Measuring outcome priorities and preferences in people with schizophrenia

In the eyes of the beholders: Subjective experiences of positive symptoms among patients with symptoms of psychosis seeking psychotherapy

BACKGROUND

Reduction of positive symptoms is often the focus of psychiatric treatment for patients with psychosis; however, it is becoming increasingly clear that some patients experience ambivalence towards positive symptoms or may even experience them as pleasant. The present study extends upon work from online studies of patients without verified diagnoses. The first aim was to examine the frequency with which patients report negative, neutral or even positive appraisals of positive symptoms. A second aim was to identify whether these appraisals were associated with medication adherence.

METHODS

One-hundred twelve treatment-seeking patients with current symptoms of psychosis completed the Subjective Perception of Positive Symptoms-Revised (SUPPOSY-R), a scale assessing appraisals of positive symptoms (e.g., gain from illness, impact on daily life), as well as questions regarding medication adherence.

RESULTS

Although most patients reported experiencing positive symptoms as predominantly unpleasant, appraisals differed between symptom clusters and up to 54.4 % reported that they would miss at least some aspects of positive symptoms should they disappear. Patients particularly welcomed the disappearance of auditory hallucinations (71.2 %). Symptom appraisal was not significantly associated with medication compliance (p > .17); however, more patients with low medication adherence reported they would feel at least some regret if their symptoms were to completely disappear (48.9 %, n = 23) versus patients with high adherence (41.7 %, n = 20).

DISCUSSION

Ambivalent or positive appraisals of positive symptoms are lower among treatment-seeking patients compared to patients recruited for online studies, who may not be actively seeking treatment. Auditory hallucinations may cause most distress among treatment-seeking patients. A collaborative approach including assessment of possible positive appraisals of symptoms is important when identifying treatment goals.

Understanding the health context for implementation of a new digital psychosocial intervention for improvement of the mental health in North Macedonia

The aim of this study was to identify the contextual attributes in North Macedonia and their characteristics relevant to the implementation of a new digital intervention to improve mental health, called DIALOG+. This research is the first of its kind in North Macedonia due to the analysis of contextual attributes that may affect the effectiveness of the intervention and its acceptability in various settings of mental health care. Some of the data processed in this paper were provided and analyzed by the National Mental Health Strategy 2018-2025 and other relevant accompanying documents from the World Health Organization and action plans, as well as through interviews with stakeholders (patients, carers, clinicians and policy makers) for their opinion before introducing the DIALOG + intervention and the report on the assessment of the situation in the centers where the implementation of the intervention should have started. The collected data were then mapped to a framework developed by the Ottawa Implementation Group, which included 14 contextual attributes. The results are summarized in 2 subgroups, and are presented as facilitators and barriers to implementation, specific to the mental health system in North Macedonia. The characteristics of DIALOG + (widely applicable psychosocial intervention) are in accordance with modern assumptions for psychosocial rehabilitation of patients with psychosis. Hence, we can conclude that it is a useful tool for professionals in monitoring and achieving the true vision and mission of these institutions. It will help patients reintegrate into society, become more independent and use their full potential in the pursuit of healthy and functional living.

The Importance of Personal Recovery and Perceived Recovery Support Among Service Users With Psychosis

OBJECTIVE

More knowledge is needed about whether personal recovery, as defined by the CHIME framework (connectedness, hope, identity, meaning and purpose, and empowerment), is considered important by service users with psychosis. This study examined the importance of personal recovery for a large, heterogeneous group of service users with psychosis and their perceived support from clinicians for personal recovery.

METHODS

This cross-sectional study used baseline data from 321 service users with psychosis from 39 clinical units across Norway. The INSPIRE Measure of Staff Support for Personal Recovery (based on CHIME) was used to examine personal recovery and perceived support provided for recovery. Twenty support-for-recovery items were each rated on importance (yes or no) and on the extent of support received (5-point scale). Bivariate and multiple linear regression models assessed variables associated with rated importance and support. Results: Most service users rated personal recovery items as important, regardless of their symptomatology and functioning. Previous experience with Illness Management and Recovery, knowledge about coping with stress and illness, and having a plan for early detection and prevention of relapse were significantly associated with higher perceived support. Higher self-reported depressive symptoms, lower score on the Global Assessment of Functioning symptom subscale, and male sex were significantly associated with less perceived support.

CONCLUSIONS

Most service users with psychosis found personal recovery important, regardless of symptomatology and functioning, which has implications for clinical practice and provides empirical evidence that recovery-oriented treatments are relevant for most service users with psychosis in various mental health services.

Relationship between quality of life and social integration among patients with schizophrenia attending a Nigerian tertiary hospital

BACKGROUND

Despite decades of de-institutionalization and the best efforts of community mental health services, individuals with schizophrenia living outside the hospital may be described as in the community but not of the community, and remain in a very real sense socially excluded.

AIM AND OBJECTIVES

To determine the relationship between social integration and quality of life among patients with schizophrenia attending the outpatient clinic of the Neuropsychiatric Hospital Abeokuta in Nigeria.

METHODS

One hundred and fifty-one patients were recruited. Sociodemographic questionnaire, MINI-PLUS, WHOQOL-BREF, Social Integration Scale and PANSS were administered. Multivariable regression analyses were performed to identify the determinants of quality of life and the relationship with social integration.

RESULTS

The mean (± SD) age of the respondents was 40.00 (± 10.23), 56.3% were males, 37.1% were single. Independent predictors of lower quality of life were: (1) more severe psychopathology for the domains of general health (p = 0.003), social relationship (p = 0.019) and environment (p = 0.008); (2) longer duration of illness for the social relationship (p = 0.028) and environment (p = 0.015) domains; and (3) negative symptoms (p = 0.034) for the physical domain.

CONCLUSION

There is a need to pay closer attention to social outcome measures such as quality of life and level of social integration among patients with schizophrenia who come in contact with psychiatry services, and not just on symptom remission only.

First-Person Accounts of Change Among Young Adults Enrolled in Coordinated Specialty Care for First-Episode Psychosis

OBJECTIVE

This study investigated how clients of a coordinated specialty care (CSC) program for first-episode psychosis perceived how they changed while attending the program, what the most important changes were, and what mechanisms they believed helped bring about these changes.

METHODS

Study participants were 121 individuals (71 men and 50 women) from 35 CSC programs across 22 U.S. states. Responses to the primary questions of interest were procured through a semistructured interview. Data on the length of time in the CSC program were also obtained. The authors used systematic content analyses to analyze these qualitative data.

RESULTS

Participants reported a greater number of changes the longer they had received CSC services. Half of the participants reported improved psychiatric symptoms, and this change was the most important for almost one-third (31%; N=32) of the sample. In addition, 39% (N=45) of participants also reported improved social and interpersonal skills, changes in their attitude to and perspective on life, and more treatment engagement. Participants most frequently endorsed therapy as the mechanism underlying their improvement.

CONCLUSIONS

Standardized outcome measures allow systematic assessment of clinical and functional status, but they do not provide a nuanced understanding of the underlying mechanisms or the areas of improvement most important to individual clients. The findings reinforce the value of mixed methods in both research and quality improvement efforts as well as for greater integration of patient-selected outcome measures.

