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

Comorbidity in Schizophrenia: Conceptual Issues and Clinical Management

Schizophrenia is a complex psychiatric disorder that affects cognitive, perceptual, and emotional functioning. The currently available evidence suggests heterogenous intertwining of biological and psychosocial etio-pathogeneses. Clinical and research interests in the comorbidity issues of schizophrenia were borne out of the real-world clinical challenges that patients often present with multiple coexisting psychopathologies as well as comorbid medical conditions. The recent DSM-5 shift toward a symptom dimensional-based perspective, the NIMH Research Domain Criteria (RDoC) initiative to examine biopsychosocial pathogeneses in mental illness, and the FDA's emphasis on real world-based clinical trial criterion all have promoted a shift in clinical research that has facilitated understanding and treatment of comorbidity in schizophrenia. This emerging conceptual shift as well as pharmacological developments that address the multidimensional pathogeneses in schizophrenia may pave the way for a better understanding and treatment.

Prevalence of comorbid depression in schizophrenia: A meta-analysis of observational studies

INTRODUCTION

Comorbid depressive symptoms (depression thereafter) often occur in schizophrenia and are associated with negative outcomes. This meta-analysis estimated the prevalence of comorbid depression and its associated factors in schizophrenia.

METHODS

Both international (PubMed, EMBASE, PsycINFO, and Web of Science) and Chinese (WANFANG and CNKI) databases were systematically searched. Studies with data on the prevalence of comorbid depression in schizophrenia measured with the Calgary Depression Scale for Schizophrenia (CDSS) were included. Random-effects models were used in all analyses.

RESULTS

Fifty-three studies covering 9,879 patients were included. The pooled prevalence of comorbid depression was 28.6% (95%CI: 25.3%-32.2%). Subgroup analyses revealed that studies examining inpatients, being published in Chinese language, or those with lower CDSS cut-od values reported higher depression rates. Meta-regression analyses indicated that the rate of depression was positively associated with publication year, proportion of males, mean age, and severity of psychotic symptoms, and negatively associated with illness duration and study quality.

CONCLUSION

Comorbid depression is common in schizophrenia. Due to its negative impact on patients' quality of life and prognosis, regular screening and effective treatment for comorbid depression should be implemented in patients with schizophrenia.

Exploring depression in schizophrenia

Background

A consistent amount of empirical research suggests that depression, besides interfering with quality of life and social functioning, may influence other symptom dimensions in schizophrenia, thus constituting an important domain for treatment strategies, outcome, and prognosis.

Aim. –

This study investigated the factorial structure of the Calgary depression scale for schizophrenia (CDSS) in a sample of schizophrenic patients and explored the relationships between such factors, major symptom dimensions and subjective experiences.

Methods

One hundred and sixty-one subjects were examined to assess the severity of schizophrenic symptoms (scored according to the five-dimensional model of Toomey et al. [28]), the distress due to the subjective experience of negative symptoms, and the degree of subjectively-felt cognitive-affective vulnerability (i.e. basic symptoms).

Results

Principal component analysis revealed CDSS to include three main factors, namely: “depression-hopelessness” (factor I), “guilty idea of reference-pathological guilt” (factor II) and “early wakening” (factor III).

Whereas the last factor did not correlate with any of the other psychopathological domains, the first two factors revealed multiple correlations with both diagnostic symptoms and subjective experiences.

Conclusions

The results confirm the threefold factorial structure of the CDSS previously reported by the authors of the scale and could shed further light on the psychopathological nature of the components of depression in schizophrenia. The specific correlation patterns with diagnostic and subjective psychopatholgy substantiate the clinical distinction between a general depression factor (“depression-hopelessness”) and a cognitive-guilt factor (“guilty idea of reference-pathological guilt”).

Rethinking Schizophrenia and Depression Comorbidity as One Psychiatric Disorder Entity: Evidence From Mouse Model

Schizophrenia is frequently accompanied by depressive symptoms, but the pathological mechanisms remain to be elucidated. In this study, we used chronic unpredicted mild stress plus MK801 injection to generate a mouse model of schizophrenia with depression, in which in vivo 2-photon calcium imaging and electrophysiological recordings were performed in conjunction with behavioral phenotyping. Compared to mice models with classical depression or to schizophrenia models, the animal models with schizophrenia and depression comorbidity presented worse psychotic and depressive symptoms. These behavioral deficits are associated with impaired neuronal calcium activities in the frontal cortex and thalamic nuclei. Moreover, in sharp contrast to classical models that have a satisfactory response to antipsychotic or antidepressant drugs, this novel schizophrenia with depression model is resilient to combined drug treatment in terms of behavioral and functional recovery. Taken together, these data indicate that schizophrenia with depression likely involves a unique pathophysiology that is different from schizophrenia or depression alone.

Evidence-based guidelines for the pharmacological treatment of schizophrenia: Updated recommendations from the British Association for Psychopharmacology

These updated guidelines from the British Association for Psychopharmacology replace the original version published in 2011. They address the scope and targets of pharmacological treatment for schizophrenia. A consensus meeting was held in 2017, involving experts in schizophrenia and its treatment. They were asked to review key areas and consider the strength of the evidence on the risk-benefit balance of pharmacological interventions and the clinical implications, with an emphasis on meta-analyses, systematic reviews and randomised controlled trials where available, plus updates on current clinical practice. The guidelines cover the pharmacological management and treatment of schizophrenia across the various stages of the illness, including first-episode, relapse prevention, and illness that has proved refractory to standard treatment. It is hoped that the practice recommendations presented will support clinical decision making for practitioners, serve as a source of information for patients and carers, and inform quality improvement.

A potential role for adjunctive omega-3 polyunsaturated fatty acids for depression and anxiety symptoms in recent onset psychosis: Results from a 16 week randomized placebo-controlled trial for participants concurrently treated with risperidone

Omega-3 treatment studies for multi-episode schizophrenia or clinical high risk for conversion to psychosis states have had variable, and often negative, results. To examine adjunctive omega-3 treatment for recent onset psychosis, participants aged 15-40 years with recent onset schizophrenia-spectrum (n = 46) or bipolar (n = 4) disorders and current psychotic symptoms were treated for 16 weeks with risperidone and randomly-assigned omega-3 (EPA 740 mg and DHA 400 mg daily) or matching placebo. The primary outcome measure was the Brief Psychiatric Rating Scale (BPRS) total score. Mean lifetime antipsychotic exposure was 18.1 days. Length of time in treatment, risperidone dose and number of omega-3/placebo capsules taken did not differ between conditions. Longitudinal analysis of the total BPRS score revealed a trend level (p = 0.0826) treatment effect favoring omega-3 treatment. Lorazepam was an allowed concomitant medication. Among the subgroup (N = 23) who did not receive lorazepam, the treatment effect on BPRS total scores favoring omega-3 was significant (p = 0.0406) and factor scores analyses revealed a substantial decrease in depression-anxiety with omega-3 but no change with placebo (treatment-by-time interaction, p = 0.0184). Motor side effects did not differ between conditions. Analysis of Systematic Assessment for Treatment Emergent Events assessments revealed fewer adverse events overall with omega-3 compared with placebo with the largest differences between conditions (all favoring omega-3) on confusion, anxiety, depression, irritability, and tiredness/fatigue. These results suggest that omega-3 adjuvant treatment is a potential option for depression and anxiety symptoms of people with recent onset psychosis. Further research is needed to confirm this potential. Clinical trial registration: NCT01786239.

