer-term study found that relapse was significantly reduced in the fluphenazine arm (n = 54, 1 RCT, RR 0.35, CI 0.19 to 0.64, very low quality evidence). A very similar number of people left the medium-term studies (six months to one year) early in the fluphenazine decanoate (24%) and placebo (19%) groups, however, a two-year study significantly favoured fluphenazine decanoate (n = 54, 1 RCT, RR 0.47, CI 0.23 to 0.96, very low quality evidence). No significant differences were found in mental state measured on the Brief Psychiatric Rating Scale (BPRS) or in extrapyramidal adverse effects, although these outcomes were only reported in one small study each. No study comparing fluphenazine decanoate with placebo reported clinically significant changes in global state or hospital admissions.Fluphenazine decanoate does not reduce relapse more than oral neuroleptics in the medium term (n = 419, 6 RCTs, RR 1.46 CI 0.75 to 2.83, very low quality evidence). A small study found no difference in clinically significant changes in global state. No difference in the number of participants leaving the study early was found between fluphenazine decanoate (17%) and oral neuroleptics (18%), and no significant differences were found in mental state measured on the BPRS. Extrapyramidal adverse effects were significantly less for people receiving fluphenazine decanoate compared with oral neuroleptics (n = 259, 3 RCTs, RR 0.47 CI 0.24 to 0.91, very low quality evidence). No study comparing fluphenazine decanoate with oral neuroleptics reported death or hospital admissions.No significant difference in relapse rates in the medium term between fluphenazine decanoate and fluphenazine enanthate was found (n = 49, 1 RCT, RR 2.43, CI 0.71 to 8.32, very low quality evidence), immediate- and short-term studies were also equivocal. One small study reported the number of participants leaving the study early (29% versus 12%) and mental state measured on the BPRS and found no significant difference for either outcome. No significant difference was found in extrapyramidal adverse effects between fluphenazine decanoate and fluphenazine enanthate. No study comparing fluphenazine decanoate with fluphenazine enanthate reported death, clinically significant changes in global state or hospital admissions.

AUTHORS' CONCLUSIONS

There are more data for fluphenazine decanoate than for the enanthate ester. Both are effective antipsychotic preparations. Fluphenazine decanoate produced fewer movement disorder effects than other oral antipsychotics but data were of low quality, and overall, adverse effect data were equivocal. In the context of trials, there is little advantage of these depots over oral medications in terms of compliance but this is unlikely to be applicable to everyday clinical practice.

Depression in the long-term course of schizophrenia

Depressive symptoms are quantitatively and qualitatively among the most important characteristics of schizophrenia. The following contribution reports on the prevalence of depression in 107 patients of the ABC schizophrenia study over 12 years after first hospital admission, looks into a preponderance of depression at certain stages of the illness and the predictive value of depressive symptoms for course and outcome. All but one of the 107 patients experienced one to 10 episodes of depressed mood between index assessment and long-term follow-up. In any month of the observation period about 30-35% of the patients presented at least one symptom of the depressive core syndrome (depressive mood, loss of pleasure, loss of interests, loss of self-confidence, feelings of guilt, suicidal thoughts/suicide attempt). Depressive symptoms are particularly frequent during a psychotic episode at a rate of approximately 50%. There were moderate but statistically significant correlations between the amount of depressive symptoms during a psychotic episode and the frequency of relapses, defined by hospital admissions as well as the total length of inpatient treatment. Depression occurring in the interval was not associated with an increased need for inpatient treatment.

Depot fluphenazine decanoate and enanthate for schizophrenia

BACKGROUND

Intramuscular injections (depot preparations) offer an advantage over oral medication for treating schizophrenia by reducing poor compliance. The benefits gained by long acting preparations, however, may be offset by a higher incidence of adverse effects.

OBJECTIVES

To investigate the clinical effects of fluphenazine decanoate and enanthate.

SEARCH STRATEGY

For this update we searched the Cochrane Schizophrenia Group's Register (May 2002).