Co-designing a virtual world with young people to deliver social cognition therapy in early psychosis

AIMS

Co-design implies genuine partnership in the generation of knowledge between service users and researchers. Service user involvement in research has been encouraged in government policy, but it is rarely achieved, especially at trial initial stages. Co-designed with service users, we adapted existing manualised social cognition intervention for people with a first episode of psychosis to a virtual world environment.

METHODS

We invited a group of young people who have used mental health services to co-design a virtual environment to deliver an accessible social cognition intervention to a hard to engage service user group. We used an iterative process with young service users and the design team that included developing initial ideas, creating a prototype and testing the virtual world.

RESULTS

Twenty young service users of local mental healthcare services provided feedback on the design and delivery of the intervention. Reflecting the demographic of the sample, young people felt the virtual environment should be familiar, urban spaces, akin to therapy rooms or classrooms they have used in real-life situations rather than non-traditional therapy spaces that were initially proposed.

CONCLUSION

The co-design process led to the development of a specific design, approach and protocol to be tested in a proof-of-concept trial. Young service users were integral to an agile and iterative design. Technological innovations should be routinely co-designed and co-produced if they are to realise their potential to deliver acceptable and affordable mental health interventions.

Antipsychotic Treatment Experiences of People with Schizophrenia: Patient Perspectives from an Online Survey

BACKGROUND

This survey examined the experiences of people living with schizophrenia who have used oral antipsychotics (APs).

METHODS

Adults with self-reported physician-diagnosed schizophrenia (N=200), who were members of an online research participation panel and reported taking one or more oral APs within the last year, completed a cross-sectional online survey that focused on direct report of their experiences regarding APs (eg, symptoms, side effects, adherence). Descriptive analyses were conducted for the total survey sample and for subgroups defined a priori by experience with specific, prevalent side effects.

RESULTS

The mean age of the sample was 41.9 (SD=11.0) years, 50% of participants were female, and 32% were nonwhite. Overall ratings were positive for medication effectiveness and convenience but negative for side effects. While most participants reported that APs improved schizophrenia symptoms (92%), 27% reported APs as having done "more harm than good." Almost all participants (98%) reported experiencing side effects of APs, with the most common being anxiety (88%), feeling drowsy/tired (86%), and trouble concentrating (85%). Side effects frequently cited as either "extremely" or "very" bothersome were weight gain (56%), sexual dysfunction (55%), and trouble concentrating (54%). Over 80% reported that side effects had negatively impacted their work and social functioning (eg, social activities or family/romantic relationships). Since initiating treatment, 56% of respondents had stopped taking APs at some point (65% of these due to side effects). Side effects commonly reported as having led to stopping AP treatment were "feeling like a 'zombie'" (22%), feeling drowsy/tired (21%), and weight gain (20%).

CONCLUSION

Most participants reported improvements in schizophrenia symptoms associated with the use of APs. However, most participants also reported experiencing numerous bothersome side effects that negatively impacted their work, social functioning, and treatment adherence. Results highlight the unmet need for new APs with favorable benefit-risk profiles.

Treatable clinical intervention targets for patients with schizophrenia

BACKGROUND

Treatment approaches for patients with psychosis need major improvement. Our approach to improvement is twofold: target putative causal mechanisms for psychotic experiences that are treatable and also that patients wish treated. This leads to greater treatment engagement and clinical benefit. To inform mental health service provision we assessed the presence of treatable causal mechanisms and patient treatment preferences.

METHODS

Patients with non-affective psychosis attending NHS mental health services completed assessments of paranoia, hallucinations, anxious avoidance, worry, self-esteem, insomnia, analytic reasoning, psychological well-being, and treatment preferences.

RESULTS

1809 patients participated. Severe paranoia was present in 53.4% and frequent voices in 48.2%. Of the causal mechanisms, severe worry was present in 67.7%, avoidance at agoraphobic levels in 64.5%, analytic reasoning difficulties in 55.9%, insomnia in 50.1%, poor psychological well-being in 44.3%, strongly negative self-beliefs in 36.6%, and weak positive self-beliefs in 19.2%. Treatment target preferences were: feeling happier (63.2%), worrying less (63.1%), increasing self-confidence (62.1%), increasing activities (59.6%), improving decision-making (56.5%), feeling safer (53.0%), sleeping better (52.3%), and coping with voices (45.3%). Patients with current paranoia and/or hallucinations had higher levels of the causal factors and of wanting these difficulties treated.

CONCLUSIONS

Patients with non-affective psychosis have high levels of treatable problems such as agoraphobic avoidance, worry, low self-esteem, and insomnia and they would like these difficulties treated. Successful treatment of these difficulties is also likely to decrease psychotic experiences such as paranoia.

Predictors of treatment satisfaction in antipsychotic-naïve and previously medicated patients with acute-phase psychosis

Background: Treatment satisfaction predicts treatment adherence and long-term outcome for patients with psychosis. It is therefore important to understand the underpinnings of patient satisfaction in psychosis treatment for optimal treatment delivery. Aims: To examine the associations between satisfaction and level and change in positive symptoms, insight, depression and side effects of antipsychotics in previously medicated and antipsychotic-naïve patients. Method: Data derive from a randomised trial, with 226 respondents at baseline and 104 at follow-up. The measures were the positive subscale and insight item from the Positive and Negative Syndrome Scale, Calgary Depression Scale, the UKU Consumer Satisfaction Rating Scale, and the UKU side effects scale. Structural equation modelling was used to test the model. The full information maximum likelihood estimator used all available data. Results: In the sample of 226 patients, 67.3% were male and 44.2% were antipsychotic-naïve. The mean age was 34.1 years. For previously medicated patients, satisfaction was predicted by level of insight (b = -2.21, β = -0.42) and reduction in positive symptoms (b = -0.56, β = -0.39). For antipsychotic-naïve patients, satisfaction was predicted by level and change of insight (b = -2.21, β = -0.46), change in depression (b = -0.37, β = -0.26) and side effects (b = -0.15, β = -0.30). All predictors were significant at the 0.05 level. Conclusion: Reducing positive symptoms and side effects are important to enhance patient satisfaction. However, improving insight and reducing depression are more important in antipsychotic-naïve patients.

Association of participant preferences on work and school participation after a first episode of psychosis

AIM

To explore baseline ratings of importance (ROI) across life domains for participants in the Recovery After an Initial Schizophrenia Episode Connection Program (RAISE CP), and investigate whether ratings were correlated with intervention outcomes over time.

METHODS

At baseline, 63 participants rated the importance of reducing symptoms, side-effects, confusion, increasing energy and school/work functioning and improving social relations. ROIs were examined in relation to work/school participation (n = 41) and occupational functioning (n = 37) after 12 months. Participants' mean age was 22.3 (±4.2).

RESULTS

The ROI domain rated as most important was school/work functioning, and higher school/work ROI at baseline predicted work/school participation after 12 months of participation.

CONCLUSIONS

It is particularly important to assess participant preferences and priorities when treating psychotic disorders because most areas of life are affected. Understanding the impact of participant goals on outcomes is essential as programs design patient-centred treatment plans.

Quantifying the treatment goals of people recently diagnosed with schizophrenia using best-worst scaling

OBJECTIVE

This study seeks to quantify the treatment goals of people recently diagnosed with schizophrenia and explore their impact on treatment plan.

