Treatment of schizophrenia with antipsychotics in Norwegian emergency wards, a cross-sectional national study

Global Neuropsychopharmacological Prescription Trends in Adults with Schizophrenia, Clinical Correlates and Implications for Practice: A Scoping Review

It is important to examine the psychotropic prescription practices in schizophrenia, as it can inform regarding changing treatment choices and related patient profiles. No recent reviews have evaluated the global neuropsychopharmacological prescription patterns in adults with schizophrenia. A systematic search of the literature published from 2002 to 2023 found 88 empirical papers pertinent to the utilization of psychotropic agents. Globally, there were wide inter-country and inter-regional variations in the prescription of psychotropic agents. Overall, over time there was an absolute increase in the prescription rate of second-generation antipsychotics (up to 50%), mood stabilizers (up to 15%), and antidepressants (up to 17%), with an observed absolute decrease in the rate of antipsychotic polypharmacy (up to 15%), use of high dose antipsychotic (up to 12% in Asia), clozapine (up to 9%) and antipsychotic long-acting injectables (up to 10%). Prescription patterns were mainly associated with specific socio-demographic (such as age), illness (such as illness duration), and treatment factors (such as adherence). Further work, including more evidence in adjunctive neuropsychopharmacological treatments, pharmaco-economic considerations, and examination of cohorts in prospective studies, can proffer insights into changing prescription trends relevant to different treatment settings and predictors of such trends for enhancement of clinical management in schizophrenia.

Treatment with Soteria-elements in acute psychiatry-Effectiveness for acutely ill and voluntarily treated patients

Objective

This article aims at evaluating the treatment outcomes of acute psychiatric patients before and after the implementation of Soteria-elements in an acute psychiatric ward. The implementation process resulted in an interconnected small locked and much larger open area, enabling continuous milieu therapeutic treatment by the same staff in both areas. This approach enabled the comparison of structural and conceptual reconstruction regarding treatment outcomes of all voluntarily treated acutely ill patients before (2016) and after (2019). A subgroup analysis focused on patients suffering from schizophrenia.

Methods

Using a pre-post design, the following parameters were examined: total treatment time, time in locked ward, time in open ward, antipsychotic discharge medication, re-admissions, discharge circumstances, and treatment continuation in day care clinic.

Results

Compared to 2016, there was no significant difference in the total time of stay in the hospital. However, data show a significant decrease of days spent in locked ward, a significant increase of days in open ward, a significant increase of treatment discontinuation but without an increase of re-admissions, and a significant interaction of diagnosis and year regarding the medication dosage, resulting altogether in a reduction of antipsychotic medication for patients suffering from schizophrenia spectrum disorder.

Conclusion

The implementation of Soteria-elements in an acute ward facilitates less potentially harmful treatments of psychotic patients, likewise enabling lower dosages of medication.

Clinical determinants, patterns and outcomes of antipsychotic medication prescribing in the treatment of schizophrenia and schizoaffective disorder: A naturalistic cohort study

BACKGROUND

Schizophrenia affects individuals, families, and systems, with treatment primarily being antipsychotic medications. Long-acting injectable (LAI) antipsychotics are increasingly being used. This study sought to identify predictors of antipsychotic choice, in terms of formulation (LAI vs oral) and class (FGA vs SGA), and clinical outcomes.

METHODS

123 patients who received LAI antipsychotics were diagnosis-matched to patients who received oral antipsychotics. Sociodemographic and clinical factors were extracted from the medical record, including indicators of illness severity. Groups were compared with Chi-Square and t-tests, and logistic regression models were used to identify independent predictors of antipsychotic choice.

RESULTS

Patients that received LAIs had longer admissions, more complex discharges, and greater illness severity; however, there were no differences in readmission rates. Independent predictors of LAIs included younger age, being single, and longer admission. Patients who received FGA LAIs were more likely to use substances and be undomiciled compared to SGA LAIs, with the only predictor being older age. Oral FGAs were more likely than Oral SGAs to be prescribed to older and female patients, as well as those with co-occurring substance use, complex discharges, and longer admissions.

CONCLUSIONS

Illness severity and duration of illness appear to drive choice of LAI vs. oral antipsychotic medication and FGA vs. SGA. While LAIs were prescribed to patients with greater illness severity, readmission rates were equivalent to those receiving oral medication, supporting the use of LAI in patients with greater illness severity. Rationales for prescribing LAIs to younger patients and FGAs to older patients are discussed.

The stress-vulnerability model on the path to schizophrenia: Interaction between BDNF methylation and schizotypy on the resting-state brain network

The interplay between schizophrenia liability and environmental influences has been considered to be responsible for the development of schizophrenia. Recent neuroimaging studies have linked aberrant functional connectivity (FC) between the default-mode network (DMN) and the frontoparietal network (FPN) in the resting-state to the underlying neural mechanism of schizophrenia. By using schizotypy as the proxy for genetic-based liability to schizophrenia and methylation of brain-derived neurotrophic factor (BDNF) to represent environmental exposure, this study investigated the impact of the interaction between vulnerability and the environment on the neurobiological substrates of schizophrenia. Participants in this study included 101 healthy adults (HC) and 46 individuals with ultra-high risk for psychosis (UHR). All participants were tested at resting-state by functional magnetic resonance imaging, and group-independent component analysis was used to identify the DMN and the FPN. The Perceptual Aberration Scale (PAS) was used to evaluate the schizotypy level. The methylation status of BDNF was measured by pyrosequencing. For moderation analysis, the final sample consisted of 83 HC and 32 UHR individuals. UHR individuals showed reduced DMN-FPN network FC compared to healthy controls. PAS scores significantly moderated the relationship between the percentage of BDNF methylation and DMN-FPN network FC. The strength of the positive relationship between BDNF methylation and the network FC was reduced when the schizotypy level increased. These findings support the moderating role of schizotypy on the neurobiological mechanism of schizophrenia in conjunction with epigenetic changes.

Efficacy of Transcranial Direct-Current Stimulation in Catatonia: A Review and Case Series

Catatonia is a severe neuropsychiatric syndrome, usually treated by benzodiazepines and electroconvulsive therapy. However, therapeutic alternatives are limited, which is particularly critical in situations of treatment resistance or when electroconvulsive therapy is not available. Transcranial direct-current stimulation (tDCS) is a promising non-invasive neuromodulatory technique that has shown efficacy in other psychiatric conditions. We present the largest case series of tDCS use in catatonia, consisting of eight patients in whom tDCS targeting the left dorsolateral prefrontal cortex and temporoparietal junction was employed. We used a General Linear Mixed Model to isolate the effect of tDCS from other confounding factors such as time (spontaneous evolution) or co-prescriptions. The results indicate that tDCS, in addition to symptomatic pharmacotherapies such as lorazepam, seems to effectively reduce catatonic symptoms. These results corroborate a synthesis of five previous case reports of catatonia treated by tDCS in the literature. However, the specific efficacy of tDCS in catatonia remains to be demonstrated in a randomized controlled trial. The development of therapeutic alternatives in catatonia is of paramount importance.

Altered Visuospatial Processing in Schizophrenia: An Event-related Potential Microstate Analysis Comparing Patients with and without Hallucinations with Healthy Controls

Patients with schizophrenia present with various symptoms related to different domains. Abnormalities of auditory and visual perception are parts of a more general problem. Nevertheless, the relationship between the lifetime history of auditory verbal hallucination (AVH), one of the most prevalent symptoms in schizophrenia, and visuospatial deficits remains unclear. This study aimed to investigate differences in hemispheric involvement and visuospatial processing between healthy controls (HCs) and schizophrenia patients with and without AVHs. HCs (N = 20), schizophrenia patients with AVH (AVH group, N = 16), and schizophrenia patients without hallucinations (NH group, N = 10) participated in a 4-choice reaction task with lateralized stimuli. An event-related potential (ERP)-microstate approach was used to analyze ERP differences between the conditions and groups. The schizophrenia patients without hallucinations had slower responses than the HCs. An early visual N1 contralateral to stimulation side was prominent in all groups of participants but with decreased amplitude in the patients with schizophrenia, especially in the AVH group over the right hemisphere. The amplitude of P3b, a cognitive evaluation component, was also decreased in schizophrenia. Compared to AVH and HC groups, the patients in the NH group had altered microstate patterns: P3b was replaced by a novelty component, P3a. Although the difference between both patient groups was only based on the presence of AVHs, our findings indicated that patients had specific visuospatial deficits associated with a lifetime history of hallucinations: patients with AVHs showed early visual component alterations in the right hemisphere, and those without AVHs had more prominent visuospatial impairment.