The relationship between negative symptoms and depression in schizophrenia: a systematic review

OBJECTIVE

To provide an update on the evidence base for the nature of the relationship between negative symptoms and depressive features in people with schizophrenia, and propose new models that reflect their complex relationship.

METHOD

A systematic review following PRISMA guidelines. A total of 2210 articles were identified from EMBASE, PsychInfo and MEDLINE, and further two articles were hand-searched from references. Twenty-seven met inclusion criteria and were included in the review.

RESULTS

In schizophrenia, primary evidence suggests symptoms of low mood, suicidal ideation and pessimism have more specificity for depression whereas alogia and blunted affect may have more specificity as negative symptoms. Anhedonia, anergia and avolition may be common to both.

CONCLUSION

It may be possible to further distinguish depressive features from negative symptoms in schizophrenia when detailed phenomenology is considered. However, in a proposed dimensional model, these two domains continue to share certain phenomena, highlighting their close relationship.

Secondary negative symptoms - A review of mechanisms, assessment and treatment

Negative symptoms in schizophrenia may be classified as primary or secondary. Primary negative symptoms are thought to be intrinsic to schizophrenia, while secondary negative symptoms are caused by positive symptoms, depression, medication side-effects, social deprivation or substance abuse. Most of the research on secondary negative symptoms has aimed at ruling them out in order to isolate primary negative symptoms. However, secondary negative symptoms are common and can have a major impact on patient-relevant outcomes. Therefore, the assessment and treatment of secondary negative symptoms are clinically relevant. Furthermore, understanding the mechanisms underlying secondary negative symptoms can contribute to an integrated model of negative symptoms. In this review we provide an overview of concepts, evidence, assessment and treatment for the major causes of secondary negative symptoms. We also summarize neuroimaging research relevant to secondary negative symptoms. We emphasize the relevance of recent developments in psychopathological assessment of negative symptoms, such as the distinction between amotivation and diminished expression, which have only rarely been applied in research on secondary negative symptoms.

Depression and Schizophrenia: Cause, Consequence, or Trans-diagnostic Issue?

The presence of depression in schizophrenia has been a challenge to the Kraepelinian dichotomy, with various attempts to save the fundamental distinction including evoking and refining diagnoses such as schizoaffective disorder. But the tectonic plates are shifting. Here we put forward a summary of recent evidence regarding the prevalence, importance, possible aetiological pathways and treatment challenges that recognizing depression in schizophrenia bring. Taken together we propose that depression is more than comorbidity and that increased effective therapeutic attention to mood symptoms will be needed to improve outcomes and to support prevention.

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.

A Longitudinal Study of the Outcome and Associated Factors of Subsyndromal and Syndromal Depression in Community-Dwelling Older Adults with Schizophrenia Spectrum Disorder

OBJECTIVE

Studies examining depression in older adults with schizophrenia have been limited by cross-sectional data. This study examines longitudinal changes in depression, predictors of depression, and the impact of depression on clinical and psychosocial variables in this population.

METHODS

The sample consisted of 104 community-dwelling persons with schizophrenia spectrum disorder aged 55 and over who developed the disorder before age 45. Mean follow-up was 54 months (range: 12-116 months), mean age was 61 years, 55% were men, and 55% were white. Presence of subsyndromal or syndromal depression (SSSD) was defined as scoring >7 on the Center for Epidemiologic Studies-Depression Scale (CES-D).

RESULTS

There were no significant differences in SSSD rates between interviews (61% baseline; 54% follow-up); 44% of the sample had SSSD at both assessments, 30% did not have SSSD at either assessment, 16% went from SSSD to nondepression, and 10% went from nondepression to SSSD. Similarly, 20%, 27%, and 53% of the sample exhibited >0.5 effect size increase, decrease, or no change, respectively, in their CES-D scores between assessments. There were two significant time 1 predictors of SSSD at time 2: SSSD and greater number of psychotropic medications. SSSD at time 1 predicted having higher time 2 anxiety scores.

CONCLUSION

Persistent ("core") depression occurs in about two-fifths of persons, 30% remain persistently nondepressed, and one-fourth may fluctuate between depression and nondepression. No association was found between depression and most predictor variables. This study supports recent findings that schizophrenia in later life is not a quiescent state or one of affective withdrawal.

Effects of event-specific memory training on autobiographical memory retrieval and depressive symptoms in schizophrenic patients

BACKGROUND AND OBJECTIVES

This report describes the effects of a specific event group-based training programme on autobiographical memory, self-consciousness of memory retrieval, and depression symptoms in a sample of 24 schizophrenic patients (experimental group).

METHODS

Twenty-six matched schizophrenic patients who participated in social skills and occupational therapy group sessions constituted the active control group. Participants in the experimental group were trained to complete a diary with specific daily memories, followed by patients' ratings of the associated emotional arousal of those entries. During training, significant specific events from childhood, adolescence, adulthood and the previous year were also reviewed.

RESULTS

After 10 weeks of group-based sessions, the experimental group demonstrated an increase in their degree of specificity for autobiographical retrievals, had a higher level of consciousness of their memories and showed a decrease in their depression scores. Significant changes in measurements of retrieval specificity and autonoetic awareness were maintained when changes in emotional symptomatology were statistically controlled.

LIMITATIONS

The present study did not assess the impact of autobiographical memory training on the positive and negative symptoms of schizophrenia.

CONCLUSIONS

These results suggest that cognitive training strategies based on event-specific autobiographical memory training should be considered for inclusion in intervention programs for schizophrenic patients.