METHODS

People aged 18-35 years with a confirmed diagnosis of schizophrenia within the past 5 years were surveyed in the UK, Germany, and Italy. Treatment goals were assessed via a validated best-worst scaling instrument, where participants evaluated subsets of 13 possible treatment goals identified using a balanced incomplete block design. Participants identified the most and least important goals within each task. Data were also collected on current treatment and preference for daily oral versus long-acting injectable (LAI) treatment. Hierarchical Bayes was used to identify preference weights for the goals, and latent class analysis was used to identify segments of people with similar goals. The segments were compared with the current treatment and preference for oral versus LAI treatment.

RESULTS

Across 100 participants, the average age was 26 years, 75% were male and 50% were diagnosed within 2 years ago. Overall, preferences were most favorable for reduced disease symptoms, think clearly, reduced hospitalizations, reduced anxiety, and take care of self. A total of 61% preferred oral medication and 39% LAI. Two groups were identified with different treatment goals; 50% of participants emphasized clinical goals, including reduced disease symptoms (preference weight =19.7%), reduced hospitalizations (15.5%), and reduced anxiety (10.5%). The other 50% emphasized functional goals, including improved relationships with family/friends (11.4%), increased interest in work (10.6%), experiencing a fuller range of emotions (8.4%), and ability to socialize (7.5%). Those emphasizing functional goals were more likely to be on LAI (44% versus 26%; p=0.059) and preferred LAI (46% versus 32%; p=0.151).

CONCLUSIONS

People with recent-onset schizophrenia may focus more on clinical goals or functional goals, a discussion of which may help facilitate patient engagement.

A patient satisfaction rating scale for psychiatric service users

Aims and method

The patient's experience of the clinician is an increasingly important area in time of ‘consumer choice’ and appraisal of the individual practitioner. Validated, easy-to-use scales are scarce. The aim was to validate a user-friendly, brief scale measuring patient satisfaction (PatSat scale). Over three phases, patients were involved in developing and validating the scale against the Verona satisfaction subscale.

Results

A highly significant correlation was found between the two scales (Spearman's correlation coefficient 0.97, two-tailed P <0.001).

Clinical implications

The PatSat is a new patient satisfaction scale validated in a psychiatric out-patient population. It appeared popular with patients and took less than 1 minute to fill in. The use of validated scales measuring patient satisfaction is a pivotal part of mental health delivery and advancing overall quality of care.

Standardising the reporting of outcomes in gastric cancer surgery trials: protocol for the development of a core outcome set and accompanying outcome measurement instrument set (the GASTROS study)

BACKGROUND

Gastric cancer is one of the leading causes of cancer-related deaths worldwide. Whilst surgery is the mainstay of curative treatment, it is associated with significant risks. Surgical strategies for treating gastric cancer should be based on evidence from systematic reviews of well-designed randomised controlled trials. However, inconsistencies in the reporting of outcomes from these trials makes evidence synthesis unreliable. We present a protocol for an international consensus study to develop a standardised set of outcomes and measurement tools - a 'core outcome set' (COS) - to be used by all future trials examining therapeutic surgical interventions for gastric cancer. The GASTROS study aims to standardise the reporting of outcomes in gastric cancer surgery trials through an international consensus process of key stakeholders including health care professionals and patients.

METHODS

The first of three stages in the study will identify a 'long-list' of potentially important outcomes to be prioritised. These will be extracted from a systematic review of relevant academic literature and patient interviews. Stage 2 will comprise an eDelphi survey which will consider the views of patients, nurse specialists and surgeons to prioritise the most important outcomes. A meeting of stakeholder representatives will ratify the COS. Stage 3 will focus on identifying appropriate instruments to measure the prioritised outcomes by means of quality assessment of available measurement instruments and stakeholder consultation.

DISCUSSION

This study aims to standardise the reporting of outcomes in future trials examining therapeutic surgical interventions for gastric cancer. It is anticipated that standardisation of outcome reporting in these surgical effectiveness trials will enhance the evidence base for clinical practice. Highlighting outcomes of greatest importance to patients will ensure that their perspectives are central to research in this field.

Treatment outcomes in schizophrenia: qualitative study of the views of family carers

BACKGROUND

Schizophrenia is a complex, heterogeneous disorder, with highly variable treatment outcomes, and relatively little is known about what is important to patients. The aim of the study was to understand treatment outcomes informal carers perceive to be important to people with schizophrenia.

METHOD

Qualitative interview study with 34 individuals and 8 couples who care for a person with schizophrenia/schizoaffective disorder. Interviews were transcribed verbatim and analysed by a thematic framework based approach.

RESULTS

Carers described well-recognised outcomes of importance, alongside more novel outcomes relating to: Safety (of the patient/others); insight (e.g. into non-reality of psychotic phenomena); respite from fear, distress or pain; socially acceptable behaviour; getting out of the house; attainment of life milestones; changes in personality and/or temperament; reduction of vulnerability to stress; and several aspects of physical health.

CONCLUSIONS

These findings have the potential to inform the development of patient- or carer- focused outcome measures that take into account the full range of domains that carers feel are important for patients.

Characterizing outcome preferences in patients with psychotic disorders: a discrete choice conjoint experiment

The majority of individuals with schizophrenia will achieve a remission of psychotic symptoms, but few will meet criteria for recovery. Little is known about what outcomes are important to patients. We carried out a discrete choice experiment to characterize the outcome preferences of patients with psychotic disorders. Participants (N=300) were recruited from two clinics specializing in psychotic disorders. Twelve outcomes were each defined at three levels and incorporated into a computerized survey with 15 choice tasks. Utility values and importance scores were calculated for each outcome level. Latent class analysis was carried out to determine whether participants were distributed into segments with different preferences. Multinomial logistic regression was used to identify predictors of segment membership. Latent class analysis revealed three segments of respondents. The first segment (48%), which we labeled "Achievement-focused," preferred to have a full-time job, to live independently, to be in a long-term relationship, and to have no psychotic symptoms. The second segment (29%), labeled "Stability-focused," preferred to not have a job, to live independently, and to have some ongoing psychotic symptoms. The third segment (23%), labeled "Health-focused," preferred to not have a job, to live in supervised housing, and to have no psychotic symptoms. Segment membership was predicted by education, socioeconomic status, psychotic symptom severity, and work status. This study has revealed that patients with psychotic disorders are distributed between segments with different outcome preferences. New approaches to improve outcomes for patients with psychotic disorders should be informed by a greater understanding of patient preferences and priorities.

The customer is always right? Subjective target symptoms and treatment preferences in patients with psychosis

Clinicians and patients differ concerning the goals of treatment. Eighty individuals with schizophrenia were assessed online about which symptoms they consider the most important for treatment, as well as their experience with different interventions. Treatment of affective and neuropsychological problems was judged as more important than treatment of positive symptoms (p < 0.005). While most individuals had experience with Occupational and Sports Therapy, only a minority had received Cognitive-Behavioral Therapy, Family Therapy, and Psychoeducation with family members before. Patients appraised Talk, Psychoanalytic, and Art Therapy as well as Metacognitive Training as the most helpful treatments. Clinicians should carefully take into consideration patients' preferences, as neglect of consumers' views may compromise outcome and adherence to treatment.

Sorting it out: Eliciting consumer priorities for recovery in supportive housing

OBJECTIVE

This study aims to understand participant priorities in their personal recovery journey and their perspectives of recovery domains.