Associations of Clozapine Use With Psychosocial Functioning and Quality of Life in Patients With Schizophrenia: A Community-Based Cross-Sectional Study

OBJECTIVE

More attempts have been made recently to improve psychosocial functioning and quality of life in patients with schizophrenia, due to their crucial role in long-term outcomes. Previous studies on the effects of clozapine on psychosocial functioning have been limited in terms of generalizability and application to clinical practice. This study examined the relationship of clozapine use with psychosocial functioning and quality of life in patients with schizophrenia in a real-world setting.

METHODS

Data were obtained from a survey targeting community-dwelling patients with schizophrenia. The Behavior and Symptom Identification Scale (BASIS) and Satisfaction with Life Scale (SWLS) were administered to evaluate psychosocial functioning and quality of life, and patients were classified into Clozapine and Non-clozapine groups. Group differences were assessed using ANCOVA, with additional sensitivity analyses for participants on atypical antipsychotic medications only.

RESULTS

Of 292 patients, the Clozapine group (n=34) had significantly better psychosocial functioning and quality of life than the Nonclozapine group (n=258), as demonstrated by their low BASIS score (F=4.651, df=1, 290, p=0.032) and high SWLS score (F=14.637, df=1, 290, p<0.001). Similar findings for psychosocial outcomes were observed in the analyses of the atypical antipsychotic subgroup (n=195).

CONCLUSION

For optimal recovery in schizophrenia, restoration of impaired social functioning and enhanced satisfaction with life are essential. In this study, clozapine use was related to high levels of psychosocial functioning and quality of life in real-world settings. Further research on the causal relationship between clozapine use and psychosocial functioning is needed.

Diffusion MRI derived free-water imaging measures in patients with schizophrenia and their non-psychotic siblings

Free-water imaging is a diffusion MRI technique that separately models water diffusion hindered by fiber tissue and water that disperses freely in the extracellular space. Studies using this technique have shown that schizophrenia is characterized by a lower level of fractional anisotropy of the tissue compartment (FA_t) and higher free-water fractional volume (FW). It is unknown, however, whether such abnormalities are an expression of pre-existing (genetic) risk for schizophrenia or a manifestation of the illness. To investigate the contribution of familial risk factors to white matter abnormalities, we used the free-water imaging technique to assess FA_t and FW in a large cohort of 471 participants including 161 patients with schizophrenia, 182 non-psychotic siblings, and 128 healthy controls. In this sample, patients did not show significant differences in FA_t as compared to controls, but did exhibit a higher level of FW relative to both controls and siblings in the left uncinate fasciculus, superior corona radiata and fornix / stria terminalis. This increase in FW was found to be related to, though not solely explained by, ventricular enlargement. Siblings did not show significant FW abnormalities. However, siblings did show a higher level of FA_t as compared to controls and patients, in line with results of a previous study on the same data using conventional DTI. Taken together, our findings suggest that extracellular free-water accumulation in patients is likely a manifestation of established disease rather than an expression of familial risk for schizophrenia and that super-normal levels of FA_t in unaffected siblings may reflect a compensatory process.

Shame and guilt in youth at ultra-high risk for psychosis

OBJECTIVE

Feelings of shame and guilt have rarely been investigated in people at ultra-high risk (UHR) for psychosis. We aimed to outline differences in shame and guilt in relation to empathy and theory of mind (ToM) in young people, particularly those at UHR for psychosis.

METHODS

First, 166 young healthy controls were assessed for their proneness to shame and guilt using the Test of Self-Conscious Affect, empathy and its four subdomains (perspective taking, fantasy, empathic concern, and personal distress) using the Interpersonal Reactivity Index (IRI), ToM using the ToM picture stories task, and neurocognitive performance using the Raven's Standard Progressive Matrices (SPM). Next, we evaluated shame and guilt in 24 UHR individuals comparing them to 24 age- and sex-matched healthy controls. Finally, we explored relationships for shame and guilt in relation to empathy and ToM in the UHR individuals.

RESULTS

In the healthy youth, a regression analysis showed fantasy and personal distress in IRI to be significant determinants of shame, while perspective taking and empathic concern in IRI, ToM, and SPM were independent predictors of guilt. Meanwhile, compared to the healthy controls, individuals with UHR exhibited higher levels of shame, which was associated with increased personal distress.

DISCUSSION

Our findings showed that four subdomains of empathy, ToM, and neurocognition were differentially associated with shame and guilt in healthy young people. Given the correlation between excessive feelings of shame and high levels of the personal distress dimension of empathy in UHR for psychosis, redressing the tendency to focus on self-oriented negative emotions upon witnessing distress of others could possibly reduce self-blame or self-stigma of help-seeking individuals.

Disentangling age- and disease-related alterations in schizophrenia brain network using structural equation modeling: A graph theoretical study based on minimum spanning tree

Functional brain networks have been shown to undergo fundamental changes associated with aging or schizophrenia. However, the mechanism of how these factors exert influences jointly or interactively on brain networks remains elusive. A unified recognition of connectomic alteration patterns was also hampered by heterogeneities in network construction and thresholding methods. Recently, an unbiased network representation method regardless of network thresholding, so called minimal spanning tree algorithm, has been applied to study the critical skeleton of the brain network. In this study, we aimed to use minimum spanning tree (MST) as an unbiased network reconstruction and employed structural equation modeling (SEM) to unravel intertwined relationships among multiple phenotypic and connectomic variables in schizophrenia. First, we examined global and local brain network properties in 40 healthy subjects and 40 schizophrenic patients aged 21–55 using resting‐state functional magnetic resonance imaging (rs‐fMRI). Global network alterations are measured by graph theoretical metrics of MSTs and a connectivity‐transitivity two‐dimensional approach was proposed to characterize nodal roles. We found that networks of schizophrenic patients exhibited a more star‐like global structure compared to controls, indicating excessive integration, and a loss of regional transitivity in the dorsal frontal cortex (corrected p <.05). Regional analysis of MST network topology revealed that schizophrenia patients had more network hubs in frontal regions, which may be linked to the “overloading” hypothesis. Furthermore, using SEM, we found that the level of MST integration mediated the influence of age on negative symptom severity (indirect effect 95% CI [0.026, 0.449]). These findings highlighted an altered network skeleton in schizophrenia and suggested that aging‐related enhancement of network integration may undermine functional specialization of distinct neural systems and result in aggravated schizophrenic symptoms.

From Wish to Reality: Soteria in Regular Care-Proof of Effectiveness of the Implementation of Soteria Elements in Acute Psychiatry

Objective: This article examines the influence of the implementation of Soteria elements on coercive measures in an acute psychiatric ward after reconstruction in 2017, thereby comparing the year 2016 to the year 2019. The special feature is that this is the only acute psychiatric ward in Hennigsdorf Hospital, connected now both spatially and therapeutically to an open ward and focusing on the treatment of patients suffering from schizophrenia and schizophrenia spectrum disorders. Methods: The following parameters were examined: aggressive assaults, use of coercion (mechanical restraints), duration of treatment in open or locked ward, type of discharge, coercive medication, and dosage of applied antipsychotics. For this purpose, the data of all legally accommodated patients in the year 2016 (before the reconstruction) and 2019 (after the reconstruction) were statistically analyzed in a pre-post mirror quasi-experimental design. Results: In 2019, the criteria of the Soteria Fidelity Scale for a ward with Soteria elements were reached. In comparison to 2016 with a comparable care situation and a comparable patient clientele, there was now a significant decrease in aggressive behavior toward staff and fellow patients, a significantly reduced number of fixations, a significantly reduced overall duration of inpatient stay, and a significant increase in treatment time in the open area of our acute ward. Conclusion: The establishment of Soteria elements in the acute psychiatric ward leads to a verifiable less violent environment of care for severely ill patients and to a drastic reduction in coercive measures.

Preclinical atherosclerosis in adolescents with psychotic or bipolar disorders investigated with carotid high-frequency ultrasound

OBJECTIVE

Early-onset psychosis (EOP) and bipolar disorder (EOBP) (at <18 years of age), are associated with an increased future risk of cardiovascular disease (CVD) and premature death. Yet it is unknown whether the arteries show visible signs of atherosclerosis in EOP and EOBP. This study investigated whether having EOP or EOBP was associated with detectable signs of preclinical atherosclerosis.