Ketamine-enhanced immobility in forced swim test: a possible animal model for the negative symptoms of schizophrenia

Schizophrenia is a chronic and highly complex psychiatric disorder characterised by cognitive dysfunctions, negative and positive symptoms. The major challenge in schizophrenia research is lack of suitable animal models that mimic the core behavioural aspects and symptoms of this devastating psychiatric disorder. In this study, we used classical and atypical antipsychotic drugs to examine the predictive validity of ketamine-enhanced immobility in forced swim test (FST) as a possible animal model for the negative symptoms of schizophrenia. We also evaluated the effects of a selective serotonin reuptake inhibitor (SSRI) on the ketamine-enhanced immobility in FST. Repeated administration of a subanaesthetic dose of ketamine (30 mg kg(-1), i.p., daily for 5 days) enhanced the duration of immobility in FST 24 h after the final injection. The effect, which persisted for at least 21 days after withdrawal of the drug, was neither observed by single treatment with ketamine (30 mg kg(-1) i.p.) nor repeated treatment with amphetamine (1 and 2 mg kg(-1) i.p., daily for 5 days). The enhancing effects of ketamine (30 mg kg(-1) day(-1) i.p.) on the duration of immobility in the FST were attenuated by clozapine (1, 5 and 10 mg kg(-1) i.p.), risperidone (0.25 and 0.5 mg kg(-1) i.p.) and paroxetine (1 and 5 mg kg(-1) i.p.). Haloperidol (0.25 and 0.50 mg kg(-1) day(-1) i.p.) failed to attenuate the ketamine-enhanced immobility in the FST. The repeated ketamine administration neither affects locomotor activity nor motor coordination in rats under the same treatment conditions with the FST, suggesting that the effects of ketamine on the duration of immobility in this study was neither due to motor dysfunction nor peripheral neuromuscular blockade. Our results suggest that repeated treatment with subanaesthetic doses of ketamine enhance the duration of immobility in FST, which might be a useful animal model for the negative symptoms (particularly the depressive features) of schizophrenia.

Prevalence of depression and its relationship with other clinical characteristics in a sample of patients with stable schizophrenia

AIM

To evaluate the prevalence of depression using the Calgary Depression Scale for Schizophrenia (CDSS) in a sample of Spanish patients with stable schizophrenia and without a diagnosis of depression.

METHODS

We included stable outpatients of 18 to 50 years of age, with a diagnosis of schizophrenia, schizoaffective disorder, or schizophreniform disorder who had not been diagnosed with depression. In this cross-sectional study, we administered the CDSS, the Positive and Negative Syndrome Scale (PANSS), the Scale for the Assessment of Negative Symptoms (SANS), the Scale to Assess Unawareness of Mental Disorder (SUMD), the Simpson Angus Scale (SAS), and the Barnes Akathisia Rating Scale (BARS).

RESULTS

A total of 95 patients were recruited, 90 of them were included in the statistical analysis. Twenty-eight patients had a total score of 5 or more points on the CDSS, making the prevalence of depression 31% (95% confidence interval, 22-41). The CDSS had a high correlation with the depressive factor of the PANSS and a moderate correlation with the general psychopathology subscale of the PANSS. The correlation of the CDSS total score with negative symptoms was moderate using the SANS and low with the PANSS-negative. There was no correlation between depressive symptoms and positive symptoms, insight, and extrapyramidal symptoms; and the correlation with akathisia was low.

CONCLUSION

Our results suggest that patients with stable schizophrenia who have not been diagnosed with depression frequently have clinically relevant symptoms of depression, and that these symptoms, with the possible exception of a contribution from negative symptoms, are not secondary to other symptoms of their disorder or to extrapyramidal adverse effects of medications.

Depressive symptoms in schizophrenic patients

Distinction between true negative and depressive symptoms in schizophrenia is difficult. In the present study we seek to establish the psychological profile of depression-prone schizophrenic patients. We addressed the issue by comparing the expression of psychological indices, such as the feelings of being in control of events, anxiety, mood, and the style of coping with stress in depressive and non-depressive schizophrenics. We also analyzed the strength of the association of these indices with the presence of depressive symptoms. A total of 49 patients (18 women and 31 men, aged 23-59) were enrolled into the study, consisting of a self-reported psychometric survey. We found that the prevalence of clinically significant depression in schizophrenic patients was 61%. The factors which contributed to the intensification of depressive symptoms were the external locus of control, anxiety, gloomy mood, and the emotion-oriented coping with stress. We conclude that psychological testing may discern those schizophrenic patients who would be at risk of depression development and may help separate the blurred boundaries between depressive and negative symptoms of schizophrenia.

Forms of antipsychotic therapy: improved individual outcomes under personalised treatment of schizophrenia focused on depression

Depressive symptoms are common in schizophrenia and they can occur during any phase of the disorder. Early diagnosis, adequate differential diagnosis and promptly initiated interventions have been shown to reduce further deterioration of illness and to improve patients' quality of life. Common psychiatric rating scales for early detection of depressive symptoms in schizophrenia are Calgary Depression Scale for Schizophrenia and Hamilton Depression Rating Scale, but the most appropriate assessment instrument today regarding this topic is Calgary Depression Scale for Schizophrenia. Treatment of depression in schizophrenia consists of a combination of pharmacologic and psychosocial approach. Atypical antipsychotics have advantages over typical in reducing depressive symptoms in the context of schizophrenia. Most of the studies referred that clozapine, olanzapine, quetiapine and risperidone have an antidepressant spectrum of activity in patients with schizophrenia. Antidepressant augmentation of antipsychotic treatment in schizophrenic patients with depressive symptoms improves depressive symptomatology, particularly SSRI and SNRI augmentation.

Evidence-based guidelines for the pharmacological treatment of schizophrenia: recommendations from the British Association for Psychopharmacology

These guidelines from the British Association for Psychopharmacology address the scope and targets of pharmacological treatment for schizophrenia. A consensus meeting, involving experts in schizophrenia and its treatment, reviewed key areas and considered the strength of evidence and clinical implications. The guidelines were drawn up after extensive feedback from the participants and interested parties, and cover the pharmacological management and treatment of schizophrenia across the various stages of the illness, including first-episode, relapse prevention, and illness that has proved refractory to standard treatment. The practice recommendations presented are based on the available evidence to date, and seek to clarify which interventions are of proven benefit. It is hoped that the recommendations will help to inform clinical decision making for practitioners, and perhaps also serve as a source of information for patients and carers. They are accompanied by a more detailed qualitative review of the available evidence. The strength of supporting evidence for each recommendation is rated.

Development of depressed mood predicts onset of psychotic disorder in individuals who report hallucinatory experiences

OBJECTIVES

Current psychological theories state that the clinical outcome of hallucinatory experiences is dependent on the degree of associated distress, anxiety, and depression. This study examined the hypothesis that the risk for onset of psychotic disorder in individuals with self-reported hallucinatory experiences would be higher in those who subsequently developed depressed mood than in those who did not.

DESIGN

A prospective cohort study of a general population sample.

METHODS

A sample of 4,670 individuals with no lifetime evidence of any psychotic disorder were interviewed with the Composite International Diagnostic Interview Schedule (CIDI) at baseline and 1 and 3 years later. At Year 3, individuals with CIDI evidence of psychotic symptoms were interviewed by clinicians to identify potential onset of psychotic disorder. Psychotic disorder was specified at three levels; two involving severity of positive symptoms of psychosis, and one using additional clinical judgment of need for care.

