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Davidson M, Carpenter WT. Targeted Treatment of Schizophrenia Symptoms as They Manifest, or Continuous Treatment to Reduce the Risk of Psychosis Recurrence. Schizophr Bull 2024; 50:14-21. [PMID: 37929893 PMCID: PMC10754173 DOI: 10.1093/schbul/sbad145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Abstract
Current pharmacological treatment of schizophrenia employs drugs that interfere with dopamine neurotransmission, aiming to suppress acute exacerbation of psychosis and maintenance treatment to reduce the risk of psychosis recurrence. According to this treatment scheme, available psychotropic drugs intended to treat negative symptoms, cognitive impairment, or anxiety are administered as add-ons to treatment with antipsychotics. However, an alternative treatment scheme proposes a targeted or intermittent treatment approach, by which antipsychotic drugs are administered upon psychosis exacerbation and discontinued upon remission or stabilization, while negative symptoms, cognitive impairment, or anxiety are treated with specific psychotropics as monotherapy. Along these lines, antipsychotics are renewed only in the event of recurrence of psychotic symptoms. This 50-year-old debate between targeted and continuous treatment schemes arises from disagreements about interpreting scientific evidence and discordant views regarding benefit/risk assessment. Among the debate's questions are: (1) what is the percentage of individuals who can maintain stability without antipsychotic maintenance treatment, and what is the percentage of those who exacerbate despite antipsychotic treatment? (2) how to interpret results of placebo-controlled 9- to 18-month-long maintenance trials in a life-long chronic disorder, and how to interpret results of the targeted trials, some of which are open label or not randomized; (3) how to weigh the decreased risk for psychotic recurrence vs the almost certainty of adverse effects on patient's quality of life. Patients' profiles, preferences, and circumstances of the care provision should be considered as the targeted vs continuous treatment options are considered.
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Affiliation(s)
- Michael Davidson
- Department of Basic and Clinical Sciences, Psychiatry, University of Nicosia Medical School, 2414, Nicosia, Cyprus and Minerva Neurosciences, 1500 District Avenue, Burlington, MA 01803, USA
| | - William T Carpenter
- University of Maryland School of Medicine, Department of Psychiatry, Maryland Psychiatric Research Center, Baltimore, MD, USA
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Li Q, Gong Y, Cui Y, Cheng C, Wang Y, Huang G, Gu W, Meng B, Wang M, Wu D, Zhao S, Yang X, Qin W, Sun J, Guo T. Efficacy of transcutaneous electrical acupoint stimulation for patients with first-episode schizophrenia: An 8-week, preliminary, randomized controlled trial. Psychiatry Res 2023; 325:115255. [PMID: 37245485 DOI: 10.1016/j.psychres.2023.115255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 05/09/2023] [Accepted: 05/15/2023] [Indexed: 05/30/2023]
Abstract
Combination therapy with antipsychotics has been investigated for treating schizophrenia, and has shown clear advantages among non-invasive therapies. Transcutaneous electrical acupoint stimulation (TEAS) is a novel non-invasive treatment with definite efficacy in treating mental disorders. The current study aimed to investigate the efficacy of TEAS in further improving the psychotic symptoms in patients with first-episode schizophrenia (FES) being treated with pharmacological drugs. This 8-week, preliminary, sham-controlled, randomized clinical trial was conducted in patients with FES to compare the efficacy of TEAS and sham TEAS in combination with aripiprazole treatment. The primary outcome was a change in the Positive and Negative Syndrome Scale (PANSS) score after ending the intervention (Week 8). A total of 49 participants completed the whole treatment cycle. The linear mixed-effects regression for PANSS indicated a significant time × group interaction (F(2, 116)=9.79, p <0.001). The PANSS score differed by 8.77 points (95% CI, -2.07 to -15.47 points; p=.01) between the TEAS group and the sham TEAS group after 8 weeks of treatment; this difference was significant. This study indicates that 8 weeks of TEAS combined with aripiprazole treatment can effectively treat FES. Thus, TEAS is an effective combination therapy to improve the psychiatric symptoms of FES.
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Affiliation(s)
- Qifu Li
- School of Second Clinical Medicine/The Second Affiliated Hospital, Yunnan University of Chinese Medicine, Kunming 650500, China
| | - Yi Gong
- Yunnan University of Chinese Medicine Teaching Hospital/Kunming Psychiatry Hospital, Kunming, 650000, China
| | - Yapeng Cui
- Engineering Research Center of Molecular and Neuro Imaging of the Ministry of Education, School of Life Science and Technology, Xidian University, Xian, 710126, China
| | - Chen Cheng
- Engineering Research Center of Molecular and Neuro Imaging of the Ministry of Education, School of Life Science and Technology, Xidian University, Xian, 710126, China
| | - Yin Wang
- Engineering Research Center of Molecular and Neuro Imaging of the Ministry of Education, School of Life Science and Technology, Xidian University, Xian, 710126, China
| | - Gaoyangzi Huang
- School of Second Clinical Medicine/The Second Affiliated Hospital, Yunnan University of Chinese Medicine, Kunming 650500, China
| | - Weiqiang Gu
- Yunnan University of Chinese Medicine Teaching Hospital/Kunming Psychiatry Hospital, Kunming, 650000, China
| | - Bin Meng
- Yunnan University of Chinese Medicine Teaching Hospital/Kunming Psychiatry Hospital, Kunming, 650000, China
| | - Mian Wang
- Yunnan University of Chinese Medicine Teaching Hospital/Kunming Psychiatry Hospital, Kunming, 650000, China
| | - Dongniya Wu
- Yunnan University of Chinese Medicine Teaching Hospital/Kunming Psychiatry Hospital, Kunming, 650000, China
| | - Siwen Zhao
- School of Second Clinical Medicine/The Second Affiliated Hospital, Yunnan University of Chinese Medicine, Kunming 650500, China
| | - Xuejuan Yang
- Engineering Research Center of Molecular and Neuro Imaging of the Ministry of Education, School of Life Science and Technology, Xidian University, Xian, 710126, China
| | - Wei Qin
- Engineering Research Center of Molecular and Neuro Imaging of the Ministry of Education, School of Life Science and Technology, Xidian University, Xian, 710126, China
| | - Jinbo Sun
- Engineering Research Center of Molecular and Neuro Imaging of the Ministry of Education, School of Life Science and Technology, Xidian University, Xian, 710126, China.
| | - Taipin Guo
- School of Second Clinical Medicine/The Second Affiliated Hospital, Yunnan University of Chinese Medicine, Kunming 650500, China; Key Laboratory for Acupuncture, Moxibustion and Tuina Prevention and Treatment of Brain Diseases in Yunnan Universities, Kunming, China.