METHODS

A card sort data gathering technique was employed to elicit priorities in recovery from consumers in supportive housing programs serving formerly homeless adults with severe mental illnesses in New York City. Participants (N=38) were asked to sort 12 cards printed with recovery domains in order of importance and describe the meaning attached to each domain.

RESULTS

Mental health (95%), physical health (89%), and housing (92%) were the domains most frequently included and prioritized in the top three rankings. Family (76%) and partner (74%) were also frequently included and endorsed as most important second only to mental health. Housing was prioritized yet rated most important less often (58%). Work, school, hobbies, program, friends and neighborhood were less frequently endorsed. 'Card sort talk' revealed critical understanding of participants' priorities and their reasons for endorsing other domains less frequently.

CONCLUSIONS

Most important to participants was regaining functional independence through improved mental and physical health and access to housing. With underlying principles of efficiency and empowerment, card sort is a promising engagement technique for providers to elicit consumer priorities in their own recovery.

Experiences of support in working toward personal recovery goals: a collaborative, qualitative study

BACKGROUND

Recovery can be understood as a subjective process guided by personal expectations, goals and hopes. The aim of the study was to explore how persons using a Community Mental Health Centre (CMHC) experienced that their expectations for treatment, and goals and hopes for recovery were supported by the health professionals during treatment.

METHODS

Employing a hermeneutic-phenomenological approach, eight service users were interviewed about their expectations for treatment and their goals and hopes for recovery at the start of their contact with health professionals at a CMHC. Two years later, they were re-interviewed about their experiences of treatment and support from the health professionals in their work towards these goals and hopes. A collaborative approach was adopted. A co-researcher with lived experience took part in all stages of the study. Data were analysed by means of a data-driven stepwise approach in line with thematic analysis.

RESULTS

Five themes reflecting how participants experienced support from health professionals at the CMHC in their work towards their recovery goals were elicited, as follows: developing an understanding of oneself and one's mental health problems; learning how to change feelings and behaviours; being 'pushed' into social arenas; finding helpful medication; and counselling in family, practical and financial issues. The participants' expectations about counselling with regard to longer-term family, practical, and financial challenges were insufficiently met by the CMHC. In the experience of the service users, recovery occurred within the context of their everyday life with or without the support of their professional helpers.

CONCLUSIONS

To facilitate recovery, health professionals should acknowledge the service user's personal goals and hopes and take a more comprehensive and longer-term approach to his or her needs and desires. Acknowledging and facilitating recovery goals by offering counselling with regard to family, practical and financial issues seems particularly important.

Tailoring Cognitive Behavioral Therapy to Subtypes of Voice-Hearing

Cognitive behavioral therapy (CBT) for voice-hearing (i.e., auditory verbal hallucinations; AVH) has, at best, small to moderate effects. One possible reason for this limited efficacy is that current CBT approaches tend to conceptualize voice-hearing as a homogenous experience in terms of the cognitive processes involved in AVH. However, the highly heterogeneous nature of voice-hearing suggests that many different cognitive processes may be involved in the etiology of AVH. These heterogeneous voice-hearing experiences do, however, appear to cluster into a set of subtypes, opening up the possibility of tailoring treatment to the subtype of AVH that a voice-hearer reports. In this paper, we (a) outline our rationale for tailoring CBT to subtypes of voice-hearing, (b) describe CBT for three putative subtypes of AVH (inner speech-based AVH, memory-based AVH, and hypervigilance AVH), and (c) discuss potential limitations and problems with such an approach. We conclude by arguing that tailoring CBT to subtypes of voice-hearing could prove to be a valuable therapeutic development, which may be especially effective when used in early intervention in psychosis services.

Development and evaluation of an Individualized Outcome Measure (IOM) for randomized controlled trials in mental health

Pre-defined, researcher-selected outcomes are routinely used as the clinical end-point in randomized controlled trials (RCTs); however, individualized approaches may be an effective way to assess outcome in mental health research. The present study describes the development and evaluation of the Individualized Outcome Measure (IOM), which is a patient-specific outcome measure to be used for RCTs of complex interventions. IOM was developed using a narrative review, expert consultation and piloting with mental health service users (n = 20). The final version of IOM comprises two components: Goal Attainment (GA) and Personalized Primary Outcome (PPO). For GA, patients identify one relevant goal at baseline and rate its attainment at follow-up. For PPO, patients choose an outcome domain related to their goal from a pre-defined list at baseline, and complete a standardized questionnaire assessing the chosen outcome domain at baseline and follow-up. A feasibility study indicated that IOM had adequate completion (89%) and acceptability (96%) rates in a clinical sample (n = 84). IOM was then evaluated in a RCT (ISRCTN02507940). GA and PPO components were associated with each other and with the trial primary outcome. The use of the PPO component of IOM as the primary outcome could be considered in future RCTs. Copyright © 2015 John Wiley & Sons, Ltd.

The other side of recovery: validation of the Portuguese version of the subjective experiences of psychosis scale

BACKGROUND

The aim of this study was to develop and validate a Portuguese version of The Subjective Experiences of Psychosis Scale (SEPS) for use in Portuguese-speaking populations in order to provide a self-report instrument to assess and monitor dimensions of psychotic experiences, translating patient's perspective and experience in terms of recovery from psychosis.

METHODS

The sample consisted of 30 participants with psychotic disorders who had recently experienced delusions or hallucinations. The SEPS was completed along with other observer-based assessments and self-report questionnaires, such as the Brief Psychiatric Rating Scale, the Insight and Treatment Attitudes Questionnaire and the Function Assessment Short Test.

RESULTS

Two main factors representing the positive and negative components of each subscale were identified. We obtained good internal consistency and test-retest reliability for the positive and negative components of all subscales. The subscales of SEPS correlated with observer-based assessments and self-report questionnaires.

CONCLUSIONS

The Portuguese version of the SEPS is a useful tool in the assessment and monitoring of psychotic symptoms.

Defining therapeutic benefit for people with schizophrenia: focus on negative symptoms

Schizophrenia is a complex, heterogeneous, multidimensional disorder within which negative symptoms are a significant and disabling feature. Whilst there is no established treatment for these symptoms, some pharmacological and psychosocial interventions have shown promise and this is an active area of research. Despite the effort to identify effective interventions, as yet there is no broadly accepted definition of therapeutic success. This article reviews concepts of clinical relevance and reports on a consensus conference whose goal was to apply these concepts to the treatment of negative symptoms. A number of key issues were identified and discussed including: assessment of specific negative symptom domains; defining response and remission for negative symptoms; assessment of functional outcomes; measurement of outcomes within clinical trials; and the assessment of duration/persistence of a response. The group reached a definition of therapeutic success using an achieved threshold of function that persisted over time. Recommendations were agreed upon with respect to: assessment of negative symptom domains of apathy-avolition and deficit of expression symptoms; thresholds for response and remission of negative symptoms based on level of symptomatology; assessing multiple domains of function including social occupation, activities of daily living, and socialization; the need for clinical trial data to include rate of change over time and converging sources of evidence; use of clinician, patient and caregiver perspectives to assess success; and the need for establishing criteria for the persistence of therapeutic benefit. A consensus statement and associated research criteria are offered as an initial step towards developing broad agreement regarding outcomes of negative symptoms treatment.