RESULTS

Given the presence of hallucinatory experiences at baseline, the increase in risk of having the psychosis outcome at Year 3 was higher in the group with depressed mood at Year 1 than in the group without depressed mood at Year 1 (any level of psychotic symptoms: risk difference 17.0%, 95% CI - 1.7, 35.7; severe level of psychotic symptoms: risk difference 21.7%, 95% CI 3.2, 40.2; needs-based diagnosis of psychotic disorder: risk difference 16.8%, 95% CI 0.4, 33.3).

CONCLUSION

The results are in line with current psychological models of psychosis that emphasize the role of secondary appraisals of psychotic experiences in the onset of clinical disorder.

Assessing the infrequent oral supplementation of olanzapine long-acting injection in the treatment of schizophrenia

OBJECTIVE

Adding another antipsychotic to a treatment regimen was previously used in evaluating the medication's efficacy. Supplementation of depot antipsychotics with oral antipsychotics is particularly meaningful because depot formulations are typically chosen for patients struggling with adherence to oral antipsychotics. This post-hoc analysis assessed supplementation of olanzapine long-acting injection (olanzapine-LAI) with oral olanzapine.

SUBJECTS AND METHODS

We used 12 months of data from an open-label, single-arm extension study of patients with schizophrenia or schizoaffective disorder (N=931) treated with olanzapine-LAI. The prevalence, duration, time to first supplementation, and best predictors of oral supplementation were assessed.

RESULTS

Oral supplementation occurred in 21% of patients for a median of 31 days with mean modal dose of 10.8 mg/day. Mean time to first supplementation was shorter for patients who were at least moderately ill at baseline compared to less ill patients (47 vs. 97 days, p<0.001). Best predictors of oral supplementation included a more severe illness profile at baseline, lower olanzapine-LAI dose prior to oral supplementation, supervised living arrangements, and being African-American.

CONCLUSION

Supplementation of olanzapine-LAI appears to be infrequent, of relatively short duration, and reserved for more severely ill patients who may require a targeted rescue medication due to signs of impending relapse.

A new nosology of psychosis and the pharmacological basis of affective and negative symptom dimensions in schizophrenia

Although first rank symptoms focus on positive symptoms of psychosis they are shared by a number of psychiatric conditions. The difficulty in differentiating bipolar disorder from schizophrenia with affective features has led to a third category of patients often loosely labeled as schizoaffective. Research in schizophrenia has attempted to render the presence or absence of negative symptoms and their relation to etiology and prognosis more explicit. A dichotomous population is a recurring theme in experimental paradigms. Thus, schizophrenia is defined as process or reactive, deficit or non-deficit and by the presence or absence of affective symptoms. Laboratory tests confirm the clinical impression showing conflicting responses to dexamethasone suppression and clearly defined differences in autonomic responsiveness, but their patho-physiological significance eludes mainstream theory. Added to this is the difficulty in agreeing to what exactly constitutes useful clinical features differentiating, for example, negative symptoms of a true deficit syndrome from features of depression. Two recent papers proposed that the general and specific cognitive features of schizophrenia and major depression result from a monoamine-cholinergic imbalance, the former due to a relative muscarinic receptor hypofunction and the latter, in contrast, to a muscarinic hypersensitivity exacerbated by monoamine depletion. Further development of these ideas will provide pharmacological principles for what is currently an incomplete and largely, descriptive nosology of psychosis. It will propose a dimensional view of affective and negative symptoms based on relative muscarinic integrity and is supported by several exciting intracellular signaling and gene expression studies. Bipolar disorder manifests both muscarinic and dopaminergic hypersensitivity. The greater the imbalance between these two receptor signaling systems, the more the clinical picture will resemble schizophrenia with bizarre, incongruent delusions and increasingly disorganized thought. The capacity for affective expression, by definition a non-deficit syndrome, will remain contingent on the degree of preservation of muscarinic signaling, which itself may be unstable and vary between trait and state examinations. At the extreme end of muscarinic impairment, a deficit schizophrenia subpopulation is proposed with a primary and fixed muscarinic receptor hypofunction.

The genomic profile of bipolar disorder and schizophrenia overlap and both have a common dopaminergic intracellular signaling which is hypersensitive to various stressors. It is proposed that the concomitant muscarinic receptor upregulation differentiates the syndromes, being marked in bipolar disorder and rather less so in schizophrenia. From a behavioral point of view non-deficit syndromes and bipolar disorder appear most proximate and could be reclassified as a spectrum of affective psychosis or schizoaffective disorders. Because of a profound malfunction of the muscarinic receptor, the deficit subgroup cannot express a comparable stress response. Nonetheless, a convergent principle of psychotic features across psychiatric disorders is a relative monoaminergic-muscarinic imbalance in signal transduction.

Chronic administration of atypical antipsychotics improves behavioral and synaptic defects of STOP null mice

INTRODUCTION

Recent studies have suggested that schizophrenia is associated with alterations in the synaptic connectivity involving cytoskeletal proteins. The microtubule-associated protein stable tubule only polypeptide (STOP) plays a key role in neuronal architecture and synaptic plasticity, and it has been demonstrated that STOP gene deletion in mice leads to a phenotype mimicking aspects of positive and negative symptoms and cognitive deficits classically observed in schizophrenic patients. In STOP null mice, behavioral defects are associated with synaptic plasticity abnormalities including defects in long-term potentiation. In these mice, long-term administration of typical antipsychotics has been shown to partially alleviate behavioral defects but, as in humans, such a treatment was poorly active on deficits related to negative symptoms and cognitive impairments. Here, we assessed the effects of risperidone and clozapine, two atypical antipsychotics, on STOP null mice behavior and synaptic plasticity.

RESULTS

Long-term administration of either drug results in alleviation of behavioral alterations mimicking some negative symptoms and partial amelioration of some cognitive defects in STOP null mice. Interestingly, clozapine treatment also improves synaptic plasticity of the STOP null animals by restoring long-term potentiation in the hippocampus.

DISCUSSION

All together, the pharmacological reactivity of STOP null mice to antipsychotics evokes the pharmacological response of humans to such drugs. Totally, our study suggests that STOP null mice may provide a useful preclinical model to evaluate pharmacological properties of antipsychotic drugs.

The burden of depressive symptoms in people with schizophrenia

People with schizophrenia and concurrent depressive symptoms have poorer long-term functional outcomes compared with the nondepressed. Their poorer quality of life, greater use of mental health services, and higher risk of involvement with law enforcement agencies underscore a need for special treatment interventions. Treatment of the nonpsychotic dimensions of schizophrenia is a critical part of recovery. In a 3-year study, the depressed cohort was significantly more likely than the nondepressed to use relapse-related mental health services (emergency psychiatric services, sessions with psychiatrists); to be a safety concern (violent, arrested, victimized, or suicidal); to have greater substance-related problems; and to report poorer life satisfaction, quality of life, mental functioning, family relationships, and medication adherence. Furthermore, changes in depressed status were associated with changes in functional outcomes.