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Liu H, Liu H, Jiang S, Su L, Lu Y, Chen Z, Li X, Li X, Wang X, Xiu M, Zhang X. Sex-Specific Association between Antioxidant Defense System and Therapeutic Response to Risperidone in Schizophrenia: A Prospective Longitudinal Study. Curr Neuropharmacol 2022; 20:1793-1803. [PMID: 34766896 PMCID: PMC9881066 DOI: 10.2174/1570159x19666211111123918] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 09/14/2021] [Accepted: 09/20/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND There are various differences in response to different antipsychotics and antioxidant defense systems (ADS) by sex. Previous studies have shown that several ADS enzymes are closely related to the treatment response of patients with antipsychotics-naïve first-episode (ANFE) schizophrenia. OBJECTIVE Therefore, the main goal of this study was to assess the sex difference in the relationship between changes in ADS enzyme activities and risperidone response. METHODS The plasma activities of glutathione peroxidase (GPx), catalase (CAT), superoxide dismutase (SOD), and total antioxidant status (TAS) were measured in 218 patients and 125 healthy controls. Patients were treated with risperidone for 3 months, and we measured PANSS for psychopathological symptoms and ADS biomarkers at baseline and at the end of 3 months of treatment. We compared sex-specific group differences between 50 non-responders and 168 responders at baseline and at the end of the three months of treatment. RESULTS We found that female patients responded better to risperidone treatment than male patients. At baseline and 3-month follow-up, there were no significant sex differences in TAS levels and three ADS enzyme activities. Interestingly, only in female patients, after 12 weeks of risperidone treatment, the GPx activity of responders was higher than that of non-responders. CONCLUSION These results indicate that after treatment with risperidone, changes in GPx activity were associated with treatment response, suggesting that changes in GPx may be a predictor of response to risperidone treatment in female patients with ANFE schizophrenia.
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Affiliation(s)
- Haixia Liu
- Department of Psychiatry, Shandong Mental Health Center, Jinan, China;
| | - Hua Liu
- Qingdao Mental Health Center, Qingdao University, Qingdao, China;
| | - Shuling Jiang
- Department of Neurology, Linyi Central Hospital, Shandong, China;
| | - Lei Su
- Department of Psychiatry, Shandong Mental Health Center, Jinan, China;
| | - Yi Lu
- Department of Psychiatry, Shandong Mental Health Center, Jinan, China;
| | - Zhenli Chen
- Department of Psychiatry, Shandong Mental Health Center, Jinan, China;
| | - Xiaojing Li
- Department of Psychiatry, Shandong Mental Health Center, Jinan, China;
| | - Xirong Li
- Department of Psychiatry, Shandong Mental Health Center, Jinan, China;
| | - Xuemei Wang
- Department of Psychiatry, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China; ,Address correspondence to these authors at the CAS Key Laboratory of Mental Health, Institute of Psychology, Chinese Academy of Sciences, Beijing, China; E-mail: ; Department of Psychiatry, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China; E-mail: ; Linyin Road, Qixing District, Suzhou, Jiangsu, 215006, China; E-mail:
| | - Meihong Xiu
- Peking University HuiLongGuan Clinical Medical School, Beijing HuiLongGuan Hospital, Beijing, China; ,Address correspondence to these authors at the CAS Key Laboratory of Mental Health, Institute of Psychology, Chinese Academy of Sciences, Beijing, China; E-mail: ; Department of Psychiatry, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China; E-mail: ; Linyin Road, Qixing District, Suzhou, Jiangsu, 215006, China; E-mail:
| | - Xiangyang Zhang
- CAS Key Laboratory of Mental Health, Institute of Psychology, Chinese Academy of Sciences, Beijing, China,Address correspondence to these authors at the CAS Key Laboratory of Mental Health, Institute of Psychology, Chinese Academy of Sciences, Beijing, China; E-mail: ; Department of Psychiatry, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China; E-mail: ; Linyin Road, Qixing District, Suzhou, Jiangsu, 215006, China; E-mail:
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Read J. The experiences of 585 people when they tried to withdraw from antipsychotic drugs. Addict Behav Rep 2022; 15:100421. [PMID: 35434245 PMCID: PMC9006667 DOI: 10.1016/j.abrep.2022.100421] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 02/28/2022] [Accepted: 03/12/2022] [Indexed: 12/14/2022] Open
Abstract
Introduction Many recipients of antipsychotic drugs try to stop taking them, primarily because of distressing adverse effects. Little research has been undertaken into the withdrawal symptoms that ensue. Methods In an online survey 585 antipsychotic users, from 29 countries, who had tried to stop taking the drugs, were asked specific questions about the process and the open question: 'What were the effects of withdrawing from the medication?' 44% had a diagnosis in the 'schizophrenia' spectrum. Results Responding to specific questions, 72% reported classical withdrawal effects of the kind associated with other central nervous system medications, including nausea, tremors, anxiety, agitation and headaches. 52% of these categorized those effects as 'severe'. 26% had tried four or more times to discontinue, and 23% took at least one year to successfully withdraw completely. In response to the open question, 73% reported one or more withdrawal effects, most frequently, insomnia, nervousness and extreme feelings; 26% reported one or more positive outcomes, most frequently more energy/alive and clearer thinking; and 18% reported psychosis. Conclusion These findings are consistent with a small but growing body of literature on this topic. Prescribers need to inform themselves about the nature, frequency and intensity of withdrawal effects from APs, and about withdrawal psychosis. National guidelines, professional bodies' statements, and drug company information urgently need to be updated to prevent the suffering that can occur when withdrawal is minimised, misunderstood or unsupported.
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Affiliation(s)
- John Read
- School of Psychology University of East London London E15 4LZ, UK
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Read J. How important are informed consent, informed choice, and patient-doctor relationships, when prescribing antipsychotic medication? J Ment Health 2022:1-9. [PMID: 35536145 DOI: 10.1080/09638237.2022.2069708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 02/25/2022] [Accepted: 03/05/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Antipsychotic medications (APs) are used for people with psychosis diagnoses and, increasingly for other problems and groups. AIMS This study examines how APs are prescribed, from the perspective of recipients. METHODS 757 people, from 30 countries, responded to questions about their experiences with APs, in an online survey. RESULTS Most (70%) were told nothing about adverse effects. Fewer than 2% recalled being told about the risks of diabetes, suicidality, sexual dysfunction, or reduced life span. None recalled being told about reduced brain volume or withdrawal effects. Only 28% recalled being offered other treatments; with only 14% offered talking therapies. 46% were not told how long to take the APs; and, of those who were told something, 48% were told to take them forever. Most respondents (76%) were not told how APs work. Only 19% were satisfied with the prescribing process, and only 25% reported a good, or very good, relationship with the prescriber. Information, satisfaction with the process, and the prescriber relationship were all positively related to three self-reported outcomes: reduction of problems the drugs were prescribed for, general helpfulness, and quality of life. CONCLUSIONS Steps need to be taken to ensure people prescribed antipsychotics are fully informed, especially about adverse effects and alternatives.