A descriptive review on methods to prioritize outcomes in a health care context

BACKGROUND

Evidence synthesis has seen major methodological advances in reducing uncertainty and estimating the sizes of the effects. Much less is known about how to assess the relative value of different outcomes.

OBJECTIVE

To identify studies that assessed preferences for outcomes in health conditions.

METHODS

SEARCH STRATEGY

we searched MEDLINE, EMBASE, PsycINFO and the Cochrane Library in February 2014.

INCLUSION CRITERIA

eligible studies investigated preferences of patients, family members, the general population or healthcare professionals for health outcomes. The intention of this review was to include studies which focus on theoretical alternatives; studies which assessed preferences for distinct treatments were excluded.

DATA EXTRACTION

study characteristics as study objective, health condition, participants, elicitation method, and outcomes assessed in the study were extracted.

MAIN RESULTS

One hundred and twenty-four studies were identified and categorized into four groups: (1) multi criteria decision analysis (MCDA) (n = 71), (2) rating or ranking (n = 25), (3) utility eliciting (n = 5) and (4) studies comparing different methods (n = 23). The number of outcomes assessed by method group varied. The comparison of different methods or subgroups within one study often resulted in different hierarchies of outcomes.

CONCLUSIONS

A dominant method most suitable for application in evidence syntheses was not identified. As preferences of patients differ from those of other stakeholders (especially medical professionals), the choice of the group to be questioned is consequential. Further research needs to focus on validity and applicability of the identified methods.

Clinical determinants of life satisfaction in chronic schizophrenia: data from the CATIE study

OBJECTIVE

Quality of life is seen as an important outcome variable for patients with schizophrenia. However, the precise definition of this construct varies and has often been used to define health-related domains. The present study sought to focus on global life satisfaction as a key subjective domain and determine its relationship with clinical variables.

METHOD

The study sample included 1437 patients with chronic schizophrenia who participated in the Clinical Antipsychotic Trial of Intervention Effectiveness (CATIE) study. Patients were evaluated with a comprehensive battery of assessments capturing symptoms, cognition and medication side effects, among other variables. Life satisfaction was evaluated with a global self-report item.

RESULTS

Greater depressive symptoms were the most robust indicator of worse life satisfaction. Lower life satisfaction was also associated with poorer psychosocial functioning, greater symptoms of anxiety, apathy and more negative attitudes toward medication. Taken together, these variables explained 20% of the variance in life satisfaction scores. Positive symptoms and other medication side effects also negatively influenced life satisfaction scores.

CONCLUSIONS

These results affirm that clinical variables have an adverse effect on the overall subjective well-being of patients with schizophrenia. The relatively small amount of variance explained, though, argues for a better understanding of those other variables that contribute to life satisfaction.

Implementing and Evaluating Goal Setting in a Statewide Psychiatric Rehabilitation Program

Although the idea of people with psychiatric disabilities determining their own treatment and rehabilitation goals is increasingly accepted, its relationship to service outcomes has rarely been evaluated programmatically. A statewide, Medicaid-funded psychiatric rehabilitation program incorporated a systematic goal setting procedure conducted by practitioners trained in helping people set their own individual rehabilitation goals. Individuals who successfully set either residential or employment goals were followed for up to 18 months to assess progress on these goals. Participants were grouped by type of goal (residential or employment) and by level of participation in the intervention (enrolled, completed 18 months, or graduated). Residential functioning for those who set residential goals increased significantly, independent of level of participation. For people who had set employment goals, only graduates of the intervention showed significant employment gains. Furthermore, employment functioning changed significantly when a goal was set in the residential area; in contrast, residential functioning did not change significantly when goals were set in the employment area. This study suggests that the programmatic effect of goal setting procedures can be evaluated, even when the person’s goals are tailored to an individual’s unique preference. Implications for rehabilitation counseling will be discussed.

The impact of newer atypical antipsychotics on patient-reported outcomes in schizophrenia

Over the past two decades there has been increasing interest in including patients' self-reports in the management of their illness. Among the many reasons for such recent interest has been a rising consumer movement over the past few decades, which has led patients, their caregivers and their families to press for more meaningful sharing with physicians in the clinical decision-making process, with the clear expectations of better therapies and improved outcomes. Patients as consumers of services, their views, attitudes towards healthcare, as well as their level of satisfaction with care, have become increasingly recognized. The recent interest by the US Food and Drug Administration (FDA), as well as other regulatory agencies, in patient-reported outcomes (PROs) in the process of developing and testing new antipsychotics, has also added more impetus. It is clear that including patients in the decision-making process about the management of their psychiatric conditions also broadens the concept of 'recovery', by empowering patients to be active participants and gives a clear message that successful treatment in schizophrenia is more than a symptomatic improvement, but also includes improved functional status. Additionally, the recent interest in personalized medicine puts the patient in the centre of such development. Since 2004, when we published our review about the impact of new antipsychotics on quality of life in CNS Drugs, a number of newer antipsychotics have been introduced and include ziprasidone, aripiprazole, paliperidone, asenapine, iloperidone and lurasidone. The current review is based on 31 selected publications that cover the years 2004-2012, and deals with the impact of such newer antipsychotics on specific domains of PROs, such as subjective tolerability, quality of life, medication preference, satisfaction and social functioning. Most of the available data deal with ziprasidone, aripiprazole and paliperidone. Though the great majority of the studies indicate the newer antipsychotics have favourably impacted on aspects of PROs, such a conclusion can only be considered a trend due to the many design and methodological limitations of many of these studies. It is interesting to note, as the field awaits more rigorous studies, that there seems to be a unifying core that exists among the various subjective outcomes and that tends to generalize from one subjective outcome to other subjective outcomes. The patient who experiences good subjective tolerability to medications tends generally to be more satisfied and has a strong medication preference. The identification of such a unifying core can prove helpful, not only in the development of appropriate scales, but also in informing and guiding the process of development of new antipsychotics.

Beyond the usual suspects: positive attitudes towards positive symptoms is associated with medication noncompliance in psychosis

Antipsychotic medication represents the treatment of choice in psychosis according to clinical guidelines. Nevertheless, studies show that half to almost three-quarter of all patients discontinue medication with antipsychotics after some time, a fact which is traditionally ascribed to side-effects, mistrust against the clinician and poor illness insight. The present study investigated whether positive attitudes toward psychotic symptoms (ie, gain from illness) represent a further factor for medication noncompliance. An anonymous online survey was set up in order to prevent conservative response biases that likely emerge in a clinical setting. Following an iterative selection process, data from a total of 113 patients with a likely diagnosis of schizophrenia and a history of antipsychotic treatment were retained for the final analyses (80%). While side-effect profile and mistrust emerged as the most frequent reasons for drug discontinuation, 28% of the sample reported gain from illness (eg, missing voices, feeling of power) as a motive for noncompliance. At least every fourth patient reported the following reasons: stigma (31%), mistrust against the physician/therapist (31%), and rejection of medication in general (28%). Approximately every fifth patient had discontinued antipsychotic treatment because of forgetfulness. On average, patients provided 4 different explanations for noncompliance. Ambivalence toward symptoms and treatment should thoroughly be considered when planning treatment in psychosis. While antipsychotic medication represents the evidence-based cornerstone of the current treatment in schizophrenia, further research is needed on nonpharmacological interventions for noncompliant patients who are willing to undergo intervention but refuse pharmacotherapy.