Controversies and Growing Points in Cognitive-Behavioural interventions for People with Schizophrenia

The growing “family” of cognitive-behavioural interventions has made impressive strides in the management of schizophrenia over the last decade. This paper critically reviews the advances that have been made and examines some of the controversies and difficulties encountered in the application of this approach and suggests areas for future growth and research. Future developments in family interventions, early intervention, the management of hallucinations and the potential utility of a form of psychotherapy to treat secondary depression and prevent suicide, are covered in depth. Service structures to integrate these interventions, their timing and duration are considered. It is suggested that the marriage of case management and psychosocial interventions in particular is now overdue.

Psychiatric comorbidities and schizophrenia

Psychiatric comorbidities are common among patients with schizophrenia. Substance abuse comorbidity predominates. Anxiety and depressive symptoms are also very common throughout the course of illness, with an estimated prevalence of 15% for panic disorder, 29% for posttraumatic stress disorder, and 23% for obsessive-compulsive disorder. It is estimated that comorbid depression occurs in 50% of patients, and perhaps (conservatively) 47% of patients also have a lifetime diagnosis of comorbid substance abuse. This article chronicles these associations, examining whether these comorbidities are "more than chance" and might represent (distinct) phenotypes of schizophrenia. Among the anxiety disorders, the evidence at present is most abundant for an association with obsessive-compulsive disorder. Additional studies in newly diagnosed antipsychotic-naive patients and their first-degree relatives and searches for genetic and environmental risk factors are needed to replicate preliminary findings and further investigate these associations.

Naturalistic follow-up of co-morbid substance use in schizophrenia: the West London first-episode study

BACKGROUND

The impact of co-morbid substance use in first-episode schizophrenia has not been fully explored.

METHOD

This naturalistic follow-up of a cohort of 152 people with first-episode schizophrenia examined substance use and clinical outcome in terms of symptoms and social and neuropsychological function.

RESULTS

Data were collected on 85 (56%) of the patient cohort after a median period of 14 months. Over the follow-up period, the proportion of smokers rose from 60% at baseline to 64%. While 30% reported lifetime problem drinking of alcohol at baseline, only 15% had problem drinking at follow-up. Furthermore, while at baseline 63% reported lifetime cannabis use and 32% were currently using the drug, by the follow-up assessment the latter figure had fallen to 18.5%. At follow-up, persistent substance users had significantly more severe positive and depressive symptoms and greater overall severity of illness. A report of no lifetime substance use at baseline was associated with greater improvement in spatial working memory (SWM) at follow-up.

CONCLUSIONS

Past substance use may impede recovery of SWM performance in people with schizophrenia in the year or so following first presentation to psychiatric services. The prevalence of substance use other than tobacco tends to diminish over this period, in the absence of specific interventions. Persistent substance use in first-episode schizophrenia is associated with more severe positive and depressive symptoms but not negative symptoms, and should be a target for specific treatment intervention.

Cognitive-behavioral therapy for medication-resistant schizophrenia: a review

Research meta-analyses have found that cognitive-behavioral therapy (CBT) is beneficial for persistent symptoms of schizophrenia. This review describes and updates the evidence base for this statement. A review of the existing literature (Medline, PsychInfo, and Embase) was carried out according to the guidelines for systematic reviews. Based on the findings of this review, the updated conclusion is that CBT has emerged as an effective adjuvant to antipsychotic medication in the treatment of persistent symptoms of schizophrenia. Studies of the use of CBT in the prodromal phase of psychosis and in combination with family therapy are currently underway.

The burden of depressive symptoms in the long-term treatment of patients with schizophrenia

OBJECTIVE

To prospectively measure the link between depressive symptoms and functional outcomes in the long-term treatment of people with schizophrenia.

METHODS

Data were drawn from a large, multi-site, 3-year, prospective, naturalistic, observational study, in which subjects with schizophrenia were assessed at enrollment and at 12-month intervals thereafter. Individuals who were "Depressed" (defined as a total score > or =16 on the Montgomery-Asberg Depression Rating Scale) at enrollment were compared to those "Non-depressed" on functional outcomes, using self-report measures, clinicians' ratings, and information from medical records. Statistical analyses included Generalized Estimation Equation and mixed regression analyses adjusted for individual characteristics. Longitudinal group comparisons across the 3-year study were augmented with a cross-sectional group comparison at enrollment.

RESULTS

At enrollment, 39.4% (877/2228) of the participants were deemed Depressed. Across the 3-year study, the depressed cohort was significantly more likely than the Non-depressed to use relapse-related mental health services (emergency psychiatric services, sessions with psychiatrists); to be a safety concern (violent, arrested, victimized, suicidal); to have greater substance-related problems; and to report poorer life satisfaction, quality of life, mental functioning, family relationships, and medication adherence. Furthermore, changes in depressed status were associated with changes in functional outcomes.

CONCLUSIONS

People with schizophrenia and concurrent depressive symptoms have poorer long-term functional outcomes compared to the Non-depressed. Their poorer quality of life, greater use of mental health services, and higher risk of involvement with law enforcement agencies underscore a need for special treatment interventions. Treatment of the non-psychotic dimensions of schizophrenia is a critical part of recovery.

First-episode schizophrenia: a focus on pharmacological treatment and safety considerations

Schizophrenia is a debilitating disorder, which is usually chronic, and is one of the most devastating medical illnesses. Early and appropriate treatment with antipsychotics is an important strategy for patients with first-episode schizophrenia. However, there are many possible safety issues for patients with schizophrenia that should be considered and properly addressed. Depressive symptoms and suicidal behaviour commonly occur in first-episode schizophrenic patients, and every effort should be made to treat and minimise these symptoms. There are also important issues and considerations in young and first-episode patients that should also be considered in the emergency treatment setting and for minimising medication nonadherence in this population. Most importantly, adverse effects should be considered, minimised and addressed. While first- and second-generation antipsychotics (SGAs) both appear to offer similar efficacy for amelioration of positive symptoms in first-episode patients, SGAs may offer better tolerability, specifically regarding extrapyramidal symptoms (EPS) and tardive dyskinesia risk, and some prolactin-sparing benefits. However, these medications do cause a host of adverse effects, including weight gain, metabolic disturbances, corrected QT interval prolongation and prolactin-related adverse effects, which are important considerations relating to both the short- and long-term safety of patients with schizophrenia being treated with SGAs. Clozapine and olanzapine are most likely to cause weight gain and metabolic effects, while risperidone is more likely to cause EPS and prolactin elevations. Most antipsychotics should be used in low doses to minimise adverse effects and each medication should be optimised in a highly individualised way to maximise adherence and treatment outcomes and minimise tolerability and safety concerns. At some point in their lives, these patients will most probably experience periods of depression, suicidal behaviours, adverse effects and nonadherence, and every effort should be made to minimise or prevent these from occurring. Thus, safety concerns in this group of young patients, in the beginning of their first psychotic episode, are a major issue as they are starting a journey of antipsychotic treatment that is likely to last for the remainder of their lives.