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Affiliation(s)
- John Read
- School of Psychology, University of East London, London, UK
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Li XR, Xiu MH, Guan XN, Wang YC, Wang J, Leung E, Zhang XY. Altered Antioxidant Defenses in Drug-Naive First Episode Patients with Schizophrenia Are Associated with Poor Treatment Response to Risperidone: 12-Week Results from a Prospective Longitudinal Study. Neurotherapeutics 2021; 18:1316-1324. [PMID: 33791970 PMCID: PMC8423973 DOI: 10.1007/s13311-021-01036-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/09/2021] [Indexed: 12/12/2022] Open
Abstract
Abnormal redox regulation is thought to contribute to schizophrenia (SCZ). Accumulating studies have shown that the plasma antioxidant enzyme activity is closely associated with the course and outcome in antipsychotics-naïve first-episode (ANFE) patients with SCZ. The main purpose of this study was to investigate the effect of risperidone on oxidative stress markers in ANFE patients and the relationship between risperidone response and changes in oxidative stress markers. Plasma activities of superoxide dismutase (SOD), catalase (CAT), glutathione peroxidase (GPx) enzyme, total antioxidant status (TAS), and malondialdehyde (MDA) levels were measured in 354 ANFE patients and 152 healthy controls. The clinical symptoms were evaluated by the Positive and Negative Syndrome Scale (PANSS). Patients received risperidone monotherapy for 12 weeks and oxidative stress markers and PANSS were measured at baseline and at follow-up. Compared with healthy controls, the patients exhibited higher activities of SOD, CAT, and TAS levels, but lower MDA levels and GPx activity. A comparison between 168 responders and 50 non-responders at baseline and 12-week follow-up showed that GPx activity decreased in both groups after treatment. Moreover, GPx activity decreased less in responders and was higher in responders than in non-responders at follow-up. These results demonstrate that the redox regulatory system and antioxidant defense enzymes may have predictive value for the response of ANFE patients to risperidone treatment.
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Affiliation(s)
- Xi Rong Li
- Department of Sleep Medicine, Shandong Mental Health Center, Jinan, China
| | - Mei Hong Xiu
- Peking University HuiLongGuan Clinical Medical School, Beijing HuiLongGuan Hospital, Changping District, Beijing, 100096, China.
| | - Xiao Ni Guan
- Peking University HuiLongGuan Clinical Medical School, Beijing HuiLongGuan Hospital, Changping District, Beijing, 100096, China
| | - Yue Chan Wang
- Peking University HuiLongGuan Clinical Medical School, Beijing HuiLongGuan Hospital, Changping District, Beijing, 100096, China
| | - Jun Wang
- Peking University HuiLongGuan Clinical Medical School, Beijing HuiLongGuan Hospital, Changping District, Beijing, 100096, China
| | - Edison Leung
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center At Houston, Houston, TX, USA
| | - Xiang Yang Zhang
- CAS Key Laboratory of Mental Health, Institute of Psychology, Beijing, China; Department of Psychology, University of Chinese Academy of Sciences, 16 Lincui Road, Chaoyang District, Beijing, 100101, China.
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Robust and Fast UV–HPLC Method for Biotransformation Analysis of Azecines. Chromatographia 2021. [DOI: 10.1007/s10337-021-04005-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
AbstractDibenzoazecines are a new class of drug candidates for the treatment of schizophrenia. Compared to the drugs currently used in therapy, the azecines have a novel mechanism of action. Thus, they have the potential to cause fewer side effects compared to the standard therapy with a constant high neuroleptic potency. This theory was substantiated by comparative in vivo tests with haloperidol and risperidone. Seventeen new azecine derivatives have already been tested furthermore of stability, physicochemical parameters, pharmacokinetics including esterase cleavage, stability in simulated gastrointestinal fluid, stability at different pH values and determination of octanol/water-partition coefficients. For these substances, class is still a lack of information concerning the metabolism. Therefore, the present study investigated and developed a reliable and reproducible gradient reversed-phase HPLC–UV method to determinate the lead structure LE404 alongside emerging metabolites in compliance with international requirements like ICH guidelines and the European Pharmacopoeia. Up to now, there is no innovative method suitable for such a determination. Chromatographic separations were achieved with a phenomenex™ Gemini column (5 µm C18 110 Å, 250 × 4.60 mm) using a mixture of acetonitrile/potassium dihydrogen phosphate buffer (4 mmol L−1, pH 2.5) as mobile phase. The gradient method flow rate was 1.0 mL min−1, and UV detection was made at 220 nm. The optimized HPLC method was found to be specific, accurate, reproducible and robust for determination of LE404.
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Johnsen E, Kroken RA, Løberg EM, Rettenbacher M, Joa I, Larsen TK, Reitan SK, Walla B, Alisauskiene R, Anda LG, Bartz-Johannessen C, Berle JØ, Bjarke J, Fathian F, Hugdahl K, Kjelby E, Sinkeviciute I, Skrede S, Stabell L, Steen VM, Fleischhacker WW. Amisulpride, aripiprazole, and olanzapine in patients with schizophrenia-spectrum disorders (BeSt InTro): a pragmatic, rater-blind, semi-randomised trial. Lancet Psychiatry 2020; 7:945-954. [PMID: 33069317 DOI: 10.1016/s2215-0366(20)30341-2] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 05/14/2020] [Accepted: 07/10/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Amisulpride, aripiprazole, and olanzapine are first-line atypical antipsychotics that have not previously been compared head-to-head in a pragmatic trial. We aimed to compare the efficacy and safety of these agents in a controlled trial. METHODS This pragmatic, rater-blind, randomised controlled trial was done in three academic centres of psychiatry in Norway, and one in Austria. Eligible patients were aged 18 years or older, met ICD-10 criteria for schizophrenia-spectrum disorders (F20-29), and had symptoms of active psychosis. Eligible patients were randomly assigned to receive oral amisulpride, aripiprazole, or olanzapine. Treatment allocation was open to patients and staff, and starting dose, treatment changes, and adjustments were left to the discretion of the treating physician. Computer-generated randomisation lists for each study centre were prepared by independent statisticians. Patients were followed up for 52 weeks after random assignment, during which assessments were done 8 times by researchers masked to treatment. The primary outcome was reduction of the Positive And Negative Syndrome Scale (PANSS) total score at 52 weeks, and primary analyses were done in the intention-to-treat population. This trial is registered with ClinicalTrials.gov, number NCT01446328. FINDINGS Between Oct 20, 2011, and Dec 30, 2016, we assessed 359 patients for eligibility. 215 patients were excluded (107 did not meet inclusion criteria, 82 declined to participate, 26 other reasons). 144 patients (mean baseline PANSS total estimated score 78·4 [SD 1·4]) were randomly assigned 1:1:1 to receive amisulpride (44 patients), aripiprazole (48 patients) or olanzapine (52 patients). After 52 weeks, the patients allocated to amisulpride had a PANSS total score reduction of 32·7 points (SD 3·1) compared with 21·9 points reduction with aripiprazole (SD 3·9, p=0·027) and 23·3 points with olanzapine (2·9, p=0·025). We observed weight gain and increases of serum lipids and prolactin in all groups. 26 serious adverse events (SAEs) among 20 patients were registered (four [9%] of 44 patients allocated to amisulpride, ten [21%] of 48 patients allocated to aripiprazole, and six [12%] of 52 patients allocated to olanzapine), with no statistically significant differences between the study drugs. 17 (65%) of the 26 SAEs occurred during the use of the study drug, with readmission or protracted hospital admission accounting for 13 SAEs. One death by suicide, one unspecified death, and one life-threatening accident occurred during follow-up, after cessation of treatment. INTERPRETATION Amisulpride was more efficacious than aripiprazole or olanzapine for reducing the PANSS total scores in adults with schizophrenia-spectrum disorders. Side-effect differences among the groups were generally small. This study supports the notion that clinically relevant efficacy differences exist between antipsychotic drugs. Future research should aim to compare first-line antipsychotics directly in pragmatic clinical trials that reflect everyday clinical practice. FUNDING The Research Council of Norway, the Western Norway Regional Health Trust, and participating hospitals and universities.