SELECTION CRITERIA

We considered all relevant randomised clinical controlled trials focusing on people with schizophrenia comparing fluphenazine decanoate or enanthate with placebo or oral anti-psychotics or other depot preparations.

DATA COLLECTION AND ANALYSIS

We reliably selected, quality rated and data extracted studies. For dichotomous data we estimated relative risk (RR) with 95% confidence intervals (CI), and, where possible, the number needed to treat/harm (NNT/H). Analysis was by intention-to-treat. We used the weighted mean difference (WMD) for normal continuous data. Tests of heterogeneity and for publication bias were undertaken.

MAIN RESULTS

This review now includes 70 randomised studies. Compared with placebo, fluphenazine decanoate did not reduce relapse over 6 months to 1 year, but one longer term study found that relapse was significantly reduced in the fluphenazine arm (n=54, RR 0.35, CI 0.2 to 0.6, NNT 2 CI 2 to 4). Fluphenazine decanoate does not reduce relapse more than oral neuroleptics (n=419, 6 RCTs, RR relapse 26-52 weeks 1.46 CI 0.8 to 2.8) or other depot antipsychotics (n=581, 11 RCTs, RR relapse 26-52 weeks 0.82 CI 0.6 to 1.2). Relapse rates over 6 months to 1 year were not significantly different between standard dosage of fluphenazine decanoate over a low dose group (n=523, 4 RCTs, RR 2.09 CI 0.6 to 7.1). Movement disorders were significantly less for people receiving fluphenazine decanoate compared with oral neuroleptics (n=259, 3 RCTs, RR 0.47 CI 0.2 to 0.9, NNT 14 CI 10 to 82). For fluphenazine enanthate there were limited data but no clear difference in global change (0 to 5 weeks) when compared with oral neuroleptics (n=31, 1 RCTs, RR 0.67 CI 0.3 to 1.7), and in relapse rates over 6-26 weeks between fluphenazine enanthate and other depots. Compared with placebo, giving the enanthate caused no more people to need need anticholinergic drugs (n=25, 1 RCT, RR 9.69 CI 0.6 to 163.0) and movement disorders, tardive dyskinesia, tremor, blurred vision and dry mouth were equally prevalent when enanthate was compared with other depot neuroleptics.

AUTHORS' CONCLUSIONS

There are more data for fluphenazine decanoate than for the enanthate ester. Both are effective antipsychotic preparations. In the context of trials, there is little advantage of these depots over oral medications in terms of compliance but this is unlikely to be applicable to everyday clinical practice.

Effect of neuroleptic treatment on depressive symptoms in acute schizophrenic episodes

This study examined depressive symptoms in acute schizophrenic episodes and their relationship to neuroleptic treatment. Sixty-three depressed and 62 non-depressed acutely exacerbated schizophrenic patients were evaluated with the Brief Psychiatric Rating Scale, the Scale for the Assessment of Positive Symptoms, the Simpson-Angus Extrapyramidal Scale, and the Hamilton Rating Scale for Depression. Subjects were then randomly assigned to different haloperidol plasma levels and followed for 3 weeks. Overall, depression improved with treatment of the acute psychosis, but a positive association between extrapyramidal side effects and depressive symptoms emerged over time. Depressive symptoms tended to be positively related to haloperidol plasma levels. The results suggest that depressive symptoms in schizophrenia are heterogeneous in origin; while neuroleptics can ameliorate depressive symptoms inherent in the acute schizophrenic episode, they can also contribute to depression.

Depressive symptoms in acute schizophrenic inpatients

Prospective and longitudinal assessment of depressive, positive, and negative symptoms were performed on 86 newly admitted schizophrenic patients. The improvement of depressive symptoms was significantly correlated with the improvement in positive symptoms, but did not correlate with the improvement in negative symptoms. However, depressive symptoms were heterogeneous. Principal components analysis was used to subdivide depressive symptoms into five factors. The improvement of the depression-anxiety factor was significantly associated with improvement of positive symptoms. On the other hand, improvement of negative symptoms was significantly related to that of the reduced activity factor. The change in hypochondriasis had a significant positive correlation with the change in positive symptoms and had a significant negative correlation with the change in negative symptoms. Changes in the other factors of depressive symptoms did not appear to be associated with changes in positive or negative symptoms. The present findings suggest that the various depressive symptoms associated with acute schizophrenia may have different pathophysiological origins.