Depressive and negative symptoms in schizophrenia: different effects on clinical features

OBJECTIVE

The primary aim of this study was to investigate whether depressive symptoms were significantly associated with functional outcome measures in a clinically stable group of outpatients with schizophrenia. We also analyzed whether depressive and negative symptoms presented different patterns of predictors.

METHOD

Seventy-eight consecutive outpatients meeting Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision criteria for schizophrenia in the stable period were enrolled in this cross-sectional study. Assessment were performed using the Calgary Depression Scale for Schizophrenia, Positive and Negative Syndromes Scale (PANSS), Clinical Global Impression Scale-severity, Social and Occupational Functioning Assessment Scale, Sheehan Disability Scale, and Quality of Life Scale. A neuropsychologic battery including the vocabulary and block design subtests of the Wechsler Adult Intelligence Scale-Revised, Wechsler Memory Scale, Wisconsin Card Sorting Test, and Continuous Performance Test was also administered to the patients. Two multiple regressions were performed testing demographic and clinical factors, rating scales, and cognitive measures as independent variables and Calgary Depression Scale for Schizophrenia and PANSS-negative subscale scores as dependent variables.

RESULTS

Four variables were predictors of depressive symptoms in our sample of schizophrenic patients: 2 outcome measures (Sheehan Disability Scale and Quality of Life Scale), gender, and Continuous Performance Test reaction time. Predictors of negative symptoms were the measures of severity of psychopathology (Clinical Global Impression Scale-severity and PANSS-general psychopathology subscale) and the cognitive tests Wechsler Adult Intelligence Scale-Revised block design and Wechsler Memory Scale.

CONCLUSION

We found that depressive symptoms in schizophrenia are mainly a function of the level of social adjustment and quality of life, whereas negative symptoms constitute an indicator of severity of schizophrenia. The 2 symptom dimensions showed also distinct cognitive correlates.

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.

Factor solution of the BPRS-expanded version in schizophrenic outpatients living in five European countries

RATIONALE

The expanded version of the Brief Psychiatric Rating Scale (BPRS-E) has improved the instrument's coverage and interrater reliability, but there is little knowledge on its subsyndromes.

OBJECTIVES

To assess: (1) whether there are common underlying BPRS-E subscales in patients living in different countries and (2) if this is the case, whether these subscales behave the same in all populations and, if not, what are the differences over these populations.

METHODS

Data are part of the EPSILON study, a collaborative project carried out in Denmark, England, Holland, Italy and Spain. A random representative sample of 404 adult patients with a ICD-10 diagnosis of schizophrenia who have been in contact with mental health services of a defined catchment area in each site were assessed. Simultaneous component analysis (SCA) was used to find component weights that optimally explain the variance of the variables in different populations simultaneously.

RESULTS

Symptom severity differed significantly among the five EPSILON sites in 12 out of 24 BPRS-E items, but a common component solution could be found. It explained 48.8% of the variance and gave four well-interpretable components: manic excitement/disorganization, depression/anxiety, negative and positive symptoms. Each component's internal consistency and intercomponent correlation matrix differed significantly among sites. The four components mean score differed significantly among sites for negative symptoms and depression/anxiety.

CONCLUSIONS

In spite of the heterogeneity of symptom's severity in the various countries, the way symptoms cluster in schizophrenia is rather stable cross-culturally. Data demonstrate that to explore schizophrenia a third component, including mania/disorganization items, is necessary beside the positive-negative symptom dimensions. The subscales derived from these analyses can be readily used in clinical trials and epidemiological studies.

Hallucinatory experiences and onset of psychotic disorder: evidence that the risk is mediated by delusion formation

OBJECTIVE

To examine the hypothesis that the risk for onset of psychotic disorder in individuals with self-reported hallucinatory experiences (HE) would be higher in those who developed delusional ideation (DE) than in those who did not.

METHOD

A population sample of 4673 individuals were interviewed with the Composite International Diagnostic Interview at baseline and 1 and 3 years later. At year 3, clinical re-interview took place to identify onset of psychotic disorder.

RESULTS

Given the presence of HEs at baseline, the increase in risk of having the psychosis outcome at year 3 was much higher in those with DE at year 1 than in those without DE (risk difference between individuals with and without DE: 18.72%, 95% CI: 2.22-35.23, chi(2) = 4.94, df = 1, P = 0.026).

CONCLUSION

The results are in line with current psychological theories stating that clinical outcome of psychosis-like experiences is related to the development of secondary beliefs and appraisals.

Possible Relationship Between Testosterone and Comorbid Major Depressive Episode in Male Patients With Schizophrenia Treated With Typical Antipsychotic Medications

In this cross-sectional study, the author tested the hypothesis that serum testosterone levels were associated with depressive illness in chronic male schizophrenia patients. The subjects were 49 male inpatients meeting DSM-IV criteria for schizophrenia treated with typical antipsychotic medications. The author found that the schizophrenia patients with major depressive episodes (MDE) had been taking significantly higher dosages of antipsychotic medications than those without an MDE. Also, there was a trend for the serum testosterone concentration to be lower in schizophrenia patients with an MDE. It is suggested that we should be aware of testosterone levels when we find depression in chronic male schizophrenia patients, especially those treated with high-dose typical antipsychotic medications.

Influence of depressive symptoms and premorbid adjustment on factor structure of phenomenology of schizophrenia: a study from India

This study investigated the nature of factor structure of schizophrenia syndromes using a sample of 151 patients with schizophrenia according to DSM-IV. The patients were assessed on the Scale for the Assessment of Positive Symptoms (SAPS), the Scale for the Assessment of Negative Symptoms (SANS), Hamilton Depression Rating Scale (HDRS) and the Phillips Rating Scale of Premorbid Adjustment in schizophrenia. Three factors-negative syndrome, reality-distortion syndrome and disorganized syndrome were extracted when only SAPS and SANS were analysed. Addition of the Phillips Rating Scale scores to SAPS and SANS ratings in the factorial equation led to splitting of the negative syndrome though reality-distortion and disorganized syndromes remained stable. Factor analysis of the HDRS scores with SAPS and SANS ratings resulted in the HDRS loading highly on reality-distortion syndrome and splitting of negative syndrome. Factor analysis of all the variables taken together resulted in delineation of four factors. The study suggests a link between depression and reality distortion. Apathy and anhedonia seem to be linked to premorbid adjustment.