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Affiliation(s)
- Erik Johnsen
- Haukeland University Hospital, Bergen, Norway; University of Bergen, Bergen, Norway; The Norwegian Centre for Mental Disorders Research Centre of Excellence, Bergen, Norway.
| | - Rune A Kroken
- Haukeland University Hospital, Bergen, Norway; University of Bergen, Bergen, Norway; The Norwegian Centre for Mental Disorders Research Centre of Excellence, Bergen, Norway
| | - Else-Marie Løberg
- Haukeland University Hospital, Bergen, Norway; University of Bergen, Bergen, Norway; The Norwegian Centre for Mental Disorders Research Centre of Excellence, Bergen, Norway
| | | | - Inge Joa
- Stavanger University Hospital, Stavanger, Norway
| | - Tor Ketil Larsen
- Stavanger University Hospital, Stavanger, Norway; University of Bergen, Bergen, Norway
| | - Solveig Klæbo Reitan
- St Olav's University Hospital, Trondheim, Norway; Norges teknisk-naturvitenskapelige universitet, Trondheim, Norway
| | - Berit Walla
- St Olav's University Hospital, Trondheim, Norway
| | - Renata Alisauskiene
- Haukeland University Hospital, Bergen, Norway; University of Bergen, Bergen, Norway
| | | | | | - Jan Øystein Berle
- Haukeland University Hospital, Bergen, Norway; University of Bergen, Bergen, Norway; The Norwegian Centre for Mental Disorders Research Centre of Excellence, Bergen, Norway
| | - Jill Bjarke
- Haukeland University Hospital, Bergen, Norway
| | - Farivar Fathian
- Norske Kvinners Sanitetsforening Olaviken Gerontopsychiatric Hospital, Erdal, Norway; The Norwegian Centre for Mental Disorders Research Centre of Excellence, Bergen, Norway
| | - Kenneth Hugdahl
- Haukeland University Hospital, Bergen, Norway; University of Bergen, Bergen, Norway
| | - Eirik Kjelby
- Haukeland University Hospital, Bergen, Norway; University of Bergen, Bergen, Norway; The Norwegian Centre for Mental Disorders Research Centre of Excellence, Bergen, Norway
| | - Igne Sinkeviciute
- Haukeland University Hospital, Bergen, Norway; University of Bergen, Bergen, Norway; The Norwegian Centre for Mental Disorders Research Centre of Excellence, Bergen, Norway
| | - Silje Skrede
- Haukeland University Hospital, Bergen, Norway; University of Bergen, Bergen, Norway
| | - Lena Stabell
- Haukeland University Hospital, Bergen, Norway; University of Bergen, Bergen, Norway; The Norwegian Centre for Mental Disorders Research Centre of Excellence, Bergen, Norway
| | - Vidar M Steen
- Haukeland University Hospital, Bergen, Norway; University of Bergen, Bergen, Norway; The Norwegian Centre for Mental Disorders Research Centre of Excellence, Bergen, Norway
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Hornstein GA, Robinson Putnam E, Branitsky A. How do hearing voices peer-support groups work? A three-phase model of transformation. PSYCHOSIS 2020. [DOI: 10.1080/17522439.2020.1749876] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- Gail A. Hornstein
- Department of Psychology, Mount Holyoke College, South Hadley, MA, USA
| | | | - Alison Branitsky
- Department of Psychology, Mount Holyoke College, South Hadley, MA, USA
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Lepping P, Whittington R, Sambhi R, Lane S, Poole R, Leucht S, Cuijpers P, McCabe R, Waheed W. Clinical relevance of findings in trials of CBT for depression. Eur Psychiatry 2020; 45:207-211. [DOI: 10.1016/j.eurpsy.2017.07.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 07/08/2017] [Indexed: 12/15/2022] Open
Abstract
AbstractCognitive behavioural therapy (CBT) is beneficial in depression. Symptom scores can be translated into Clinical Global Impression (CGI) scale scores to indicate clinical relevance. We aimed to assess the clinical relevance of findings of randomised controlled trials (RCTs) of CBT in depression. We identified RCTs of CBT that used the Hamilton Rating Scale for Depression (HAMD). HAMD scores were translated into Clinical Global Impression – Change scale (CGI-I) scores to measure clinical relevance. One hundred and seventy datasets from 82 studies were included. The mean percentage HAMD change for treatment arms was 53.66%, and 29.81% for control arms, a statistically significant difference. Combined active therapies showed the biggest improvement on CGI-I score, followed by CBT alone. All active treatments had better than expected HAMD percentage reduction and CGI-I scores. CBT has a clinically relevant effect in depression, with a notional CGI-I score of 2.2, indicating a significant clinical response. The non-specific or placebo effect of being in a psychotherapy trial was a 29% reduction of HAMD.