Long-term depot antipsychotics. A risk-benefit assessment

The main advantage of depot antipsychotic medication is that it overcomes the problem of covert noncompliance. Patients receiving depot treatment who refuse their injection or fail to receive it for any other reason can be immediately identified and appropriate action taken. In the context of a carefully monitored management programme, depot treatment can have a major impact on compliance and, consequently, the risk of relapse and hospitalisation can be reduced. Another major advantage is that the considerable individual variation in bioavailability and metabolism with oral antipsychotic drugs is markedly reduced with depot treatment. A better correlation between the dose administered and the concentration of medication found in blood or plasma is achieved with depot treatment, and thus, the clinician has greater control over the amount of drug being delivered to the site of activity. A further benefit of depot treatment is the achievement of stable plasma concentrations over long periods, allowing injections to be given every few weeks. However, this also represents a potential disadvantage in that there is a lack of flexibility of administration. Should adverse effects develop, the drug cannot be rapidly withdrawn. Furthermore, adjustment to the optimal dose becomes a long term strategy. The controlled studies of low dose maintenance therapy with depot treatment suggest that it can take months or years for the consequences of dose reduction, in terms of increased risk of relapse, to become manifest. When weighing up the risks and benefits of long term antipsychotic treatment for the individual patient with schizophrenia, the clinician must take into account the nature, severity and frequency of past relapses, and the degree of distress and disability related to any adverse effects. However, the clinical decision to prescribe either a depot or an oral antipsychotic for maintenance treatment will probably rest largely on an assessment of the risk of poor compliance in the particular patient. There is no convincing evidence that the range, nature or severity of adverse effects reported with depot treatment is significantly different from that seen with oral treatment, and depot treatment has been shown to be as good or better than oral medication in preventing or postponing relapse. Furthermore, when adjusting the dose or frequency of depot injection, to improve control of psychotic symptoms or reduce adverse effects, the clinician can be confident that the dose prescribed is the dose being received by the patient.

Depression and the experience of psychological deficits in schizophrenia

A study of the relationships between depression and the subjective experience of psychological deficits was carried out in a group of 50 schizophrenic patients selected from a population of long-term mentally ill patients. Experience of psychological deficits was associated with depression, and furthermore the temporal relationships between the phenomena supported the hypothesis that experience of psychological deficits is associated with vulnerability to depression in schizophrenia. In addition, the patients' self-reporting of depressed mood and negative cognitions was congruent with an observer's assessment of depression. These findings indicate that subjective experiences of deficits characteristic of the schizophrenic illness confer vulnerability to depression, but nonetheless the patients' experience of depression resembles that typical of depressed non-schizophrenic patients.

Post-psychotic depression in schizophrenia

Post-psychotic depression (PPD) is defined as the development of depression during the phase of remission of schizophrenia. Two groups of DSM-III-R schizophrenics, one with PPD and the other without PPD (30 subjects in each group) were compared. Significantly more patients in PPD group belonged to nuclear families, had longer duration of psychotic phase of the illness, were hospitalised more frequently and had more sadness and anxiety-somatisation during florid illness phase. The PPD group also had more past history of depression. Although PPD patients had better premorbid personal-social adjustment in comparison with non-PPD group, they perceived themselves to be lacking in social support and had experienced more stressful life events. For patients in the PPD group, stepwise multiple regression analysis revealed age of onset, sadness during florid psychotic state, premorbid adjustment, social support and life events as significant determinants of severity of depression in the post-psychotic phase.

Training community psychiatric nurses for psychosocial intervention. Report of a pilot study

Community psychiatric nurses were trained to deliver psychosocial intervention to clients with a diagnosis of schizophrenia living at home with relatives. The training package consisted of family assessment, health education, and family stress management strategies. In a 'quasi-experimental' design, a sample of families (n = 54) were recruited to either a control or experimental condition and followed up for 12 months. A number of favourable outcomes were observed in the experimental group, including improvements in the client's target symptoms, personal functioning, and social adjustment. Relatives' satisfaction with services increased and reports of their own minor psychiatric morbidity improved.