METHOD

By using 22 MHz high-frequency ultrasound, different layers of the arterial wall of the left common carotid artery (LCCA) were assessed in 77 individuals with EOP (n = 25), EOBP (n = 22), and in age-matched healthy controls (n = 30). Conventional CVD confounders were included in the analyses.

RESULTS

Adolescents with EOP and EOBP, compared to controls, had a significantly thicker LCCA intima thickness (0.132 vs. 0.095 mm, p < .001) and intima/media ratio (0.24 vs. 0.17 p < .001). There was a nonsignificant intima difference between EOP and EOBP. Conventional CVD risk factors did not explain the association between EOP/EOBP and intima thickness. In the group of EOP/EOBP, there was a significant correlation between the dose of current antipsychotic medication and intima thickness; however, the correlation was attenuated to a nonsignificant level when adjusted for global function.

CONCLUSIONS

Adolescents with EOP or EOBP had an increased LCCA intima thickness, interpreted as a sign of preclinical atherosclerosis. Global function of the disorders was the strongest determinant of intima thickness. The findings, if replicated, might have implications for long-term treatment of EOP and EOBP in order to reduce a future risk of CVD.

Reduced activation of the ventromedial prefrontal cortex during self-referential processing in individuals at ultra-high risk for psychosis

OBJECTIVE

Defects in self-referential processing and perspective-taking are core characteristics that may underlie psychotic symptoms and impaired social cognition in schizophrenia. Here, we investigated the neural correlates of self-referential processing regardless of the perspective taken and third-person perspective-taking regardless of the target person to judge relevance in individuals at ultra-high risk for psychosis. We also explored relationships between alterations in neural activity and neurocognitive function and basic self ('ipseity') disorder.

METHODS

Twenty-two ultra-high-risk individuals and 28 healthy controls completed a functional magnetic resonance imaging task. While being scanned, participants were asked to take a first-person perspective or to put themselves in their close relative's place thereby adopting a third-person perspective during judgments of the relevance of personality trait adjectives to one's self and a close relative.

RESULTS

For self-referential (vs other-referential) processing, ultra-high-risk individuals showed less neural activity in the left ventromedial prefrontal cortex/medial orbitofrontal cortex, which was correlated with poor working memory performance. When taking a third-person perspective (vs first-person perspective), ultra-high-risk individuals showed more activity in the middle occipital gyrus.

CONCLUSION

Taken together, our findings suggest that ultra-high-risk individuals already show aberrant neural activity during self-referential processing which may possibly be related to engagement of working memory resources.

Individualizing antipsychotic treatment selection in schizophrenia: characteristics of empirically derived patient subgroups

Treatment of schizophrenia with antipsychotic drugs is frequently sub-optimal. One reason for this may be heterogeneity between patients with schizophrenia. The objectives of this study were to identify patient, disease and treatment attributes that are important for physicians in choosing an antipsychotic drug, and to identify empirically subgroups of patients who may respond differentially to antipsychotic drugs. The survey was conducted by structured interview of 744 randomly-selected psychiatrists in four European countries who recruited 3996 patients with schizophrenia. Information on 39 variables was collected. Multiple component analysis was used to identify dimensions that explained the variance between patients. Three axes, accounting for 99% of the variance, were associated with disease severity (64%), socioeconomic status (27%) and patient autonomy (8%). These dimensions discriminated between six discrete patient subgroups, identified using ascending hierarchical classification analysis. The six subgroups differed regarding educational level, illness severity, autonomy, symptom presentation, addictive behaviors, comorbidities and cardiometabolic risk factors. Subgroup 1 patients had moderately severe physician-rated disease and addictive behaviours (23.2%); Subgroup 2 patients were well-integrated and autonomous with mild to moderate disease (6.7%); Subgroup 3 patients were less well-integrated with mild to moderate disease, living alone (11.2%); Subgroup 4 patients were women with low education levels (5.4%), Subgroup 5 patients were young men with severe disease (36.8%); and Subgroup 6 patients were poorly-integrated with moderately severe disease, needing caregiver support (16.7%). The presence of these subgroups, which require confirmation and extension regarding potentially identifiable biological markers, may help individualizing treatment in patients with schizophrenia.

Brain morphometry of individuals with schizophrenia with and without antipsychotic medication – The Northern Finland Birth Cohort 1966 Study

Background

In schizophrenia, brain morphometric changes may be associated with antipsychotic medication. Only limited data is available concerning individuals with schizophrenia without antipsychotic medication. We aimed to study the associations of: use versus no use of antipsychotic medication; length of continuous time without antipsychotic medication; cumulative dose of lifetime antipsychotic medication; and type of antipsychotic medication; with brain morphometry in schizophrenia after an average of 10 years of illness.

Methods

Data of 63 individuals with schizophrenia (mean duration of illness 10.4 years) from the Northern Finland Birth Cohort 1966 were gathered by interview and from hospital and outpatient records. Structural MRI data at age 34 years were acquired and grey matter volume maps with voxel-based morphometry were analyzed using FSL tools.

Results

Of the individuals studied, 15 (24%) had taken no antipsychotic medication during the previous year. Individuals with antipsychotic medication had lower total grey matter (TGM) volume compared with non-medicated subjects, although this association was not statistically significant (Cohen's d = –0.51, P = 0.078). Time without antipsychotic medication associated with increased TGM (P = 0.028). Longer time without antipsychotic medication associated with increased regional volume in right precentral gyrus and right middle frontal gyrus. There were no associations between cumulative dose of lifetime antipsychotic medication or type of antipsychotic medication and brain morphometry.

Conclusions

Unlike some previous investigators, we found no association between cumulative dose of lifetime antipsychotic medication and brain morphological changes in this population-based sample. However, longer continuous time without antipsychotic medication preceding the MRI scan associated with increased gray matter volume.

Earlier tracheostomy is associated with an earlier return to walking, talking, and eating

BACKGROUND

Conjecture remains regarding the optimal timing for tracheostomy. Most studies examine patient mortality, ventilation duration, intensive care unit (ICU) length of stay, and medical complications. Few studies examine patient-centric outcomes. The aim of this study was to determine whether timing of tracheostomy had an impact on length of stay, morbidity, mortality, and patient-centric outcomes towards their functional recovery.

METHODS

This prospective observational study included data for all tracheostomised patients over 4 y in a tertiary ICU. The study time period commenced with the insertion of an endotracheal tube. Data collected included patient and disease specifics; mortality up to 4 y; mobility scores; and time to oral intake, talking, and out-of-bed exercises. To assess differences between timing of tracheostomy, a survival analysis was conducted to dynamically compare patients on days before and after tracheostomy tube (TT) placement during their ICU admission.

RESULTS

TT was placed in 276 patients. After tracheostomy, the patients were able to (on average) verbally communicate 7.4 d earlier (confidence interval [CI] = -9.1 to -4.9), return to oral intake 7.0 d earlier (CI = -10 to -4.6), and perform out-of-bed exercises 6.2 d earlier (CI = -8.4 to -4) than those who did not yet have a TT. In patients with an endotracheal tube, none were able to talk or have oral intake, and the majority (99%) did not participate in out-of-bed exercises/active rehabilitation. After tracheostomy, patients subsequently received significantly less analgesic and sedative drugs and more antipsychotics. No clear differences in ICU and long-term mortality were associated with tracheostomy timing.

CONCLUSIONS

Earlier tracheostomy is associated with earlier achievement of patient-centric outcomes - patients returning to usual daily activities such as talking, out-of-bed mobility, and eating/drinking significantly earlier, whilst also receiving less sedatives and analgesics.

Long-term antipsychotic use and its association with outcomes in schizophrenia – the Northern Finland Birth Cohort 1966

Background

Due to the paucity of previous studies, we wanted to elucidate the pharmacoepidemiology of antipsychotics in schizophrenia in a general population sample, and the association between long-term antipsychotic use and outcomes.

Methods

The sample included 53 schizophrenia subjects from the Northern Finland Birth Cohort 1966 with at least ten years of follow-up (mean 18.6 years since illness onset). Data on lifetime medication and outcomes (remission, Clinical Global Impression [CGI], Social and Occupational Functioning Assessment Scale [SOFAS]) were collected from medical records, interviews, and national registers.

Results

During the first two years 22 (42%), between two to five years 17 (32%), and between five to ten years 14 (26%) subjects had used antipsychotics less than half of the time. Drug-free periods became rarer during the follow-up. The mean lifetime daily dose of antipsychotics was 319 mg in chlorpromazine equivalents. A high lifetime average and cumulative dose and antipsychotic polypharmacy were associated with a poorer outcome in all measures, whereas having no drug-free periods was associated with a better SOFAS score and a low proportion of time on antipsychotics with a better CGI score.