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Read J, Williams J. Positive and Negative Effects of Antipsychotic Medication: An International Online Survey of 832 Recipients. Curr Drug Saf 2020; 14:173-181. [PMID: 30827259 PMCID: PMC6864560 DOI: 10.2174/1574886314666190301152734] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 02/16/2019] [Accepted: 02/22/2019] [Indexed: 12/22/2022]
Abstract
Background: Antipsychotic medication is currently the treatment of choice for psychosis, but few studies directly survey the first-hand experience of recipients. Objective: To ascertain the experiences and opinions of an international sample of users of antipsychotic drugs, regarding positive and negative effects. Methods: An online direct-to-consumer questionnaire was completed by 832 users of antipsychotics, from 30 countries – predominantly USA, UK and Australia. This is the largest such sample to date. Results: Over half (56%) thought, the drugs reduced the problems they were prescribed for, but 27% thought they made them worse. Slightly less people found the drugs generally ‘helpful’ (41%) than found them ‘unhelpful’ (43%). While 35% reported that their ‘quality of life’ was ‘improved’, 54% reported that it was made ‘worse’. The average number of adverse effects reported was 11, with an average of five at the ‘severe’ level. Fourteen effects were reported by 57% or more participants, most commonly: ‘Drowsiness, feeling tired, sedation’ (92%), ‘Loss of motivation’ (86%), ‘Slowed thoughts’ (86%), and ‘Emotional numbing’ (85%). Suicidality was reported to be a side effect by 58%. Older people reported particularly poor outcomes and high levels of adverse effects. Duration of treatment was unrelated to positive outcomes but significantly related to negative outcomes. Most respondents (70%) had tried to stop taking the drugs. The most common reasons people wanted to stop were the side effects (64%) and worries about long-term physical health (52%). Most (70%) did not recall being told anything at all about side effects. Conclusion: Clinical implications are discussed, with a particular focus on the principles of informed consent, and involving patients in decision making about their own lives.
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Affiliation(s)
- John Read
- School of Psychology, University of East London, London, United Kingdom
| | - James Williams
- Department of Psychological Sciences, Swinburne University of Technology, Melbourne, Australia
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Davidson M. The debate regarding maintenance treatment with antipsychotic drugs in schizophrenia. DIALOGUES IN CLINICAL NEUROSCIENCE 2019. [PMID: 30581291 PMCID: PMC6296388 DOI: 10.31887/dcns.2018.20.3/mdavidson] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Several large meta-analyses of maintenance trials have confirmed that patients who suffer from chronic schizophrenia, randomized to placebo, are likely to experience earlier symptomatic worsening than patients randomized to a dopamine (DA)-blocking drug. These findings led expert groups to issue treatment guidelines, which recommend treatment with DA-blocking drugs for periods ranging from several years to indefinitely. The recommendations were accepted by the majority of, but not all, the experts, some of whom proposed a targeted or intermittent therapy approach by which DA-blocking drugs are discontinued upon symptomatic remission, to be renewed in case of symptom re-emergence. The debate between continued and targeted treatment approaches arises from disagreements regarding scientific and ethical questions. Scientifically, the discussion focuses on the quality and interpretation of the supporting or detracting evidence regarding each treatment option. For example, what is the percentage of individuals who can maintain stability off drugs? What is the rate of individuals who exacerbate despite maintenance treatment? What is the percentage of individuals who experience drug-related adverse effects? How can we interpret results of open-label, nonrandomized targeted trials? Regarding ethical questions, the debating sides disagree on how to weigh the impact of the decreased risk for exacerbation versus the certainty of adverse effects on the patients quality of life, and how to reach a patient-therapist shared decision within the constraints of mental illness.
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Affiliation(s)
- Michael Davidson
- UniSackler School of Medicine, Tel Aviv, Israel; Nicosia Medical School, Nicosia, Cyprus
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13
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Lonergan A. The Meaning of Voices in Understanding and Treating Psychosis: Moving Towards Intervention Informed by Collaborative Formulation. EUROPES JOURNAL OF PSYCHOLOGY 2017; 13:352-365. [PMID: 28580031 PMCID: PMC5450989 DOI: 10.5964/ejop.v13i2.1199] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Accepted: 12/10/2016] [Indexed: 11/20/2022]
Abstract
From a medical perspective, hearing voices is perceived as a symptom of mental illness and their content as largely irrelevant. The effectiveness of antipsychotic medication has made it central to the treatment of psychosis. However pharmacological treatment alone is rarely sufficient for this disabling condition. This review examined the feasibility of formulating an understanding of the meaning of voices in psychosis to inform intervention. Examination of the literature demonstrated the need for a paradigm shift to a recovery model, drawing on biopsychosocial factors in formulating an understanding of the meaning of voices in the context of a person's life. Providing the opportunity to talk about their experiences may aid the development of an interpersonally coherent narrative representing opportunities for psychological growth. Findings have implications for treatment planning and assessment of outcome. Collaborative formulation regarding the subjective meaning of voices may aid in understanding their development and maintenance and guide intervention. Hearing voices with reduced negative effects on wellbeing and functioning may reduce distress and improve quality of life even in the presence of voices. CFT, CBT, Relating Therapy and Open Dialogue may be effective in applying these principles. Findings are limited by the lack of controlled studies. Further controlled studies and qualitative explorations of individual experiences are recommended.
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Affiliation(s)
- Aoife Lonergan
- Department of Psychology, University College Dublin, Dublin, Ireland
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14
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Leucht S, Fennema H, Engel RR, Kaspers-Janssen M, Lepping P, Szegedi A. What does the MADRS mean? Equipercentile linking with the CGI using a company database of mirtazapine studies. J Affect Disord 2017; 210:287-293. [PMID: 28068617 DOI: 10.1016/j.jad.2016.12.041] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2016] [Revised: 11/07/2016] [Accepted: 12/22/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Little is known about the clinical relevance of the Montgomery Asberg Depression Rating Scale (MADRS) total scores. It is unclear how total scores translate into clinical severity, or how commonly used measures for response (reduction from baseline of ≥50% in the total score) translate into clinical relevance. Moreover, MADRS based definitions of remission vary. METHODS We therefore compared: a/ the MADRS total score with the Clinical Global Impression - Severity Score (CGI-S) b/ the percentage and absolute change in the MADRS total scores with Clinical Global Impression - Improvement (CGI-I); c/ the absolute and percentage change in the MADRS total scores with CGI-S absolute change. The method used was equipercentile linking of MADRS and CGI ratings from 22 drug trials in patients with Major Depressive Disorder (MDD) (n=3288). RESULTS Our results confirm the validity of the commonly used measures for response in MDD trials: a CGI-I score of 2 ('much improved') corresponded to a percentage MADRS reduction from baseline of 48-57%, and a CGI-I score of 1 ('very much improved') to a reduction of 80-84%. If a state of almost complete absence of symptoms were required for a definition of remission, a MADRS total score would be <8, because such scores corresponded to a CGI-S score of 2 ('borderline mentally ill'). LIMITATIONS Although our analysis is based on a large number of patients, the original trials were not specifically designed to examine our research question. CONCLUSIONS The results might contribute to a better understanding and improved interpretation of clinical trial results in MDD.