Dysphoric mood and symptomatology in schizophrenia

The relationships between depression, anxiety and positive and negative symptoms of schizophrenia were examined in a study of 95 schizophrenic patients who were receiving out-patient care. Various measures of depression and anxiety showed a pattern of interrelationships which suggested that they were measuring a general state of dysphoria rather than separate dimensions of anxiety and depression. Dysphoria was found to be more reliably related to level of positive symptomatology than to negative symptoms.

Depressive syndromes in schizophrenic patients after discharge from hospital. ANI Study Group Berlin, Düsseldorf, Göttingen, Munich

A total of 364 schizophrenic outpatients who were stabilized for 3 months on continuous neuroleptic therapy after discharge from the hospital were rated according to three different scales for depressive syndromes (Brief Psychiatric Rating Scale anxious depression factor, AMDP/depression, and the self-rating PD-S depression scale). Between 19.5% and 27.5% of the patients were rated as depressed, or 35.7%-42.8%, when mild depressive syndromes were included. There were low, but significant correlations between demographic or life-event data and depression scores on the self-rating scale, whereas fewer correlations were found on the observer ratings. No associations were found between social adjustment and depression. Moderate correlations were found between measures of the apathetic syndrome and depression ratings, while observer ratings showed higher correlations than the self-rating. High depression scores, especially in the observer ratings, correlated with scales for global psychopathological assessment (CGI, GAS). There were significant correlations between extrapyramidal rigidity and observer rating depression scores, whereas the total amount of neuroleptics given had no influence. These results are interpreted on the basis of hypotheses about depressive syndromes in schizophrenia.

The nature and prevalence of depression in chronic schizophrenic in-patients

Out of 194 chronic schizophrenic in-patients, depressed mood (item 23 of the PSE) was present in 25 (13%). When compared with 25 matched controls, the patients with depressed mood had significantly higher scores on the MADRS and the Beck Depression Inventory. Serious suicidal ideas and auditory hallucinations were significantly more common in the depressed group. However, there were no significant differences between the matched groups in terms of negative symptoms, Parkinsonism, tardive dyskinesia, anticholinergic medication, or current dose of antipsychotic drug, which suggests that the depression identified was not related to drug treatment, nor was it a direct manifestation or misinterpretation of negative symptoms. Over three-month follow-up, the MADRS and Beck scores covaried closely with the presence or absence of depressed mood. This depressive syndrome persisted over the three months in the majority of patients originally depressed.

Negative and depressive symptoms in schizophrenia

Ninety-five schizophrenic patients were assessed using the Present State Examination, the Brief Psychiatric Rating Scale and the Scale for the Assessment of Negative Symptoms. Negative and depressive symptoms were frequent, and significant relationships among negative symptom complexes and depressive syndromes were noted. Retardation, lack of energy, slowness, and other symptoms of depression were significantly associated with the negative symptoms of schizophrenia. Depressed affect per se did not have a significant correlation with negative symptoms.

Depression in schizophrenia: current guidelines to treatment

Depressive symptoms and syndromes in schizophrenia are common but heterogeneous with respect to etiology, presentation, course, and treatment. Based on a comprehensive differential diagnosis that identifies ten clinical subgroups, the authors review relevant treatment studies and offer current treatment guidelines. The clinical recommendations focus on addressing underlying problems such as medication side effects and substance abuse, attempting to identify and treat medication-responsive syndromes, and preventing suicide. The categories and treatments presented here are expected to evolve as researchers continue to elucidate clinically meaningful syndromes and to develop specific treatments. Nevertheless, current knowledge suggests that many schizophrenics with depression and depression-like symptoms can be treated effectively.