Conclusions

In our population-based sample, the use of antipsychotics increased during the first five years of illness and was relatively stable after that. Our results suggest that both low dose and proportion of use, and having no drug-free periods, are associated with better outcomes, which concords with current treatment recommendations and algorithms. High long-term doses and polypharmacy may relate to poor outcomes.

Impaired Facial Emotion Recognition in Individuals at Ultra-High Risk for Psychosis and Associations With Schizotypy and Paranoia Level

BACKGROUND

Patients with schizophrenia and individuals at ultra-high risk for psychosis (UHR) have been reported to exhibit impaired recognition of facial emotion expressions. This impairment has involved both inaccuracy and negative bias of facial emotion recognition. The present study aimed to investigate whether UHR individuals display both types of impaired facial emotion recognition and to explore correlations between these impairments and schizotypy, as well as paranoia levels, in these individuals.

METHODS

A total of 43 UHR individuals and 57 healthy controls (HC) completed a facial emotion recognition task consisting of 60 standardized facial photographs. To explore correlations, we assessed schizotypy using the Revised Physical Anhedonia Scale and Magical Ideation Scale and paranoia level using the Paranoia Scale and persecution/suspicious item of the Positive and Negative Syndrome Scale in UHR individuals.

RESULTS

Compared with HC, UHR individuals exhibited less accuracy for facial emotion recognition (70.6% vs. 75.6%, p=0.010) and a higher rate of "fear" responses for neutral faces (14.5% vs. 6.0%, p=0.003). In UHR individuals, inaccuracy was significantly correlated with schizotypy scores, but not with paranoia level. Conversely, "disgust" response for neutral faces was the only fear response correlated with paranoia level, and no threat-related emotion response correlated with schizotypy scores.

DISCUSSION

UHR individuals exhibited inaccuracy and negative bias of facial emotion recognition. Furthermore, schizotypy scores were associated with inaccuracy but not with negative bias of facial emotion recognition. Paranoia level was correlated with "disgust" responses for neutral faces but not with inaccuracy. These findings suggest that inaccuracy and negative bias of facial emotion recognition reflect different underlying processes, and that inaccuracy may be a vulnerability marker for schizophrenia.

Sedatives, analgesics and antipsychotics in tracheostomised ICU patients - Is less more?

BACKGROUND

Sedation and anaesthesia are used universally to facilitate mechanical ventilation - with larger cumulative doses being used in those with prolonged ventilation. Transitioning from an endotracheal to a tracheostomy tube enables the depth of sedation to be reduced. Early use of speaking valves with tracheostomised patients has become routine in some intensive care units (ICU). The return of verbal communication has been observed to improve ease of patient care and increase patient and family engagement, with a perceived reduction in patient agitation.

OBJECTIVES

To investigate the potential impact of speaking valve (SV) use on requirements of sedatives, analgesics and antipsychotics in ICU patients with a tracheostomy.

METHODS

A retrospective data audit was undertaken for all tracheostomised patients in a cardio-respiratory ICU from 2011 to 2014. Use of sedative, analgesic and antipsychotic drugs was captured for endotracheal tube, tracheostomy and SV periods, including patient demographics, disease specifics and severity. Stratified Cox regression analysis was performed to determine the effects of SV on drug dosage.

RESULTS

Of 257 patients, 144 (56%) received an SV. Use of an SV was associated with reduced risk of being in the upper quartile of daily dosage of analgesics (HR: 0.6; 95% CI: 0.5-0.8; p < 0.001). In the final adjusted multivariable model, analgesic dose was additionally associated with age, and attendance to operating theatre during ICU. Sedative dose was associated with age, gender and SOFA score. Antipsychotic dose was associated with gender (less likely in females: HR 0.6, 95% CI: 0.4-0.8), age and APACHE score.

CONCLUSIONS

There was significantly less analgesic used in patients with an SV compared to those without. However, SV use in patients with tracheostomy was not found to be associated with reduced dose of sedatives or antipsychotics, despite the clinical impression. Future prospective studies are needed to more adequately investigate the association between drugs and patients' ability to verbally participate in their care.

Consumers' understanding and expectations of a community-based recovery-oriented mental health rehabilitation unit: a pragmatic grounded theory analysis

AIMS

Incorporating consumer perspectives into mental health services design is important in working to deliver recovery-oriented care. One of the challenges faced in mental health rehabilitation services is limited consumer engagement with the available support. Listening to consumers' expectations of mental health services, and what they hope to achieve, provides an opportunity to examine the alignment between existing services and the priorities and preferences of the people who use them. We explored consumer understandings and expectations of three recovery-oriented community-based residential mental-health rehabilitation units using semi-structured interviews; two of these units were trialling a staffing model integrating peer support with clinical care.

METHODS

Twenty-four consumers completed semi-structured interviews with an independent interviewer during the first 6 weeks of their stay at the rehabilitation unit. Most participants had a primary diagnosis of schizophrenia or a related psychotic disorder (87%). A pragmatic approach to grounded theory guided the analysis, facilitating identification of content and themes, and the development of an overarching conceptual map.

RESULTS

The rehabilitation units were considered to provide a transformational space and a transitional place. The most common reason given for engagement was housing insecurity or homelessness rather than the opportunity for rehabilitation engagement. Differences in expectations did not emerge between consumers entering the clinical and integrated staffing model sites.

CONCLUSIONS

Consumers understand the function of the rehabilitation service they are entering. However, receiving rehabilitation support may not be the key driver of their attendance. This finding has implications for promoting consumer engagement with rehabilitation services. The absence of differences between the integrated and clinical staffing models may reflect the novelty of the rehabilitation context. The study highlights the need for staff to find better ways to increase consumer awareness of the potential relevance of evidence-based rehabilitation support to facilitating their recovery.

Optimization of Antipsychotic and Benzodiazepine Drugs in Patients with Severe Mental Disorders in an Intensive Case Management Program

The Intensive Case Management (ICM) model is a community-based program for people with severe mental illness that may reduce hospitalization and increase retention in care. The aims of this study were to analyze changes in the antipsychotic and benzodiazepine dosage in 106 patients who participated in an Individualized Service Program based on the ICM model for at least 6 months and to assess the change in the number of patients taking a high or very high dose of an antipsychotic drug and the number receiving antipsychotic polytherapy. Both the average daily dose of antipsychotic and benzodiazepine drugs and the number of patients with high doses of antipsychotic and more than one antipsychotic drug decreased significantly. Implementing the ICM program in patients with severe mental illness could help to decrease adverse drug effects and health care expenditures.

Psychotic conversion of individuals at ultra-high risk for psychosis: The potential roles of schizotypy and basic symptoms

AIM

To improve strategies for the early identification of individuals at a heightened risk for the development of psychosis, we investigated the relationships and interactions between 3 psychosis-proneness dimensions for the development of schizophrenia spectrum psychosis: schizotypy, basic symptoms and the ultra-high risk (UHR) criteria.

METHODS

Seventy-seven UHR individuals and 79 healthy controls were assessed for schizotypy and basic symptoms using self-report questionnaires at baseline. UHR participants were monthly assessed for conversion to psychosis over a mean period of 25.8 months.

RESULTS

Sixteen UHR participants (20.8%) converted to schizophrenia spectrum psychosis. In stepwise Cox regression, the interaction between basic symptoms and physical anhedonia was selected as a sole predictor of conversion in UHR participants, whereby the self-reported number of the 8 basic symptoms significantly increased the risk for conversion in those with pronounced physical anhedonia.

CONCLUSION

Our findings suggest that questionnaire-assessed basic symptoms, irrespective of their predictive validity, may predict a psychotic breakdown in pre-identified UHR individuals who are with genetic vulnerability to schizophrenia. Including all 3 psychosis-proneness dimensions into prediction models might help establish a more valid pathogenetic model of schizophrenia, and moreover, may provide some clues about course alteration strategies in hopes of preventing UHR individuals from converting to psychosis.

Hypo-activity of the dorsolateral prefrontal cortex relates to increased reaction time variability in patients with schizophrenia

Increased reaction time intra-subject variability (RT-ISV) in fast decision tasks has been confirmed in patients with schizophrenia and has been hypothesized to result from a deficit in the control of attention. Here, an attentional task and functional brain imaging were used to probe the neural correlates of increased RT-ISV in schizophrenia.