Neuroticism and visual memory impairments as predictors of the severity of delusions in schizophrenia

This study examined whether levels of emotional distress and impairments in visual memory were uniquely associated with severity of delusions in schizophrenia. Severity of delusions was assessed using select items from the positive component of the Positive and Negative Syndrome Scale among 44 persons with schizophrenia or schizoaffective disorder in a post-acute phase of illness. Emotional distress was assessed using the neuroticism subscale of the NEO Five Factor Inventory, and visual memory was assessed using the Rey Complex Figure Test. Controlling for executive function, visual attention, and verbal memory, a multiple regression analysis revealed that visual memory and neuroticism were each significantly related to severity of delusions, with the two combined accounting for one quarter of the variance. These same variables were unrelated to negative and excitement symptoms. Severity of delusions is linked to both higher levels of neuroticism and greater impairment in visual memory.

Differential effect of quetiapine on depressive symptoms in patients with partially responsive schizophrenia

While atypical antipsychotics appear to be effective in reducing depressive symptoms in the acute phase of schizophrenia, little is known about their efficacy in patients with ongoing symptoms. The present study assessed whether quetiapine (Seroquel) is more effective than haloperidol in treating depressive symptoms in patients with persistent positive symptoms, and investigated whether this effect is independent, or secondary to, reductions in other symptoms such as positive, negative or extrapyramidal symptoms. Patients with schizophrenia and a history of partial refractoriness to conventional antipsychotics who had not responded to 4 weeks of fluphenazine treatment (20 mg/day) were randomized to receive either quetiapine (600 mg/day) or haloperidol (20 mg/day) for a further 8 weeks. Change in the Positive and Negative Syndrome Scale depression factor score from baseline to endpoint was calculated and path analyses were performed on data from 269 patients. Quetiapine produced a greater reduction in depressive scores than haloperidol (-1.60 versus -0.54; p = 0.006). The path analyses indicated that this was a direct effect on depressive symptoms. These findings extend the evidence for an antidepressant effect for the novel antipsychotics in schizophrenia, and suggest that this is not limited to acutely psychotic patients.

The factor structure for the Positive and Negative Syndrome Scale (PANSS) in recent-onset psychosis

The Positive and Negative Syndrome Scale (PANSS) is a widely used instrument for measuring severe psychopathology in adult patients with schizophrenia. Data, primarily on chronic patients, have been used to define factors for the PANSS. The present study examines the PANSS factor structure in a large sample of subjects with recent-onset schizophrenia, schizophreniform disorder and schizoaffective disorder who had been exposed to very limited antipsychotic medication. Equamax factor analysis was conducted on PANSS baseline assessments from a multicenter, 11 country drug trial that enrolled 535 patients. The forced five-factor solution essentially corresponds to the factors most frequently described previously, namely negative, positive, disorganized (or cognitive), excited and anxiety/depression. In the exploratory analysis, a seven-factor solution was obtained, with depression and anxiety symptoms separating and a motor component emerging. The results of this study partially support the use of a five-factor model for the PANSS, but suggest that scales for catatonia, depressive and anxiety syndromes should be included in future studies.

Depressive symptoms in chronic schizophrenia patients: any differences between patients with and without a major depressive episode?

The author investigated the differences between schizophrenia patients with and without a major depressive episode (MDE) using the Japanese Calgary Depression Scale for Schizophrenics. The total depression score was correlated with the dosage of antipsychotics in patients without an MDE, but such a correlation was not found in patients with an MDE.

A double-blind, placebo-controlled trial of sertraline for depressive symptoms in patients with stable, chronic schizophrenia

There have been no studies specifically examining the efficacy of selective serotonin reuptake inhibitor antidepressants for the symptoms of depression in schizophrenia. This study aimed to determine the efficacy and safety of sertraline as a treatment for depressive symptoms in patients with stable, chronic schizophrenia. The Beck Depression Inventory (BDI) was used as the principal outcome measure and other measures of depressive symptoms as secondary outcome measures. Twenty-six patients were entered into a double-blind, placebo-controlled, 8-week trial of sertraline and were included in the intent-to-treat (ITT) analysis (13 in each group). Eight patients in the sertraline group and 12 in the placebo group completed at least four weeks in the study and were considered to have had adequate treatment. On the ITT analysis, the mean score on the BDI fell 14.5% for the sertraline group and 5.6% for the placebo group (p > 0.05); the mean score on the Hamilton Depression Rating Scale (HDRS) fell 16.99% for the sertraline group and 8.3% for the placebo group (p > 0.05). When the analysis was repeated for those who had received adequate treatment, the mean BDI score fell by 28% for the sertraline group and 6% for the placebo group (p = 0.1); the mean HDRS score fell 31% for the sertraline group and 8.6% for the placebo group (p = 0.02). On the Clinical Global Impression-Improvement Scale, 10 of the 13 patients on sertraline improved against four of the 13 in the placebo group (p = 0.05). Sertraline-treated patients showed a significant improvement on the anxiety/ depression subscale of the BPRS on ITT analysis (F = 10.1, p = 0.004). There was no significant effect on negative or positive symptoms. Sertraline was well tolerated. The results suggest that sertraline is useful as a treatment for depressive symptoms in schizophrenia.

Differential effects of high-dose amisulpride versus flupentixol on latent dimensions of depressive and negative symptomatology in acute schizophrenia: an evaluation using confirmatory factor analysis

While many acutely ill schizophrenic patients suffer from depressive symptoms, most studies on the efficacy of antipsychotic drugs focus on positive and negative symptoms. Dimensional models of schizophrenic symptoms, based on confirmatory factor analysis (CFA) using structural equation modelling, offer a methodological alternative to compare antipsychotics on empirically justified latent factors. The present report is a refined analysis of a published double-blind study on the D2/D3-selective antagonist amisulpride (ASP) versus the mixed D1-5/5-HT2 antagonist flupentixol (FPX). CFA was applied to Brief Psychiatric Rating Scale, Scale for the Assessment of Negative Symptoms, Bech-Rafaelsen Melancholia Scale and Simpson-Angus Scale subscores to examine differential effects of high doses of ASP and FPX on negative and depressive symptom dimensions in 126 acutely ill schizophrenic patients. A four-factor model comprising the full spectrum of acute symptomatology and a three-factor model ('negative', 'anhedonia-apathy', 'depressive') restricted to negative and depressive symptoms were yielded with an identical 'depressive' dimension in both models. Analyses of CFA-derived factor scores showed that ASP was significantly superior to FPX regarding the latent 'depressive' dimension, independent of baseline scores, dosage and changes in akinesia. Neither the negative' dimension nor 'anhedonia-apathy' showed significantly different treatment effects. CFA-based analyses appear to be suitable for psychotropic drug evaluation when more refined and data-related information on drug efficacy profiles are required.

Differential diagnosis of depressed mood in patients with schizophrenia: a diagnostic algorithm based on a review

OBJECTIVE

To review the available literature on depressive symptomatology in schizophrenia in order to establish a diagnostic algorithm of depressive syndromes in schizophrenia.

METHOD

A literature search was performed using PubMed and Medline. Additional information was gained by cross-referencing from papers found in the database. Data from controlled studies as well as supplementary information from review articles and psychiatric manuals pertinent to the topic were used. Depressive symptoms were classified with respect to their temporal relationship to acute psychotic symptoms before the background of nosological entities as operationalized by Diagnostic Statistical Manual IV (DSM IV).