The natural history of schizophrenia: a five-year follow-up study of outcome and prediction in a representative sample of schizophrenics

Longitudinal studies of schizophrenia based on at least 70 subjects and a minimum five-year follow-up period are reviewed in respect of the requirements of adequate method. A cohort of 121, PSE-diagnosed, schizophrenic admissions from a defined population was identified. The sex-distribution of the subjects was almost equal. Forty per cent were first admissions; 65% of the men and 24% women were unmarried; the mean age of onset for men was 28.6 years, for women 33.2 years. Almost half (48%) were continuously employed (including house and child care) for 2 years prior to admissions. First rank symptoms of schizophrenia were present in 79% of the men and 86% of the women. Comprehensive, standardized assessments of clinical state and social function were made on discharge from hospital and at follow-up by home interview of patient and relative(s). Outcome was also assessed by duration and frequency of readmission and by duration of employment. First admissions were analysed separately from the whole cohort. There were 49 first admissions generating an incidence of 7.4 per 100,000 general population per annum. Sixty-nine per cent of men and 13% of women were unmarried. The mean age of admission for men was 30.8 years, women 40.3 years and the mean age of onset 30.7 and 38.6 respectively. After 5 years first rank symptoms were present in 46% of the males and 35% of the females. The proportion showing depressive symptoms fell from 39% at intake to 22% at five years. In terms of a combination of symptoms and readmissions there was a good outcome in 50% of men and 65% of women, a trend comparable to that found in the whole cohort. For the whole cohort a combination of the number of symptoms and admissions disclosed a good outcome for 48%. The mean total duration of readmissions during the five years for men was 76 weeks and for women 27 weeks. Depressive symptoms were present in 38% at intake and 21% after 5 years. An overall rating of social functioning at 5 years showed no more than mild impairment for 47% of men and 74% of women, although individual items were more impaired. However, 38% of the group showed no more than mild impairment in any aspect of social functioning rated. Clinical and social outcome were, in general, closely correlated. The difference in outcome between men and women and the relations between clinical and social outcome are discussed. By means of an application of measures of association between independent and dependent variables to the onset data the clinical and social categories of pathology and impairment at 5 years were forecast.(ABSTRACT TRUNCATED AT 400 WORDS)

Depressive symptoms in schizophrenia: comprehensive differential diagnosis

Depression is a common complication of schizophrenia and is associated with increased morbidity and mortality. Contrary to traditional clinical wisdom, depressive symptoms occur during all phases of schizophrenia and are not restricted to the postpsychotic period. In this review, the authors summarize current empirical research and offer a practical approach to the identification of depressive subtypes in schizophrenia. The following subtypes are considered: (1) depressive symptoms occurring secondary to organic factors (caused by medications, substance abuse, or underlying medical problems); (2) nonorganic depressive symptoms occurring with acute psychotic symptoms (intrinsic to the acute psychotic episode or schizoaffective disorder); and (3) nonorganic depressive symptoms occurring without acute psychotic symptoms (prodromal symptoms, negative symptoms, acute dysphoria, secondary depressive syndrome, or chronic demoralization). The authors discuss each of these entities and offer guidelines for diagnosis.

Temporal course of symptoms and social functioning in relapsing schizophrenics: a 6-year follow-up

As a part of the Copenhagen High Risk project, a 6 year follow-up of relapses after first hospitalisation of 67 schizophrenic women was performed. Four dimensions of psychopathology were examined: positive symptoms, negative symptoms, formal thought disorder and depressive symptoms. Each symptom group was its own best predictor over time. Only depressive symptoms diminished significantly at a relapse 6 years after first hospitalisation. Broadly defined subtyping of schizophrenia into paranoid and non-paranoid, retained stability over a 6 year period. It is concluded that there is a stability of psychopathology across onset episodes and relapses.

Fluphenazine decanoate dose and severity of depression in patients with post-psychotic depression

The authors examined the fluphenazine decanoate dose and the fluphenazine plasma levels in comparison with measures of severity of depression in schizophrenic and schizoaffective patients. All patients were selected for study on the basis of having stable, syndromally defined, antiparkinsonian non-responsive syndromes of post-psychotic depression. No meaningful relationships were found. The implications of this observation with regard to the notion that depressive symptomatology in such patients is neuroleptic-induced is discussed.