Thirty patients and 30 age and sex matched controls performed the Eriksen flanker spatial attention task with concurrent measurement of brain activity using functional magnetic resonance imaging (fMRI). The behavioral measures included accuracy, mean, standard deviation of RT (RTSD), coefficient of variation of RT (RTCV) and ex-Gaussian model of RT distribution parameters (mu, sigma and tau).

Larger mean RT and Ex-Gaussian mu was observed for patients compared to controls. The group difference was larger for incongruent (attentionally demanding) versus congruent trials confirming a deficit in the control of spatial attention for patients. Significant increase in RT-ISV measures (RTSD, sigma and tau) for patients compared to controls was observed and was not modulated by trial congruency. Attention modulation (congruency effect) resulted in activation of bilateral frontal and parietal areas that was not different between patients and controls. Right middle frontal, right superior temporal and bilateral cingulate areas were more active in controls compared to patients independent of congruency. Activation in ROIs extracted from attention (congruency) and group related areas correlated with RT-ISV measures (especially RTCV and tau). Hypo-activation of the right middle frontal area correlated with increased tau specifically in patients.

Hypo-activity of the right prefrontal cortex predicted increased RT-ISV in schizophrenia. This effect was unrelated to the effects of spatial attention and might be linked to a deficit in the inhibitory control of action for these patients.

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Schizophrenia patients show increased reaction time intra-subject variability (RT-ISV).

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fMRI of patients and aged matched controls while performing a spatial attention task.

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RT-ISV measures were increased in patients independent of spatial attention load.

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Activity of the right middle frontal cortex predicted RT-ISV increase in patients.

Factors Associated With Psychosocial Functioning and Outcome of Individuals With Recent-Onset Schizophrenia and at Ultra-High Risk for Psychosis

Background: Patients with schizophrenia have impairments in social functioning and are readmitted to healthcare institutions frequently. Individuals at ultra-high risk (UHR) for psychosis already present poor social functioning; among those individuals, the conversion rate from the putative prodromal phase to overt psychosis is 20%-30% within 1-2 years. Here, we analyzed the factor structure of self-related variables and neuro- and socio-cognitive function, and investigated whether these factors were associated with psychosocial function and prognostic outcome in individuals with recent-onset schizophrenia (ROSPR) or at UHR for psychosis. Methods: We evaluated 60 individuals at UHR for psychosis, 47 individuals with ROSPR, and 71 healthy controls using a comprehensive neurocognitive test battery and self-reported attribution scales, self-esteem, resilience, aberrant subjective experiences of schizotypy (physical anhedonia, social anhedonia, magical ideation, and perceptual aberration), and basic symptoms. We assessed psychosocial function with the Quality of Life Scale (QLS). Results: Factor analysis of all subjects revealed a four-factor structure comprising social-cognitive bias, reflective self, neurocognition, and pre-reflective self factors. Multiple regression analysis at baseline revealed that the factor structure predicted QLS. In the UHR group, social-cognitive bias, reflective self, neurocognition, and negative symptoms were significant determinants, explaining 38.0% of total QLS score variance. In the ROSPR group, reflective self and negative symptoms were significant determinants, explaining 54.4% of total QLS score variance. During follow-up, 13 individuals at UHR for psychosis developed psychosis (cumulative prevalence: 31.2% ± 7.6% at 6 years), with neurocognition score at baseline remaining a significant predictor of conversion [χ²(1) = 4.009, p = 0.045; hazard ratio 0.56, 95% confidence interval 0.31-0.99, p = 0.048]. Five patients with schizophrenia were (re)admitted during follow-up (cumulative prevalence: 16.1% ± 7.1% at 6 years); no factor was found to predict (re)admission. Conclusion: Factor analysis revealed an intrinsic four-factor structure of social-cognitive bias, reflective self, neurocognition, and pre-reflective self. The four factors were associated with social functioning at baseline and prodrome-to-psychosis conversion during follow-up, indicating the clinical significance of the four-factor structure. These findings provide a framework for understanding schizophrenia.

Management of Violence and Aggression in Emergency Environment; a Narrative Review of 200 Related Articles

CONTEXT

The aim of this study is to reviewing various approaches for dealing with agitated patients in emergency department (ED) including of chemical and physical restraint methods.

EVIDENCE ACQUISITION

This review was conducted by searching "Violence," "Aggression," and "workplace violence" keywords in these databases: PubMed, Scopus, EmBase, ScienceDirect, Cochrane Database, and Google Scholar. In addition to using keywords for finding the papers, the related article capability was used to find more papers. From the found papers, published papers from 2005 to 2018 were chosen to enter the paper pool for further review.

RESULTS

Ultimately, 200 papers were used in this paper to conduct a comprehensive review regarding violence management in ED. The results were categorized as prevention, verbal methods, pharmacological interventions and physical restraint.

CONCLUSION

In this study various methods of chemical and physical restraint methods were reviewed so an emergency medicine physician be aware of various available choices in different clinical situations for agitated patients.

Predicting parkinsonism side-effects of antipsychotic polypharmacy prescribed in secondary mental healthcare

BACKGROUND

Computer-modelling approaches have the potential to predict the interactions between different antipsychotics and provide guidance for polypharmacy.

AIMS

To evaluate the accuracy of the quantitative systems pharmacology platform to predict parkinsonism side-effects in patients prescribed antipsychotic polypharmacy.

METHODS

Using anonymized data from South London and Maudsley NHS Foundation Trust electronic health records we applied quantitative systems pharmacology, a neurophysiology-based computer model of humanized neuronal circuits, to predict the risk for parkinsonism symptoms in patients with schizophrenia prescribed two concomitant antipsychotics. The performance of the quantitative systems pharmacology model was compared with the performance of simple parameters such as: combination of affinity constants (1/K_sum); sum of D₂R occupancies (D₂R) and chlorpromazine equivalent dose.

RESULTS

We identified 832 patients with schizophrenia who were receiving two antipsychotics for six or more months, between 1 January 2007 and 31 December 2014. The area under the receiver operating characteristic (AUROC) curve for the quantitative systems pharmacology model was 0.66 ( p = 0.01), while AUROCs for D₂R, 1/K_sum and chlorpromazine equivalent dose were 0.52 ( p = 0.350), 0.53 ( p = 0.347) and 0.52 ( p = 0.330) respectively.

CONCLUSION

Our results indicate that quantitative systems pharmacology has the potential to predict the risk of parkinsonism associated with antipsychotic polypharmacy from minimal source information, and thus might have potential decision-support applicability in clinical settings.

Aberrant Tendency of Noncurrent Emotional Experiences in Individuals at Ultra-High Risk for Psychosis

OBJECTIVE

This study aimed to investigate whether aberrant tendency of noncurrent emotion was present in individuals at ultra-high risk (UHR) for psychosis and to explore its associations with various clinical profiles.

METHODS

Fifty-seven individuals at UHR and 49 normal controls were enrolled. The tendency of experiencing noncurrent emotion was assessed using various noncurrent emotional self-reported formats, including trait [Neuroticism and Extraversion of the Eysenck Personality Questionnaire], hypothetical (Chapman's Revised Physical and Social Anhedonia Scales), and retrospective [AnhedoniaAsociality Subscale of the Scale for the Assessment of Negative Symptoms (SANS)] measures. Self-related beliefs (Self-Perception Scale), clinical positive and negative symptoms (SA Positive Symptoms and SANS), psychosocial function (Global Functioning Scale: Role Function and Global Functioning Scale: Social Function) were also examined.

RESULTS

Subjects at UHR for psychosis reported more trait unpleasant and less trait pleasant emotions, more hypothetical physical and social anhedonia, and more retrospective anhedonia than normal controls. In UHR, self-perception was correlated to trait unpleasant emotion and hypothetical physical and social anhedonia. Negative symptoms in UHR were associated with hypothetical physical anhedonia and retrospective anhedonia. Global social functioning was related to trait pleasant emotion, hypothetical physical and social anhedonia, and retrospective anhedonia. Neurocognitive function, positive symptoms, and global role functioning were not related with any noncurrent emotional experience measures in UHR.

CONCLUSION

These findings suggest that the aberrant tendency of noncurrent emotional experience may be present at the 'putative' prodromal phase and are grossly associated with self-related beliefs and psychosocial functioning but not neurocognitive functioning.