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Affiliation(s)
- Stefan Leucht
- Department of Psychiatry and Psychotherapy, Technische Universität München, Klinikum rechts der Isar, Ismaningerstr 22, 81675 München, Germany.
| | | | - Rolf R Engel
- Department of Psychiatry and Psychotherapy, Ludwig-Maximilians Universität München, Germany
| | | | - Peter Lepping
- Betsi Cadwaladr University Health Board, Centre for Mental Health and Society, Bangor University, UK; Mysore Medical College and Research Institute, India
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15
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Abstract
This article reviews the results of longitudinal studies on frontal brain volume reduction in patients with schizophrenia spectrum disorders and focuses on the relationship with antipsychotic treatment. Based on a systematic literature search all studies were included in which results on changes of brain volumes over a longer period of time were correlated with antipsychotic treatment dose and disease severity. The findings indicate that there is evidence for grey and white matter volume changes of the frontal brain, which cannot be explained by the severity of the disease alone but are also very likely a manifestation of long-term effects of antipsychotics. Whether second generation antipsychotics have an advantage compared to first generation antipsychotics is currently unclear. Considering the contribution of antipsychotics to the changes in brain structure, which seem to depend on cumulative dosage and can exert adverse effects on neurocognition, negative and positive symptoms and psychosocial functioning, the guidelines for antipsychotic long-term drug treatment should be reconsidered. This is the reason why we and others recommend prescribing the lowest dose necessary to control symptoms. In non-schizophrenic psychiatric disorders, antipsychotics should be used only with great caution after a careful risk-benefit assessment. Moreover, treatment approaches which can help to minimize antipsychotic medication or even administer them only selectively are of increasing importance.
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16
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Steibliene V, Bunevicius A, Savickas A, Prange AJ, Nemeroff CB, Bunevicius R. Triiodothyronine accelerates and enhances the antipsychotic effect of risperidone in acute schizophrenia. J Psychiatr Res 2016; 73:9-16. [PMID: 26679760 DOI: 10.1016/j.jpsychires.2015.11.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Revised: 11/09/2015] [Accepted: 11/13/2015] [Indexed: 12/26/2022]
Abstract
In acute psychotic schizophrenia patients we investigated if the combination of triiodothyronine (T3) plus risperidone was more effective when compared to risperidone monotherapy. Thirty-two in-patients meeting the DSM-IV-TR diagnostic criteria for schizophrenia and without thyroid disease received risperidone (flexibly adjusted dose for tolerability) and were randomized to additionally receive either T3 (25 μg daily; risperidone plus T3 group) or placebo (risperidone plus placebo group). Treatment lasted until meeting the response to treatment criteria defined as score of ≤ 3 on the Clinical Global Impression Severity and Improvement scales. Acute psychotic episode symptom severity was evaluated using the Brief Psychiatric Rating Scale (BPRS) at treatment initiation and at the final study assessment. Fourteen patients were randomized to receive risperidone plus T3 and eighteen to receive risperidone plus placebo. The time until treatment response was shorter in the risperidone plus T3 group relative to the risperidone plus placebo group (25.5 ± 4.4 days vs 32.2 ± 8.2 days, respectively; p = 0.001). Moreover, there was a greater reduction of BPRS-total score (p = 0.01) in the risperidone plus T3 group relative to the risperidone plus placebo group. Treatment with T3 was associated with shorter time to treatment response (β = -0.440, p = 0.022) and with greater improvement in BPRS score (β = 0.240, p = 0.053), independent of patients' gender, age, baseline BPRS score and mean risperidone dose. The study confirms that addition of T3 to risperidone was associated with accelerated and enhanced treatment response in acutely psychotic schizophrenic patients.
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Affiliation(s)
- Vesta Steibliene
- Clinic of Psychiatry, Lithuanian University of Health Sciences, Mickeviciaus str. 9, Kaunas, LT-44307, Lithuania.
| | - Adomas Bunevicius
- Laboratory of Clinical Research, Institute of Neurosciences, Lithuanian University of Health Sciences, Eiveniu str. 2, Kaunas, LT-50009, Lithuania.
| | - Arunas Savickas
- Department of Drug Technology and Social Pharmacy, Lithuanian University of Health Sciences, Mickeviciaus str. 9, LT-44307, Kaunas, Lithuania.
| | - Arthur J Prange
- Department of Psychiatry, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Charles B Nemeroff
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, 1120 Northwest 14 Street, Suite 1455, Miami, FL, 33136, USA.
| | - Robertas Bunevicius
- Behavioral Medicine Institute, Lithuanian University of Health Sciences, Vyduno str. 4, Palanga, LT-00135, Lithuania
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17
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Nicotra E, Casu G, Piras S, Marchese G. On the use of the Positive and Negative Syndrome Scale in randomized clinical trials. Schizophr Res 2015; 165:181-7. [PMID: 25937460 DOI: 10.1016/j.schres.2015.04.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Revised: 03/30/2015] [Accepted: 04/07/2015] [Indexed: 11/16/2022]
Abstract
In the last 25 years, the Positive and Negative Syndrome Scale (PANSS) has been largely used to assess schizophrenia symptom intensity, but little information is available on how this scale was generally applied when evaluating the efficacy of schizophrenia therapies in randomized clinical trials. In the attempt to address this topic, a systematic PubMed Search was carried out using the keywords "PANSS" and "Randomized Clinical Trials". The analysis of retrieved articles highlighted that PANSS has constituted a suitable psychometric instrument to investigate the efficacy of pharmacological and non-pharmacological therapies. However, the information potentially provided by this scale was only partially reported in research articles, when characterizing the symptomatic features of patients at baseline. Furthermore, a consensus is needed to identify methodological strategies that may properly adapt PANSS-subscale structure with the symptomatic profiles of individuals enrolled in randomized controlled trials. The possibility that PANSS interview procedures and enrollment eligibility criteria may influence the symptomatic composition of patients involved in these studies is also discussed.
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Affiliation(s)
- Eraldo Nicotra
- Department of Pedagogy, Psychology, Philosophy, University of Cagliari, Bld. 1, Is Mirrionis Str., I-09123 Cagliari, Italy
| | - Gianluca Casu
- National Research Council, Institute of Translational Pharmacology, UOS of Cagliari, Bld. 5, Loc. Piscinamanna, POLARIS, I-09010 Pula, Cagliari, Italy
| | - Sara Piras
- National Research Council, Institute of Translational Pharmacology, UOS of Cagliari, Bld. 5, Loc. Piscinamanna, POLARIS, I-09010 Pula, Cagliari, Italy
| | - Giorgio Marchese
- National Research Council, Institute of Translational Pharmacology, UOS of Cagliari, Bld. 5, Loc. Piscinamanna, POLARIS, I-09010 Pula, Cagliari, Italy.