A test of concordance between patient and psychiatrist valuations of multiple treatment goals for schizophrenia

BACKGROUND

While much discussion has been placed on the problem of poor compliance in the treatment of schizophrenia, there has been little discussion on the concordance between patients and psychiatrists, an important contributing factor to patient-centred care.

OBJECTIVE

To estimate the concordance between patients' and psychiatrists' (ordinal and cardinal) valuations of multiple goals for schizophrenia treatment and to illustrate the utility of the self-explicated method in valuing a large number of treatment goals.

DESIGN

Twenty treatment goals were identified during focus groups and literature review and were presented to patients and psychiatrists during structured interviews. Respondents were asked to rank the multiple treatment goals and rate them on a 5-point Likert scale. Three scores were calculated based on the ranking (1-20), rating (Likert scale) (1-5) and a self-explicated method estimated as the product of rating and ranking score (1-100). Concordance was tested using Spearman's rho for overall ordinal rankings and via anova and F-test for the cardinal values assigned to a specific treatment goal.

PARTICIPANTS

A total of 105 outpatients diagnosed with schizophrenia and 160 psychiatrists in Germany.

RESULTS

Patient and psychiatrist values were concordant when the ordinal properties of their valuations were assessed by rating (ρ = 0.63; P = 0.002), ranking (ρ = 0.51; P = 0.02) and self-explicated methods (ρ = 0.54; P = 0.01). Significant discordances were found when comparing the cardinal value placed on any given treatment goal using all three approaches, but the self-explicated method produced a more discerning statistic. Relative to patients, psychiatrists significantly (P < 0.05) overvalued reduced lack of emotion, improved sexual pleasure and improved communication while undervaluing reuptake of activities of daily living, improved satisfaction and recovered capacity for work.

CONCLUSIONS

While there is an overall concordance between patients' and psychiatrists' valuation, significantly different valuations on specific goals can be identified. Here, psychiatrists tend to focus on 'textbook' outcomes, while patients are more concerned with functioning and living a normal life. This study also demonstrates the importance of comparing the concordance in treatment goals and the importance of preference-based methods, such as the self-explicated method, in the study of concordance.

The care needs of elderly patients with schizophrenia spectrum disorders

OBJECTIVE

Elderly patients constitute the fastest growing segment of the schizophrenia population. Still, their needs for care are poorly understood. This study aimed to gain insight into the care needs of older patients with schizophrenia spectrum disorders.

SETTING AND PARTICIPANTS

Patients, aged 60 years and older, in contact with mental health services within a Dutch psychiatric catchment area, diagnosed with schizophrenia spectrum disorders.

MEASUREMENTS

Needs and the extent to which these were met were assessed from the perspective of both patients and staff members. Agreement between patients and staff on the presence of needs was evaluated. In addition, the association between patient characteristics and the number of unmet needs was examined.

RESULTS

On average, patients (N = 114, mean age: 69 years) reported 7.6 needs, of which 6.1 were met and 1.5 were unmet. Staff members reported slightly more needs, both met and unmet. Patients and staff showed consensus on the presence of most needs, but discrepancies existed in individual need areas. Psychological and social needs were unmet more often than environmental and physical needs. The number of unmet needs correlated with several patient variables, with the strongest association found for self-reported quality of life.

CONCLUSION

In elderly schizophrenia patients, similar to what has been reported in younger patients, psychological and social needs appear to be under serviced. Having more unmet needs was associated with a lower perceived quality of life.

Patient-reported outcome measures: are they patient-generated, patient-centred or patient-valued?

BACKGROUND

In the past two decades, there has been a growing interest in the development of a more patient-centred approach to assessing treatment outcomes. This interest has resulted in the increasing use of patient-reported outcome measures (PROMs) in both clinical trials and usual clinical practice.

AIMS

To briefly discuss the paucity of efficacy and effectiveness studies in the field of mental health (exemplified by schizophrenia, depression and opioid dependence) that significantly incorporate the patient's perspective. The limited concordance between the perspectives of patients and clinicians in outcome assessment is also addressed. Finally, we propose a new PROM classification system based on the degree to which these instruments incorporate the patient's perspective.

CONCLUSIONS

PROMs may differ little from traditional instruments unless they truly incorporate the patient's perspective and not just the perspectives of clinicians and researchers. Efforts to develop new PROMs that provide a more patient-centred outcome assessment should use qualitative and participatory methods to capture and incorporate patient perspectives and values.

Outcomes that matter: a qualitative study with persons with schizophrenia and their primary caregivers in India

BACKGROUND

Involving persons with schizophrenia and their families in designing, implementing and evaluating mental health services is increasingly emphasised. However, there is little information on desired outcomes from the perspectives of these stakeholders from low and middle income countries (LMIC).

AIMS

To explore and define outcomes desired by persons with schizophrenia and their primary caregivers from their perspectives.

METHOD

In-depth interviews were held with 32 persons with schizophrenia and 38 primary caregivers presenting for care at one rural and one semi-urban site in India. Participants were asked what changes they desired in the lives of persons affected by the illness and benefits they expected from treatment. Data was analysed using thematic and content analysis.

RESULTS

Eleven outcomes were desired by both groups: symptom control; employment/education; social functioning; activity; fulfilment of duties and responsibilities; independent functioning; cognitive ability; management without medication; reduced side-effects; self-care; and self-determination. Social functioning, employment/education and activity were the most important outcomes for both groups; symptom control and cognitive ability were more important to persons with schizophrenia while independent functioning and fulfilment of duties were more important to caregivers.

CONCLUSIONS

Interventions for schizophrenia in India should target both clinical and functional outcomes, addressing the priorities of both affected persons and their caregivers. Their effectiveness needs to be evaluated independently from both perspectives.

Valuation and attainment of treatment goals in schizophrenia: perspectives of patients, relatives, physicians, and payers

OBJECTIVE

This study investigated and compared the valuation and perceived attainment of multiple treatment goals in schizophrenia from the perspectives of four different groups of stakeholders.

METHOD

Twenty treatment goals (identified in a qualitative patient-based pre-study) were ranked and rated according to their relevance in standardized interviews. Goal attainment was also rated. A rank correlation was computed to identify congruencies among the stakeholder groups. A hierarchical cluster analysis of the data from the stakeholders groups was also conducted.

RESULTS

In this study, 105 outpatients, 160 physicians, 50 relatives, and 30 payers were interviewed. All goals were considered very relevant by all stakeholder groups. "Improved cognitive abilities" was ranked among the top three goals by patients, physicians, and relatives, while "reduced disease-related symptoms" was ranked first by relatives and second by physicians. Payers gave the highest priority to goals that were more likely to affect costs (i.e., ability to resume work, reduced disease-related symptoms, less hospitalization/ need for outpatient visits). Pairwise agreement rates ranged from 38.9% to 63.3%. Rank correlations were found between relatives and patients (r=0.51; P=0.002), relatives and physicians (r=0.43; P=0.008), and payers and patients (r=0.43; P=0.008). The cluster analysis revealed a relevant congruency among patients, relatives, and physicians. Goal attainment was rated lower than goal relevance by all groups, with patients judging attainment the best on average, followed by relatives, physicians, and payers. Reduction in disease-related symptoms was rated as the goal that was best achieved.