Trends in pharmacological emergency treatment of patients suffering from schizophrenia over a 16-year observation period

Patients suffering from schizophrenia are often treated in locked psychiatric units because of psychomotor agitation, hostility and aggressive behavior, or suicidality. Because of legal conditions, investigations on these acutely ill patients are difficult, and many studies do not represent 'real-life psychiatry'. This retrospective survey was conducted at the Department of Psychiatry, Psychotherapy and Psychosomatics of the Medical University, Innsbruck, Austria. Data were collected from the records of all adult inpatients suffering from a schizophrenia spectrum disorder according to the International Classification of Diseases, 10th ed. (ICD-10) (F2x) who had been admitted to a locked unit in 1997, 2002, 2007, and 2012. In addition to demographic data, diagnoses at the time of admission, length of stay at the locked unit, and psychopharmacological treatment (3 h before and following admission) were recorded. The mean length of stay at a locked unit decreased significantly from 11.8±4.43 days (mean±SD) in 1997 to 8.5±12.96 days (mean±SD) in 2012. The use of antipsychotics decreased nonsignificantly from 1997 to 2012. Despite an increasing use of second compared with first-generation antipsychotic drugs over the course of time, haloperidol was the most frequently used single compound in all investigated years except 2012. The majority of medications were administered orally. The use of benzodiazepines did not change substantially over the course of time. All in all, pharmacological emergency treatment of patients suffering from schizophrenia spectrum disorders in locked units was in line with current treatment guidelines, which recommend the use of second-generation antipsychotic drugs, monotherapy, oral application, and cautious dosing.

Coping styles in individuals at ultra-high risk for psychosis: Associations with cognitive appraisals

Maladaptive coping may play an important role in the manifestation of symptoms, functioning, and overt psychosis onset in individuals at ultra-high risk (UHR) for psychosis. To determine the factors associated with coping strategies, the relationships between cognitive appraisals and coping styles were investigated in UHR individuals. Sixty-five UHR individuals and 83 healthy controls were assessed for coping styles and cognitive appraisals of attribution bias as a primary appraisal and self-efficacy and perceived social support as a secondary appraisal. UHR participants relied more on a passive, tension-reduction coping style and less on an active, problem-focused coping style. These maladaptive coping styles in UHR individuals were significantly associated with their cognitive appraisals of stress. Aberrant attribution style of hostility perception and composite blaming bias were associated with problem-focused coping and tension-reduction, respectively. Perceived social support was related to problem-focused coping, seeking social support, and wishful thinking. General self-efficacy was associated with problem-focused coping. Our findings suggest that cognitive appraisals themselves may be the major determinants of coping styles in UHR individuals. The identified attribution styles, perceived social support, and self-efficacy may provide some clues regarding specialized interventions for the buildup of adaptive coping strategies in UHR individuals.

Cortical magnetization transfer abnormalities and connectome dysconnectivity in schizophrenia

Macroscale dysconnectivity in schizophrenia is associated with neuropathological abnormalities. The extent to which alterations in cortical myelination as revealed in vivo by magnetization transfer ratio (MTR) are related to macroscale dysconnectivity remains unknown. We acquired magnetization transfer imaging (MTI) data and diffusion weighted imaging (DWI) data from 78 schizophrenia patients and 93 healthy controls for MTR extraction and connectome reconstruction to examine the possible link between cortical myelination and macroscale dysconnectivity. Our findings showed significant cortical MTR disruptions in several prefrontal areas in schizophrenia patients, including bilateral rostral middle frontal areas, right pars orbitalis, and right frontal pole. Furthermore, cortical MTR alterations between patients and controls were significantly correlated with the level of regional disconnectivity. Together, our findings provide evidence that microstructural neuropathological abnormalities in schizophrenia are predominately present in prefrontal areas of the cortex and are associated with alterations in structural connectome architecture at the whole brain network level.

Polypharmacy and high-dose antipsychotics at the time of discharge from acute psychiatric wards

Aims and method

To determine the extent of prescribed antipsychotic polypharmacy and high-dose antipsychotics at the time of discharge from an acute psychiatric ward. Copies of discharge summaries for patients between the ages of 18 and 65 were examined; only those that had antipsychotic medications at the time of discharge were included. Names and doses of antipsychotics and all other medications concurrently prescribed were recorded.

Results

A total of 651 discharge summaries were included in the study. Nearly a quarter of individuals were discharged on one antipsychotic as the only medication to take home; only 6.8% were discharged on a high-dose antipsychotic and of those on combinations 59.6% were on depot medications. Combining antipsychotics significantly predicted the use of high dose.

Clinical implications

Most patients were discharged on doses of antipsychotics within the British National Formulary limits; however, a small proportion is still sent home on high doses of antipsychotics. Combining antipsychotics remains the strongest predictor of high-dose antipsychotic use; clinicians need to be aware of this.

Risky decision-making under risk in schizophrenia: A deliberate choice?

BACKGROUND AND OBJECTIVES

Patients with schizophrenia reveal impaired decision-making strategies causing social, financial and health care problems. The extent to which deficits in decision-making reflect intentional risky choices in schizophrenia is still under debate. Based on previous studies we expected patients with schizophrenia to reveal a riskier performance on the GDT and to make more disadvantageous decisions on the IGT.

METHODS

In the present study, we investigated 38 patients with schizophrenia and 38 matched healthy control subjects with two competing paradigms regarding feedback: (1) The Game of Dice Task (GDT), in which the probabilities of winning or losing are stable and explicitly disclosed to the subject, to assess decision-making under risk and (2) the Iowa Gambling Task (IGT), which requires subjects to infer the probabilities of winning or losing from feedback, to investigate decision-making under ambiguity.

RESULTS

Patients with schizophrenia revealed an overall riskier performance on the GDT; although they adjusted their strategy over the course of the GDT, they still made significantly more disadvantageous choices than controls. More positive symptoms in patients with schizophrenia indicated by higher PANSS positive scores were associated with riskier choices and less use of negative feedback. Compared to healthy controls, they were not impaired in net score but chose more disadvantageous cards than controls on the first block of the IGT.

LIMITATIONS

Effects of medication at the time of testing cannot be ruled out.

CONCLUSIONS

Our findings suggest that patients with schizophrenia make riskier decisions and are less able to regulate their decision-making to implement advantageous strategies, even when the probabilities of winning or losing are explicitly disclosed. The dissociation between performance on the GDT and IGT suggests a pronounced impairment of executive functions related to the dorsolateral prefrontal cortex.

Antipsychotic Use Pattern in Schizophrenia Outpatients: Correlates of Polypharmacy

Background:

This study investigates the antipsychotic use patterns of patients with schizophrenia and its correlations in their daily drug use patterns.

Methods:

Patients with schizophrenia who have regular records at two different community counselling centres (CCS) were included in the study. Information about their medications and sociodemographic data was recorded through face-to-face interviews and supporting information about their drug use patterns was obtained from their relatives/caregivers/nurse. The Clinical Global Impression Scale (severity of illness) and the General Assessment of Functionality scales were also administered.

Results:

Patients with schizophrenia used 2.0 ± 0.81 antipsychotics daily and 3.52 ± 2.55 pills (1–18). Seventy-one percent of the patients used two or more kinds of psychotropic drugs. The most frequently used antipsychotics were quetiapine, a second generation antipsychotic, and haloperidol, a typical antipsychotic. Clinical severity, regular visits to a CCS and use of depot antipsychotics were independent predictors for polypharmacy.

Conclusion:

The rate of polypharmacy use is high in Turkey. There are multiple risk factors related with polipharmacy. New studies should focus risk factors for preventing polypharmacy.

Treatment profiles in a Danish psychiatric university hospital department

BACKGROUND

Despite concerns about rising treatment of psychiatric patients with psychotropic medications and declining treatment with psychotherapy, actual treatment profiles of psychiatric patients are largely unknown.

AIMS

To describe patterns in the treatment of patients in a large psychiatric university hospital department.

METHODS

A descriptive mapping of treatment of in- and outpatients in a psychiatric department at Aarhus University Hospital Risskov, Denmark. Information was collected by healthcare staff using a 25-item survey form. The p-value was calculated with a chi-squared test and p < 0.05 was considered significant. The study was preceded by a pilot study on 41 patients.

RESULTS

Over a 1 month period, a total of 343 consecutive patients were assessed and hereof 200 were included in the age range 18-90 years (mean 53.76); 86 men and 114 women. One-hundred and eighty-eight patients (94%) used psychotropic medication, 37 (19%) as monotherapy, and 148 (74%) in combination with non-pharmacological therapy. Ninety-seven (49%) had psychotherapy and 104 (52%) social support. Among inpatients, 21 (64%) had physical therapy, and 10 (30%) electroconvulsive therapy. In total, 163 (82%) had non-pharmacological therapy. Fifty-two (26%) patients had monotherapy, and 148 (74%) polytherapy. Mean number of treatment modalities used per patient was 2.07 for all patients and 3.23 for inpatients.