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18
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Moncrieff J, Kirsch I. Empirically derived criteria cast doubt on the clinical significance of antidepressant-placebo differences. Contemp Clin Trials 2015; 43:60-2. [PMID: 25979317 DOI: 10.1016/j.cct.2015.05.005] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Revised: 05/07/2015] [Accepted: 05/09/2015] [Indexed: 12/20/2022]
Abstract
Meta-analyses indicate that antidepressants are superior to placebos in statistical terms, but the clinical relevance of the differences has not been established. Previous suggestions of clinically relevant effect sizes have not been supported by empirical evidence. In the current paper we apply an empirical method that consists of comparing scores obtained on the Hamilton rating scale for depression (HAM-D) and scores from the Clinical Global Impressions-Improvement (CGI-I) scale. This method reveals that a HAM-D difference of 3 points is undetectable by clinicians using the CGI-I scale. A difference of 7 points on the HAM-D, or an effect size of 0.875, is required to correspond to a rating of 'minimal improvement' on the CGI-I. By these criteria differences between antidepressants and placebo in randomised controlled trials, including trials conducted with people diagnosed with very severe depression, are not detectable by clinicians and fall far short of levels consistent with clinically observable minimal levels of improvement. Clinical significance should be considered alongside statistical significance when making decisions about the approval and use of medications like antidepressants.
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Affiliation(s)
- Joanna Moncrieff
- University College London, Division of Psychiatry, Maple House, 149, Tottenham Court Road, London, W1T 7NF, UK.
| | - Irving Kirsch
- Harvard Medical School, Program in Placebo Studies, Beth Israel Deaconess Medical Centre, 330 Brookline Avenue, Boston, MA 02215, United States.
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19
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Relationship between symptomatic improvement and overall illness severity in patients with schizophrenia. J Clin Psychopharmacol 2015; 35:128-33. [PMID: 25679125 DOI: 10.1097/jcp.0000000000000286] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Whether improvement on ratings of global illness severity is differentially associated with improvement in specific symptom domains in patients with schizophrenia is not well understood. The present study examined the independent relationships between improvement in specific symptom clusters and change in global impressions of illness severity. METHODS This study included 589 patients with chronic schizophrenia who were assessed at baseline and after 6 months of antipsychotic treatment. Both clinicians and patients completed the Clinical Global Impressions-Severity of Illness Scale (CGI-S). Symptom severity was assessed using factor scores derived from the Positive and Negative Syndrome Scale. RESULTS Change in illness severity ratings made by the clinician and those made by the patient demonstrated moderate overlap. Nearly half of the patients were evaluated as clinically improved during the 6-month period, as rated by the clinician, with less than a third of patients experiencing a reduction in illness severity as determined by both the clinician and themselves. Improvements in clinician-rated CGI-S scores were most strongly associated with reduction in positive symptom severity. In contrast, change in patient-rated CGI-S scores was not linked to reduction in positive symptoms but rather to improvement in depressive and anxiety symptoms. This latter finding remained in a subsample of patients with relatively preserved insight into illness, suggesting that lack of insight cannot account for these findings. Finally, reduction in positive symptoms beyond 2 to 3 points was found to be clinically meaningful. CONCLUSIONS In conclusion, change in overall illness severity, as determined by clinicians, is not necessarily interchangeable with patients' view of improvement of their own clinical status. Moreover, changes in the 2 evaluations of illness severity are associated with changes in different symptom domains.
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20
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Glenthøj LB, Fagerlund B, Randers L, Hjorthøj CR, Wenneberg C, Krakauer K, Vosgerau A, Gluud C, Medalia A, Roberts DL, Nordentoft M. The FOCUS trial: cognitive remediation plus standard treatment versus standard treatment for patients at ultra-high risk for psychosis: study protocol for a randomised controlled trial. Trials 2015; 16:25. [PMID: 25623736 PMCID: PMC4318160 DOI: 10.1186/s13063-014-0542-8] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Accepted: 12/23/2014] [Indexed: 12/31/2022] Open
Abstract
Background Cognitive deficits are a distinct feature among people at ultra-high risk (UHR) for psychosis and pose a barrier to functional recovery. Insufficient evidence exists on how to ameliorate these cognitive deficits in patients at UHR for psychosis and hence improve daily living and quality of life. The aim of the trial is to investigate whether cognitive remediation can improve cognitive and psychosocial function in patients at UHR for psychosis. Methods The FOCUS trial (Function and Overall Cognition in Ultra-high risk States) is a randomised, parallel group, observer-blinded clinical trial enrolling 126 patients meeting the standardised criteria of being at UHR for psychosis. Patients are recruited from psychiatric in- and outpatient facilities in the Copenhagen catchment area. Patients are randomised to one of the two treatment arms: cognitive remediation plus standard treatment versus standard treatment. The cognitive remediation consists of 24 weekly group-based and manualised sessions targeting neurocognition and social cognition. In addition to the group sessions, the patients will be offered 12 individual sessions aiming at maximising the transfer of the effects of the cognitive training to their everyday lives. Follow-up assessments will be conducted at 6 and 12 months after randomisation. The primary outcome is the composite score on the Brief Assessment of Cognition in Schizophrenia at cessation of treatment after 6 months. Secondary outcomes are social and daily functioning, psychosis-like symptoms, negative symptomatology, and depressive symptomatology as measured with the Personal and Social Performance Scale, Brief Psychiatric Rating Scale-Expanded Version, Scale for the Assessment of Negative Symptoms, and the Montgomery-Åsberg Depression Rating Scale. Discussion This is the first trial to evaluate the effects of neurocognitive and social cognitive remediation in UHR patients. The FOCUS trial results will provide evidence on the effect of targeted and comprehensive cognitive rehabilitation on cognition, daily living, and symptomatology as well as long-term outcome in preventing transition to psychosis in UHR patients. Trial registration ClinicalTrials.gov NCT 02098408. Date of registration 18 March 2014.