RESULTS

Depression is a common and devastating comorbid syndrome in patients suffering from schizophrenic disorder. The paper summarizes the relevant diagnostic steps to guide the clinician towards therapeutic interventions, which differ depending on the nature of the depressive syndrome.

CONCLUSION

Differentiating depressives states in schizophrenia has consequences in terms of choosing therapeutic strategies. An algorithm which leads the practitioner to a reliable diagnosis and in consequence to a valid therapy is presented.

The dimensional symptom structure of schizophrenia and its association with temperament and character

Recent studies suggest that personality may influence symptom expression and social functioning in schizophrenia. This study investigated the relationships between personality and symptom dimensions in schizophrenia patients. Fifty-two schizophrenia patients and 25 five healthy subjects were assessed using the Temperament and Character Inventory (TCI). The patients were also assessed for positive and negative symptoms using SAPS and SANS and scored according to Andreasen's (1995: Andreasen, N.C., Arndt, S., Alliger, R., Miller, D., Flaum, M. 1995. Symptoms of schizophrenia. Methods, meanings, and mechanisms. Arch. Gen. Psychiatry, 52, 341-351) classical three dimensional model and by the five dimensional model of Toomey et al. (1997: Toomey, R., Kremen, W.S., Simpson J.C., Samson, J.A., Seidman, L.J., Lyons, M.J., Faraone, S.V., Tsuang, M.T. 1997. Revisiting the factor structure for positive and negative symptoms: evidence from a large heterogeneous group of psychiatric patients. Am. J. Psychiatry, 154, 371-377). Comparisons between patients and controls revealed significant differences on various TCI scores consistent with a global disorganization of personality in schizophrenia involving both basic neurophysiological and potentially genetically determined traits (i.e. temperament) and developmental aspects of personality (i.e. character). Correlation analysis showed distinct associations between symptoms and personality dimensions. The results suggest that the negative and disorganized dimensions of schizophrenia are related temperamental factors, whereas the psychotic symptoms are more related to characterological abnormalities. The observed patterns of associations also underline the heterogeneity of the classical negative and positive dimensions of schizophrenia.

Depressive, positive, negative and parkinsonian symptomsin schizophrenia

OBJECTIVE

Depressive symptoms are common in schizophrenia but their relationship to the positive and negative symptoms of the disorder and to extrapyramidal side-effects remains unclear. Considerable overlap exists between these symptom clusters when rated with traditional clinical rating scales. The aim of this study was to investigate the relationship of depressive to positive, negative and parkinsonian symptoms using the recent adaptation of the Positive and Negative Syndrome Scale (PANSS).

METHOD

The study involved the cross-sectional measurement of symptoms in a sample of community-treated and hospitalized patients with schizophrenia. Structured assessment included thePANSS, Montgomery-Asberg Depression Rating Scale (MADRS) and the Extrapyramidal Side Effects Rating Scale (ESRS).

RESULTS

Depressive symptoms were common and correlated with positive and negative symptoms. These correlations were of a similar magnitude using either the original PANSS factor structure or the newer pentagonal model. The overlap between depressive and negative symptoms was limited to certain items in the rating scales and there was a clear separation between these symptom clusters and the other items. Parkinsonian symptoms also correlated with negative symptoms rated with either PANSS model.

CONCLUSION

Use of the pentagonal PANSS model does not improve its capacity to distinguish between depressive and negative symptoms. Positive, negative, parkinsonian and depressive symptoms overlap using common rating scales but there appears to be some separation between these symptom domains when rated with individual scale items rather than total scale scores.

Suicide and schizophrenia

Suicide and suicide attempts occur at a significantly greater rate in schizophrenia than in the general population. Common estimates are that 10% of people with schizophrenia will eventually have a completed suicide, and that attempts are made at two to five times that rate. Demographically associated with suicidality in schizophrenia are being young, being early in the course of the illness, being male, coming from a high socioeconomic family background, having high intelligence, having high expectations, not being married, lacking social supports, having awareness of symptoms, and being recently discharged from the hospital. Also associated are reduced self-esteem, stigma, recent loss or stress, hopelessness, isolation, treatment non-compliance and substance abuse. Clinically, the most common correlates of suicidality in schizophrenia are depressive symptoms and the depressive syndrome, although severe psychotic and panic-like symptoms may contribute as well. This review specifically explores the issue of depression in schizophrenia, in relation to suicide, by organizing the differential diagnosis of this state and highlighting their potentially treatable or correctable causes. This differential diagnosis includes both acute and chronic disappointment reactions, the prodrome of an acute psychotic episode, neuroleptic induced akinesia and akathisia, the possibility of direct neuroleptic-induced depression, negative symptoms of schizophrenia, and the possible co-occurrence of an independent depressive diathesis. The potential beneficial roles of 'atypical' antipsychotic agents, including both clozapine and more novel agents, and adjunctive treatment with other psychopharmacological medications are considered, and the important roles of psychosocial factors and interventions are recognized.

Schizophrenia

To provide the most effective care for this difficult patient population, it is helpful to remember that patients with schizophrenia have disease-intrinsic limitations that limit their ability to participate in their care. These limitations are symptoms of a disease and not volitional. For the physician to substitute for these deficits, a certain degree of flexibility as well as the willingness to use unorthodox interventions is necessary. Good medical care is as important for the patient with schizophrenia as for any other patient.

Familiality of symptom dimensions in schizophrenia

The division of schizophrenic symptoms into three core dimensions - psychomotor poverty, reality distortion, and disorganisation - is well established. When factor analytic studies have included affective symptoms they have identified two additional dimensions - manic and depressive. Whether these five dimensions represent underlying psychopathology of a genetic or environmental aetiology remains unclear. The aims of this study were to perform factor analysis of symptoms in a group of familial schizophrenic patients and to investigate the familiality of the symptom dimensions identified, and their relationship to clinical characteristics. Symptoms were recorded, using the Operational Criteria Checklist for Psychotic Illness, for 155 Caucasian subjects with an RDC diagnosis of schizophrenia, schizoaffective disorder, or psychosis of unknown origin, from 61 families multiply affected with schizophrenia. Factor analysis indicated five symptom dimensions: depressive, manic, reality distortion, disorganisation, and psychomotor poverty. The psychomotor poverty, disorganisation, and manic dimensions were shown to be familial. Psychomotor poverty, disorganisation, and reality distortion were all associated with deterioration from premorbid functioning and chronic course of the disorder. In addition, psychomotor poverty was significantly related to poor premorbid functioning, as well as to single marital status and unemployment at onset. Disorganisation was significantly related to single marital status and unemployment at onset. The familiality of the psychomotor poverty, disorganisation, and manic dimensions supports their use in the delineation of homogeneous subsets for genetic studies.