CONCLUSION

Discordances among the groups with respect to their valuation of treatment goals should encourage stakeholders to better understand others' preferences as a prerequisite for improved shared decision making and potentially improved treatment outcomes.

Change in level of productivity in the treatment of schizophrenia with olanzapine or other antipsychotics

BACKGROUND

When treating schizophrenia, improving patients' productivity level is a major goal considering schizophrenia is a leading cause of functional disability. Productivity level has been identified as the most preferred treatment outcome by patients with schizophrenia. However, little has been done to systematically investigate productivity levels in schizophrenia. We set out to better understand the change in productivity level among chronically ill patients with schizophrenia treated with olanzapine compared with other antipsychotic medications. We also assessed the links between productivity level and other clinical outcomes.

METHODS

This post hoc analysis used data from 6 randomized, double-blind clinical trials of patients with schizophrenia or schizoaffective disorder, with each trial being of approximately 6 months duration. Change in productivity level was compared between olanzapine-treated patients (HGBG, n = 172; HGHJ, n = 277; HGJB, n = 171; HGLB, n = 281; HGGN, n = 159; HGDH, n = 131) and patients treated with other antipsychotic medications (separately vs. haloperidol [HGGN, n = 97; HGDH, n = 132], risperidone [HGBG, n = 167; HGGN, n = 158], quetiapine [HGJB, n = 175], ziprasidone [HGHJ, n = 271] and aripiprazole [HGLB, n = 285]). Productivity was defined as functional activities/work including working for pay, studying, housekeeping and volunteer work. Productivity level in the prior 3 months was assessed on a 5-point scale ranging from no useful functioning to functional activity/work 75% to 100% of the time.

RESULTS

Chronically ill patients treated with olanzapine (OLZ) experienced significantly greater improvement in productivity when compared to patients treated with risperidone (RISP) (OLZ = 0.22 ± 1.19, RISP = -0.03 ± 1.17, p = 0.033) or ziprasidone (ZIP) (OLZ = 0.50 ± 1.38, ZIP = 0.25 ± 1.27, p = 0.026), but did not significantly differ from the quetiapine, aripiprazole or haloperidol treatment groups. Among first episode patients, OLZ therapy was associated with greater improvements in productivity levels compared to haloperidol (HAL), during the acute phase (OLZ = -0.31 ± 1.59, HAL = -0.69 ± 1.56, p = 0.011) and over the long-term (OLZ = 0.10 ± 1.50, HAL = -0.32 ± 1.91, p = 0.008). Significantly more chronically ill and first episode patients treated with olanzapine showed moderately high (>50%-75% of the time) and high levels of productivity (>75%-100% of the time) at endpoint, when compared to risperidone or haloperidol-treated patients (p < .05), respectively. Higher productivity level was associated with significantly higher study completion rates and better scores on the positive, negative, disorganized thoughts, hostility and depression subscales of the Positive and Negative Symptom Scale (PANSS).

CONCLUSIONS

Some antipsychotic medications significantly differed in beneficial impact on productivity level in the long-term treatment of patients with schizophrenia. Findings further highlight the link between clinical and functional outcomes, showing significant associations between higher productivity, lower symptom severity and better persistence on therapy.

TRIAL REGISTRATION

clinicaltrials.gov identifier NCT00088049; NCT00036088.

Illness self-management assessment in psychiatric vocational rehabilitation

OBJECTIVE

People with severe mental illnesses experience difficulty finding and maintaining employment, even if they are offered psychiatric vocational rehabilitation services. When service recipients are able to apply more effective illness self-management strategies, vocational rehabilitation outcomes improve. To assess the use of these strategies, the Illness Self-Management assessment instrument for Psychiatric Vocational Rehabilitation (ISM-PVR) was developed.

METHODS

Experts were consulted to design the ISM-PVR instrument which was then tested by 8 vocational rehabilitation workers and 26 of their service recipients.

RESULTS

This study indicated sufficient internal consistency of the ISM-PVR self-report questionnaire, especially for the subscales assessing goal related self-efficacy, perceived illness-related barriers, and four of the eight coping scales. The number of self-reported illness barriers was associated with a higher number of reported work-related coping strategies. The ISM-PVR aided the identification of specific mental illness-related barriers perceived by the service recipients. The instrument also facilitated obtaining information on individual self-management strategies that clients employed to overcome such barriers or make them manageable.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

The application of the ISM-PVR in vocational rehabilitation practice warrants further research. The study suggests that this instrument is a useful add-on to existing vocational assessment and provides insight in self-management strategies that people use, and that may help those people and their job coaches make more effective vocational plans.

Young people at risk of psychosis: a user-led exploration of interpersonal relationships and communication of psychological difficulties

AIM

The aim of the present study was to qualitatively explore experiences and perceptions of interpersonal relationships and interpersonal communication among young people at risk of psychosis.

METHOD

Semi-structured interviews were conducted using a qualitative grounded theory approach. Participants had entered into a service providing psychological interventions for young people assessed to be at a high risk of developing psychosis (Northwest UK). Our sample comprised one female and seven male participants (n = 8), ranging in age from 16 to 28 years, with a mean age of 22.4 years.

RESULTS

Analyses identified three central themes: difficulty with interpersonal relationships and reduced opportunities for helpful communication, difficulty talking to others about psychological problems, and experiences of talking to others about psychological problems.

CONCLUSIONS

Individuals at risk of psychosis may have experienced significant difficulties with interpersonal relationships. Such difficulties may contribute directly to the development of unusual psychological experiences, and to an inability or reluctance to communicate these to others. In addition, commonly held stigmatizing ideas associated with unusual psychological experiences may contribute to a fear among at-risk individuals that they are 'going mad', and this may lead to concealment of their difficulties, and to delayed help-seeking. For at-risk individuals, helpful communication of psychological distress offers significant benefits, including improved psychological and emotional well-being and reduced risk of psychosis. Thus, while concealment of distress may directly impact on the development of unusual psychological difficulties, communication of such difficulties may be central to recovery.

Identifying patient-relevant endpoints among individuals with schizophrenia: An application of patient-centered health technology assessment

Objectives:Schizophrenia imposes a great burden on society, and while evaluation should play an important role in informing society's efforts to alleviate these burdens, it is unclear what “endpoints” should be chosen as the objective of such analyses. The objectives of the study were to elicit endpoints directly from patients with schizophrenia, to ascertain whether patients are sufficiently cognoscente to express what endpoints are and are not important to them and to rank the relevant endpoints.

Methods:We applied principles of patient-centered health technology assessment to identify and value endpoints from the patient's perspective. Focus groups were conducted to elicit endpoints, using interpretive phenomalogical analysis (IPA) to guide the collection, analysis and interpretation of data. Patient interviews were subsequently used to elicit patient preference over endpoints. Respondents were presented with cards outlining the endpoints and asked to remove irrelevant cards. They where then asked to identify and rank their five most relevant endpoints in order of importance. Interviews were recorded for the purposed of triangulation, and data was analyzed using descriptive statistics. Patients were recruited from five geographically diverse cities in Germany. Eligibility required a diagnosis of schizophrenia by a physician and treatment with an antipsychotic medication for at least one year. Respondents were excluded if they were experiencing an acute episode.