Re-evaluation of the evidence on the prognostic importance of schizophrenic and affective symptoms

An earlier literature noted consistently that depressive symptoms appear to bode well for outcome in schizophrenia and related disorders. Although this view is psychodynamically plausible, most of the studies suggesting it have substantial shortcomings. In particular, most studies have been confounded by the effects of variations in duration and history of disorder, which have a major influence on both affective expression and outcome. A contrary view is that depressive symptoms in patients with schizophrenia and related disorders suggest an increased risk of self-harm and social dysfunction, just as these symptoms do in individuals with other disorders. The substantial risks of mortality and morbidity from self-harm, the link between suicide and depression, and the high prevalence of depressive symptoms in the acute and chronic stages of the disorder have all been documented in people diagnosed as having schizophrenia. Social influences are well known to be crucial to the course and outcome of schizophrenia. The expectations of others and patients' own attitudes to their illness are also known to influence outcome. Despite this, there is no longitudinal study of first admission patients to allow us to examine the possible intervening or other role of depression in the development of chronic disability.

Post psychotic depression: the Fulbourn cohort

A comparison is reported, based on a 10 year follow-up, between an index sample of 29 subjects suffering from schizophrenia and post psychotic depression and a control sample of 41 subjects suffering from schizophrenia alone, all having had their first admission to the same hospital in 1974. The index subjects were significantly older on onset of schizophrenia and exhibited more auditory hallucinations. Follow-up patients with post psychotic depression were admitted more often, but their admissions were shorter. No difference was found between the two groups in the frequency of family history of affective disorder, in the duration of treatment with depot neuroleptics or in the dose level of the depot injection received immediately prior to readmission.

Depression in schizophrenia: a study of prevalence and treatment

In an investigation of white, coloured, and black patients admitted to a psychiatric hospital, the prevalence and treatment of depression in schizophrenia was assessed and found to be 30% in group of acute, nuclear schizophrenics. While the prevalence was similar in the three groups, depression was clinically under-detected in black patients.

Genetic factors in the response to neuroleptics in schizophrenia: a psychopharmacogenetic study

A psychopharmacogenetic strategy was used to investigate a genetic heterogeneity model of schizophrenia. This model consisted of various genetic subtypes represented by patients classified hypothetically according to the types and genealogical (Mendelian) patterns of illnesses in first-degree relatives. The effect of neuroleptics on these subtypes (drug x genetic subtype interactions) were tested for evidence of post-treatment responses which discriminated between them. The findings revealed that schizophrenics who had depressed relatives tended to exhibit (1) depression and more severe pseudoparkinsonism irrespective of types of neuroleptics, and (2) greater remission of paranoid-hostility symptoms when treated with neuroleptics of the aliphatic-piperadine type. Schizophrenics who had schizophrenic relatives failed to show these responses. Interpretation of these findings emphasized the recognition of these responses as arising from neuroleptic-induced alterations of defective neurologic-neurochemical systems underlying this subtype and as "pharmacogenetic criteria" by which it can be discriminated.

ECT for schizophrenia

Electroconvulsive therapy (ECT) in the treatment of schizophrenia was evaluated in a double-blind trial; the clinical change after ECT was compared with that after a treatment procedure identical to it but for two exceptions--no electricity was used and no convulsion was induced. All patients had paranoid schizophrenia according to Present State Examination criteria and all received standard doses of neuroleptics for at least 2 weeks before random assignment to the two groups. 20 patients completed the trial: 10 had ECT and 10 were in the control group. Treatment was given three times a week, with a minimum of eight treatments and a maximum of twelve. Clinical change was assessed by the Comprehensive Psychiatric Rating Scale. Both groups improved but the improvement of patients receiving ECT was significantly greater than that of controls both after six treatments (p=0.02) and at the end of treatment (p=0.004). Thus the group receiving ECT gained a clear and early advantage compared with the control group, although by 16 weeks there was little difference between the two groups. Possible reasons for this are discussed.