CONCLUSIONS

In this department, polytherapy including non-pharmacological modalities is applied widely across all settings and patient categories. However, psychotropic medication clearly dominates as the most frequently applied treatment.

Lifetime antipsychotic medication and cognitive performance in schizophrenia at age 43 years in a general population birth cohort

This naturalistic study analysed the association between cumulative lifetime antipsychotic dose and cognition in schizophrenia after an average of 16.5 years of illness. Sixty participants with schizophrenia and 191 controls from the Northern Finland Birth Cohort 1966 were assessed at age 43 years with a neurocognitive test battery. Cumulative lifetime antipsychotic dose-years were collected from medical records and interviews. The association between antipsychotic dose-years and a cognitive composite score based on principal component analysis was analysed using linear regression. Higher lifetime antipsychotic dose-years were significantly associated with poorer cognitive composite score, when adjusted for gender, onset age and lifetime hospital treatment days. The effects of typical and atypical antipsychotics did not differ. This is the first report of an association between cumulative lifetime antipsychotic dose and global cognition in midlife schizophrenia. Based on these data, higher lifetime antipsychotic dose-years may be associated with poorer cognitive performance at age 43 years. Potential biases related to the naturalistic design may partly explain the results; nonetheless, it is possible that large antipsychotic doses harm cognition in schizophrenia in the long-term.

Investigation of the Endogenous Stress Response System in Patients with Chronic Schizophrenia

OBJECTIVE

Cardiophysiological and neuroendocrine studies suggest that the two components of the endogenous stress response system, the sympathetic nervous system (SNS) and the hypothalamic-pituitary-adrenal (HPA) axis, are dysregulated in patients with schizophrenia. However, cardiophysiological measures are influenced by several confounding factors and the secretion of α-amylase in saliva is believed to represent a more reliable index of SNS activity. Therefore, to characterize the functional status of the SNS and HPA axis in schizophrenia we explored the concomitant salivary secretion of cortisol and α-amylase.

METHODS

Saliva cortisol and α-amylase levels were measured after awakening in 30 patients with chronic schizophrenia and 22 healthy subjects.

RESULTS

After awakening, saliva cortisol increased in a similar way in both patients and healthy controls, while saliva α-amylase concentrations showed a clear-cut decrease in healthy subjects but not in patients with schizophrenia. No significant correlation emerged between biochemical measures and patients' demographic or psychopathological characteristics.

CONCLUSIONS

These findings demonstrate normal activity of the HPA axis with an enhanced SNS tone, which suggests a functional dissociation of the two components of the endogenous stress response system in patients with chronic schizophrenia. The pathophysiological significance of such dysregulation needs further studies to be clarified.

Experiential pleasure deficits in the prodrome: A study of emotional experiences in individuals at ultra-high risk for psychosis and recent-onset schizophrenia

BACKGROUND

Previous studies report deficits in noncurrent but not current pleasure experience in schizophrenia, but little is known about pleasure experiences of the prodrome. This study investigated noncurrent and current pleasure experiences and its relationship with neurocognitive function and self-esteem in ultra-high risk (UHR) for psychosis and recent-onset schizophrenia (ROSPR).

METHODS

Twenty-four UHR, 25 ROSPR and 42 normal controls completed the physical and social anhedonia scales for noncurrent emotional experience and the laboratory-based assessment of valence and arousal evoked by positive, neutral and negative emotional stimuli for current emotional experience. Relationships of current and noncurrent emotional experience, episodic memory and self-esteem were investigated.

RESULTS

For ROSPR, noncurrent pleasure, but not current pleasure evoked by positive stimuli, was diminished. Noncurrent anhedonia in ROSPR was related to episodic memory deficits and low self-esteem. In UHR subjects, both noncurrent pleasure and current pleasure to positive and neutral stimuli were diminished. Noncurrent anhedonia in UHR was not associated with episodic memory nor self-esteem. For arousal, ROSPR patients showed higher arousal than UHR subjects to positive stimuli.

CONCLUSIONS

Findings indicate the presence of experiential hedonic deficits during the prodrome phase. Diminished noncurrent pleasure reports exist in ROSPR, which seems to be associated with cognitive deficits and low self-concept. Future research is needed to probe into further underlying mechanisms.

Patient satisfaction after acute admission for psychosis

Background Measuring patient satisfaction in mental health care potentially provides valuable information, but studies in acutely admitted psychosis patients are scarce. Aims The aims were to assess satisfaction among patients acutely admitted with psychosis, to compare satisfaction in voluntarily versus involuntarily admitted patients, and to assess the influence of symptom load and insight. Methods The UKU Consumer Satisfaction Rating Scale (UKU-ConSat) was used. A total of 104 patients completed the UKU-ConSat at discharge/follow-up (between 6-11 weeks after admittance if not discharged earlier) (mean duration of stay 4 weeks), thus corresponding to the end of the acute treatment phase. Results A total of 88.4% had total scores above zero (satisfied). Only three of the eight single items were statistically significantly different among patients admitted voluntarily versus involuntarily, and only the information item score remained significantly different in adjusted analyses. Insight level at admittance, and an increasing level of insight during the acute phase were positively associated with patient satisfaction, whereas levels and changes in positive and negative psychosis symptoms were indirectly related to satisfaction via this process of insight. Conclusions The vast majority of the acutely admitted patients were satisfied with treatment. There were few differences between the involuntarily and voluntarily admitted patient groups, except that the involuntary care group was clearly less satisfied with the information provided. Poor insight had a major negative impact on treatment satisfaction in psychosis. The provision of sufficient and adequate information is an important target for mental health care service improvement.

Therapeutic Body Wraps in Swiss public adult acute inpatient wards. A retrospective descriptive cohort study

WHAT IS KNOWN ON THE SUBJECT?: Various expert opinions reported relational benefits and tranquilizing effects of therapeutic body wraps (TBW) in adults experiencing high anxiety in the context of psychosis. Yet, this tranquilizing effect was never investigated in larger samples and in the context of modern psychopharmacology. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: This is the first study to establish descriptive statistics of this mind-body therapy in French-speaking Switzerland where TBWs are routinely used in two public psychiatric hospitals. It brings knowledge on patients nowadays treated with TBW. Moreover, it opens a new area of investigation on the potential of this nursing technique, which may contribute to reduce anxiolytic medication in severely ill patients. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: This study sheds light on a clinical practice in mental health nursing and upon nurses' specific contribution to psychiatric clinic. It investigates a potential for TBWs to reduce the use of anxiolytic medications by patients who agreed to have TBW as part of their treatment. It may help to inform the mental health nursing practice.

ABSTRACT

Introduction Many patients suffering from serious mental illness experience severe anxiety and those with psychosis often report the feeling of their bodies falling apart. While it is believed that these patients benefit from therapeutic body wraps (TBWs), the use of this adjunct therapy has rarely been studied in adult patients. Aims The aim of this study was to obtain descriptive statistics on the clinical, social-demographic and institutional reality of TBW therapy in Swiss public adult inpatient wards. Methods Retrospective data related to a cohort of 172 adult inpatients were retrieved from records of two public hospitals. Correlations between TBW and the prescriptions of lorazepam were explored. Results TBWs were primarily used for patients diagnosed with either schizophrenia, schizotypal, delusional and other non-mood psychotic disorders or mood disorders. Patients had, on average, four psychiatric hospitalizations, and in 30% of the cases, TBWs were offered during the first hospitalization. Moreover, TBWs were mostly practiced by nurses. Body wraps were potentially associated with a reduction in both anxiolytic and neuroleptic drugs. Discussion/Implication for practice Based on our results, TBW might contribute to the clinical management of anxiety by nurses. The efficacy of TWB regarding anxiety has yet to be investigated in a randomized controlled trial.

Prevalence, Employment Rate, and Cost of Schizophrenia in a High-Income Welfare Society: A Population-Based Study Using Comprehensive Health and Welfare Registers

Schizophrenia is associated with recurrent hospitalizations, need for long-term community support, poor social functioning, and low employment rates. Despite the wide- ranging financial and social burdens associated with the illness, there is great uncertainty regarding prevalence, employment rates, and the societal costs of schizophrenia. The current study investigates 12-month prevalence of patients treated for schizophrenia, employment rates, and cost of schizophrenia using a population-based top-down approach. Data were obtained from comprehensive and mandatory health and welfare registers in Norway. We identified a 12-month prevalence of 0.17% for the entire population. The employment rate among working-age individuals was 10.24%. The societal costs for the 12-month period were USD 890 million. The average cost per individual with schizophrenia was USD 106 thousand. Inpatient care and lost productivity due to high unemployment represented 33% and 29%, respectively, of the total costs. The use of mandatory health and welfare registers enabled a unique and informative analysis on true population-based datasets.