Results:Thirteen endpoints emerged as important from the focus groups spanning side-effects, functional status, processes of care and clinical outcomes. Respondents could clearly identify relevant and irrelevant endpoints, and rank which factors were important to them. Triangulation between field notes of the ranking exercise and recordings confirmed that rankings were not arbitrary, but justified from the respondents' point of view.

Conclusions:Patients with schizophrenia can express preferences over endpoints. Our results show that qualitative methods such as IPA can be used to identify factors, but ranking exercises provide a more robust method for ranking the importance of endpoints. Future research involving patients with schizophrenia ranking outcomes is needed to identify variations across patients and methods such as conjoint analysis could prove beneficial in identifying acceptable tradeoffs across endpoints.

Extrapyramidal side-effects of antipsychotics in a randomised trial

BACKGROUND

There are claims that second-generation antipsychotics produce fewer extrapyramidal side-effects (EPS) compared with first-generation drugs.

AIMS

To compare the incidence of treatment-emergent EPS between second-generation antipsychotics and perphenazine in people with schizophrenia.

METHOD

Incidence analyses integrated data from standardised rating scales and documented use of concomitant medication or treatment discontinuation for EPS events. Mixed model analyses of change in rating scales from baseline were also conducted.

RESULTS

There were no significant differences in incidence or change in rating scales for parkinsonism, dystonia, akathisia or tardive dyskinesia when comparing second-generation antipsychotics with perphenazine or comparing between second-generation antipsychotics. Secondary analyses revealed greater rates of concomitant antiparkinsonism medication among individuals on risperidone and lower rates among individuals on quetiapine, and lower rates of discontinuation because of parkinsonism among people on quetiapine and ziprasidone. There was a trend for a greater likelihood of concomitant medication for akathisia among individuals on risperidone and perphenazine.

CONCLUSIONS

The incidence of treatment-emergent EPS and change in EPS ratings indicated that there are no significant differences between second-generation antipsychotics and perphenazine or between second-generation antipsychotics in people with schizophrenia.

Physical wellness and employment status among adults with serious mental illness

This study examined whether concurrent medical status contributes to employment outcomes among those with psychiatric disabilities. Thirty-five percent (n = 70) of the 200 participants reported being currently employed. Sixty-three percent (n = 127) reported one or more co-occurring medical conditions; thirty-six percent (n = 71) reported two or more, and twenty-one percent (n = 41) reported three or more co-occurring medical conditions. Individuals with higher self-ratings of physical health functioning were more likely to be employed. Neither the number of co-occurring medical conditions nor any specific medical condition was related to employment status. Recommendations to enhance existing models of supported employment programs with physical health and wellness promotion components are offered.

Ranking of outcome domains for use in real-time outcomes feedback laboratory by patients with schizophrenia

The purpose of this study was to prioritize real-time outcomes from the perspective of patients with schizophrenia. Thirty-eight patients were interviewed and ranked 15 outcome domains according to their preference for communicating these outcomes with their mental health provider in the context of a real-time outcomes feedback laboratory. Subjects with schizophrenia ranked overall physical health as the most important outcome domain that they wanted to communicate to their mental health provider in the context of a real-time outcomes feedback laboratory. The ranking of physical health as the most important outcome domain was true for subjects regardless of total psychosis symptom severity, positive symptom severity, age, or level of insight. Outcomes feedback interventions for patients with schizophrenia should include physical health problems in addition to the usual mental health parameters.

Structured patient-clinician communication and 1-year outcome in community mental healthcare: cluster randomised controlled trial

BACKGROUND

Patient-clinician communication is central to mental healthcare but neglected in research.

AIMS

To test a new computer-mediated intervention structuring patient-clinician dialogue (DIALOG) focusing on patients' quality of life and needs for care.

METHOD

In a cluster randomised controlled trial, 134 keyworkers in six countries were allocated to DIALOG or treatment as usual; 507 people with schizophrenia or related disorders were included. Every 2 months for 1 year, clinicians asked patients to rate satisfaction with quality of life and treatment, and request additional or different support. Responses were fed back immediately in screen displays, compared with previous ratings and discussed. Primary outcome was subjective quality of life, and secondary outcomes were unmet needs and treatment satisfaction.

RESULTS

Of 507 patients, 56 were lost to follow-up and 451 were included in intention-to-treat analyses. Patients receiving the DIALOG intervention had better subjective quality of life, fewer unmet needs and higher treatment satisfaction after 12 months.

CONCLUSIONS

Structuring patient-clinician dialogue to focus on patients' views positively influenced quality of life, needs for care and treatment satisfaction.

The CATIE schizophrenia trial: results, impact, controversy

The CATIE (Clinical Antipsychotic Trials for Intervention Effectiveness) Schizophrenia Trial was designed to examine fundamental issues about second-generation antipsychotic (SGA) medications (olanzapine, risperidone, quetiapine, and ziprasidone) - their relative effectiveness and their effectiveness compared to a first-generation antipsychotic (FGA), perphenazine. This article reviews these and other findings from this important trial and offers a perspective regarding their meaning for practice and their significance for the advancement of research in psychiatry. The primary outcome measure, time to discontinuation, served as an index of effectiveness and was remarkably short; only 26% of subjects completed the 18-month trial on the medicine to which they were initially randomized. Subjects receiving olanzapine experienced a slightly longer time to discontinuation. Based on this single criterion, olanzapine showed greater effectiveness than the other agents despite its association with significant metabolic disturbance, especially weight gain. Perphenazine unexpectedly showed comparable levels of effectiveness and produced no more extrapyramidal side effects than the other agents. Despite modest prolactin elevation, risperidone was the best-tolerated medication. Ziprasidone was associated with weight loss and with positive impact on lipids and blood glucose. In Phase 2, clozapine demonstrated better effectiveness compared to other SGAs for subjects who discontinued their Phase 1 medication because of efficacy. Olanzapine and risperidone showed greater effectiveness in the tolerability pathway. CATIE secondary outcomes are currently being examined. Improvements in cognition were modest among all the agents in Phase 1, and perphenazine was no less effective in improving cognitive performance than the SGAs. Cost-effectiveness analysis revealed a significant advantage for perphenazine, due to the impact of the high-priced, brand-name SGAs on overall health care costs.

Patient-reported outcomes in schizophrenia

BACKGROUND

Patient-reported outcomes are increasingly used to evaluate the care of people with schizophrenia.

AIMS

To review established and emerging patient-reported outcomes in schizophrenia research, assessmenttools and key findings.

METHOD

A non-systematic review addressing relevant constructs, the associated scales and key empirical findings.

RESULTS

Patient-reported outcomes in schizophrenia relate either to evaluation of illness and benefit from treatment or to resilience of the self. Of the former, needs for care, treatment satisfaction and the therapeutic relationship are most common. Less common are symptoms, insight, attitude towards medication, and clinical communication. Increasing expectations of treatment have led to new measures assessing resilience ofthe self, including empowerment, self-esteem, sense of coherence and recovery. Scores of different patient-related outcomes overlap and are influenced by a general tendency, largely influenced by mood, for more or less positive appraisal.

CONCLUSIONS

The conceptual and empirical basis for different patient-reported outcomes varies, with most data available for treatment satisfaction. More than one such outcome should be used only if there is a specific hypothesis. For new patient-reported outcomes, relative independence from existing constructs should be demonstrated.