Profiling cognitive impairment in treatment-resistant schizophrenia patients

The aim of this study was to compare cognitive performance between schizophrenia patients with and without treatment resistance (TRS and non-TRS patients) taking into account psychopathological symptoms and antipsychotic treatment. The following cognitive tests were administered to 53 TRS patients and 32 non-TRS subjects: Rey Auditory Verbal Learning Test (RAVLT), Trail Making Tests (TMT-A and TMT-B), verbal fluency tests (FAS test and Supermarket), as well as selected Wechsler Adults Intelligence Scale (WAIS-R-PI) subtests: Digit Symbol Coding Test, Digit Span Forward and Backward and Similarities. TRS patients performed significantly worse in comparison with non-TRS patients on the measures of processing speed (TMT-A, Stroop test, FAS test, Supermarket test, Digit Symbol Coding test), verbal fluency (FAS test, Supermarket test), cognitive flexibility and executive functions (Stroop test) after controlling for age, illness duration, clinical symptoms severity, the number of years of completed education and antipsychotics' dose. Cognitive performance was associated with negative and general symptomatology. Anticholinergic activity of antipsychotics had debilitating effect on cognitive functioning in non-TRS patients (FAS test) and in TRS patients (TMT-B test, Stroop test, RAVLT subtests, Digit Coding test and Similarities test), while low anticholinergic activity of antipsychotics was associated with better cognitive performance in non-TRS patients (Backward Digit Span test) and in TRS patients (Similarities test). Results of this study indicate that cognitive deficits are more robust in TRS patients than in non-TRS subjects, and are associated with clinical symptoms as well as the treatment with antipsychotics that exert high anticholinergic activity.

Use of psychiatric medications in schizophrenia and other psychoses in a general population sample

The information on the use of psychiatric medications in general population-based samples is limited. Our aim was to analyse the use of psychiatric medications and factors associated with antipsychotic use in psychoses in a general population sample. Fifty-five persons with schizophrenia, 21 with bipolar psychosis or psychotic depression and 20 with other psychoses from the Northern Finland Birth Cohort 1966 were examined at about 43 years of age. The frequency of use and dosage of psychiatric medication and the factors associated with the use of antipsychotics were analysed. Antipsychotics were used by 85% of schizophrenia, 65% of bipolar psychosis or psychotic depression and 62% of other psychoses cases; antidepressants were used by 22%, 60% and 33%; and benzodiazepines by 42%, 35% and 10%, respectively. In all the diagnostic groups, higher symptom scores and a higher number of hospital days were associated with the use of antipsychotics. In schizophrenia and other psychoses, poorer social and occupational functioning, and in other psychoses, female gender and lower education were also associated with the use of antipsychotics. Our results may partly indicate that, especially in schizophrenia, the effectiveness of antipsychotics is not as good as expected.

Reduction in ventral striatal activity when anticipating a reward in depression and schizophrenia: a replicated cross-diagnostic finding

In the research domain framework (RDoC), dysfunctional reward expectation has been proposed to be a cross-diagnostic domain in psychiatry, which may contribute to symptoms common to various neuropsychiatric conditions, such as anhedonia or apathy/avolition. We used a modified version of the Monetary Incentive Delay (MID) paradigm to obtain functional MRI images from 22 patients with schizophrenia, 24 with depression and 21 controls. Anhedonia and other symptoms of depression, and overall positive and negative symptomatology were also measured. We hypothesized that the two clinical groups would have a reduced activity in the ventral striatum when anticipating reward (compared to anticipation of a neutral outcome) and that striatal activation would correlate with clinical measures of motivational problems and anhedonia. Results were consistent with the first hypothesis: two clusters in both the left and right ventral striatum were found to differ between the groups in reward anticipation. Post-hoc analysis showed that this was due to higher activation in the controls compared to the schizophrenia and the depression groups in the right ventral striatum, with activation differences between depression and controls also seen in the left ventral striatum. No differences were found between the two patient groups, and there were no areas of abnormal cortical activation in either group that survived correction for multiple comparisons. Reduced ventral striatal activity was related to greater anhedonia and overall depressive symptoms in the schizophrenia group, but not in the participants with depression. Findings are discussed in relation to previous literature but overall are supporting evidence of reward system dysfunction across the neuropsychiatric continuum, even if the specific clinical relevance is still not fully understood. We also discuss how the RDoC approach may help to solve some of the replication problems in psychiatric fMRI research.

Multitarget drug discovery projects in CNS diseases: quantitative systems pharmacology as a possible path forward

Clinical development in brain diseases has one of the lowest success rates in the pharmaceutical industry, and many promising rationally designed single-target R&D projects fail in expensive Phase III trials. By contrast, successful older CNS drugs do have a rich pharmacology. This article will provide arguments suggesting that highly selective single-target drugs are not sufficiently powerful to restore complex neuronal circuit homeostasis. A rationally designed multitarget project can be derisked by dialing in an additional symptomatic treatment effect on top of a disease modification target. Alternatively, we expand upon a hypothetical workflow example using a humanized computer-based quantitative systems pharmacology platform. The hope is that incorporating rationally multipharmacology drug discovery could potentially lead to more impactful polypharmacy drugs.

Motivated to do well: an examination of the relationships between motivation, effort, and cognitive performance in schizophrenia

The uncertain relationship between negative symptoms, and specifically motivational deficits, with cognitive dysfunction in schizophrenia is in need of further elucidation as it pertains to the interpretation of cognitive test results. Findings to date have suggested a possible mediating role of motivational deficits on cognitive test measures, although findings from formal examinations of effort using performance validity measures have been inconsistent. The aim of this study was to examine the relationships between motivation, effort exerted during cognitive testing, and cognitive performance in schizophrenia. Sixty-nine outpatients with schizophrenia or schizoaffective disorder were evaluated for psychopathology, severity of motivational deficits, effort exerted during cognitive testing, and cognitive performance. Motivation and degree of effort exerted during cognitive testing were significantly related to cognitive performance, specifically verbal fluency, verbal and working memory, attention and processing speed, and reasoning and problem solving. Further, effort accounted for 15% of the variance in cognitive performance, and partially mediated the relationship between motivation and cognitive performance. Examining cognitive performance profiles for individuals exerting normal or reduced effort revealed significant differences in global cognition, as well as attention/processing speed and reasoning and problem solving. These findings suggest that cognitive domains may be differentially affected by impairments in motivation and effort, and highlight the importance of understanding the interplay between motivation and cognitive performance deficits, which may guide the appropriate selection of symptom targets for promoting recovery in patients.

Abnormal emotion processing, but intact fairness and intentionality considerations during social decision-making in schizophrenia

Schizophrenia is a severe mental disorder that is highly characterized by social cognitive impairments. Most studies investigating these impairments focus on one specific social domain such as emotion recognition. However, in daily life, processing complex social situations relies on the combination of several social cognitive and affective processes simultaneously rather than one process alone. A modified version of the economically based Ultimatum Game was used to measure the interplay between fairness, intentionality, and emotion considerations during social decision-making. In this task, participants accept or reject fair and unfair monetary offers proposed intentionally or unintentionally by either angry, happy, neutral, or sad proposers. Behavioral data was collected from a group of schizophrenia patients (N = 35) and a group of healthy individuals (N = 30). Like healthy participants, schizophrenia patients differentiated between fair and unfair offers by rejecting unfair offers more compared to fair offers. However, overall patients did reject more fair offers, indicating that their construct of fairness operates within different margins. In both groups, intentional unfair offers were rejected more compared to unintentional ones, indicating a normal integration of intentionality considerations in schizophrenia. Importantly, healthy subjects also differentiated between proposers' emotion when rejecting unfair offers (more rejections from proposers depicting angry faces compared to proposers depicting, happy, neutral, or sad faces). Schizophrenia patients' decision behavior on the other hand, was not affected by the proposers' emotions. The current study thus shows that schizophrenia patients have specific problems with processing and integrating emotional information. Importantly, the finding that patients display normal fairness and intentionality considerations emphasizes preservation of central social cognitive processes in schizophrenia.