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Affiliation(s)
- Louise B Glenthøj
- Mental Health Centre Copenhagen, Copenhagen University Hospital, DK-2400, Copenhagen, Denmark. .,Centre for Clinical Intervention and Neuropsychiatric Schizophrenia Research, CINS, DK-2600, Glostrup, Denmark.
| | - Birgitte Fagerlund
- Centre for Clinical Intervention and Neuropsychiatric Schizophrenia Research, CINS, DK-2600, Glostrup, Denmark. .,Centre for Neuropsychiatric Schizophrenia Research (CNSR), Mental Health Centre Glostrup, Copenhagen University Hospital, DK-2600, Glostrup, Denmark.
| | - Lasse Randers
- Mental Health Centre Copenhagen, Copenhagen University Hospital, DK-2400, Copenhagen, Denmark. .,Centre for Clinical Intervention and Neuropsychiatric Schizophrenia Research, CINS, DK-2600, Glostrup, Denmark.
| | - Carsten R Hjorthøj
- Mental Health Centre Copenhagen, Copenhagen University Hospital, DK-2400, Copenhagen, Denmark.
| | - Christina Wenneberg
- Mental Health Centre Copenhagen, Copenhagen University Hospital, DK-2400, Copenhagen, Denmark. .,Centre for Clinical Intervention and Neuropsychiatric Schizophrenia Research, CINS, DK-2600, Glostrup, Denmark.
| | - Kristine Krakauer
- Mental Health Centre Copenhagen, Copenhagen University Hospital, DK-2400, Copenhagen, Denmark. .,Centre for Clinical Intervention and Neuropsychiatric Schizophrenia Research, CINS, DK-2600, Glostrup, Denmark.
| | - Astrid Vosgerau
- Mental Health Centre Copenhagen, Copenhagen University Hospital, DK-2400, Copenhagen, Denmark. .,Centre for Rehabilitation for Brain Injury, DK-2300, Copenhagen, Denmark.
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital, DK-2100, Copenhagen, Denmark.
| | - Alice Medalia
- Columbia University Medical Center, New York, NY, 10032, USA.
| | - David L Roberts
- Department of Psychiatry, Division of Schizophrenia and Related Disorders, University of Texas Health Science Center, San Antonio, TX, 78229, USA.
| | - Merete Nordentoft
- Mental Health Centre Copenhagen, Copenhagen University Hospital, DK-2400, Copenhagen, Denmark. .,Centre for Clinical Intervention and Neuropsychiatric Schizophrenia Research, CINS, DK-2600, Glostrup, Denmark.
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21
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Aubin HJ, Reimer J, Nutt DJ, Bladström A, Torup L, François C, Chick J. Clinical relevance of as-needed treatment with nalmefene in alcohol-dependent patients. Eur Addict Res 2015; 21:160-168. [PMID: 25832297 DOI: 10.1159/000371547] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Accepted: 12/13/2014] [Indexed: 11/19/2022]
Abstract
Nalmefene is the first drug approved for reduction of alcohol consumption. The aim of this study was to evaluate the clinical relevance of treatment with nalmefene in alcohol-dependent patients with a high drinking risk level from two randomised placebo-controlled 6-month studies (NCT00811720 and NCT00812461). Response criteria were based on alcohol consumption, Clinical Global Impression, and Short Form Health Survey mental component summary scores at month 6, analysed using logistic regression. The proportion of responders was higher in the nalmefene group than in the placebo group with odds ratios significantly in favour of nalmefene for all responder criteria; numbers-needed-to-treat ranged from 6 to 10. Significant differences from placebo in clinician-rated and patient-reported outcomes, and liver enzymes further supported the clinical relevance of the treatment effect. In conclusion, this study supports the clinical relevance of nalmefene treatment in patients with alcohol dependence. Nalmefene may help to reduce the alcohol-related burden and the large treatment gap, with currently less than 10% of alcohol-dependent patients in Europe receiving treatment.
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Abstract
This article addresses four major challenges for efforts to create synergy between the global mental health movement and cultural psychiatry. First, although they appear to share domains of mutual interest, the worlds of global mental health and cultural psychiatry have distinct lineages. Expanding their horizons by learning from adjacent disciplines would be mutually beneficial. A second challenge concerns the conceptualization of a new classification system for mental health problems. Adopting a classification system that integrates new insights from socio-neurobiology and from a networks perspective could bring cultural psychiatry and global mental health closer and change the way each field addresses the mental health gap, which constitutes the third challenge. I summarize attempts to achieve comprehensive mental health coverage around the globe and question whether the strategies employed to achieve these goals have been successful, both in high- (HIC) and low- and middle-income countries (LMIC). In LMIC, the dominant strategy needs to be complemented by mobilization of other community resources including local practitioners. A fourth challenge is the lack of mathematical models to guide action and research and solve major preoccupations such as access to care or multi-level analyses in complex ecological or health systems.
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23
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Lepping P, Schönfeldt-Lecuona C, Sambhi RS, Lanka SVN, Lane S, Whittington R, Leucht S, Poole R. A systematic review of the clinical relevance of repetitive transcranial magnetic stimulation. Acta Psychiatr Scand 2014; 130:326-41. [PMID: 24724996 DOI: 10.1111/acps.12276] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/20/2014] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Repetitive transcranial magnetic stimulation (rTMS) is an approved treatment for depression. The clinical relevance of its efficacy is unclear. The clinical relevance of findings in the rTMS literature was assessed by translating Hamilton Depression Rating Scale (HAMD) data into Clinical Global Impression-Improvement scale (CGI-I) scores. METHOD We performed electronic searches of MEDLINE, Embase, PsycINFO, PubMed and Cochrane Central Register of Controlled Trials for RCTs and non-RCT trials on rTMS using Hamilton Depression Rating Scale (HAMD). Articles were included if published in English before January 2014. We translated HAMD scores into nominal CGI-I scores for rTMS for depression and for treatment-resistant depression (TRD). RESULTS About 960 abstracts were retrieved. Sixty-three studies were included, yielding 130 study arms. For depression, the mean percentage change in HAMD scores in all sham-controlled rTMS treatment arms was 35.63 (SD 16.35) and for sham-rTMS 23.33 (SD 16.51). For TRD, active rTMS in sham-controlled studies showed a mean HAMD percentage reduction of 45.21 (SD 10.94) versus 25.04 (SD 17.55) for sham-rTMS. When aggregated scores were translated into notional CGI-I scores, for the treatment of depression, the notional CGI-I score difference between rTMS and sham-rTMS was 0.5 in favour of rTMS; for TRD, it was 0.75 in favour of rTMS. Differences between rTMS and sham-rTMS were bigger when all study arms were combined. CONCLUSION Whilst rTMS appears to be efficacious for both non-refractory and treatment-resistant depression, the clinical relevance of its efficacy is doubtful.
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Affiliation(s)
- P Lepping
- Department of Psychiatry, Betsi Cadwaladr University Health Board, North Wales, UK; Centre for Mental Health and Society, Bangor University, Wrexham, Wales, UK
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24
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Timimi S. No more psychiatric labels: Why formal psychiatric diagnostic systems should be abolished. Int J Clin Health Psychol 2014. [DOI: 10.1016/j.ijchp.2014.03.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
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25
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Affiliation(s)
- Dimitrios Kontis
- Psychiatric Hospital of Attica and Experimental Psychology Laboratory, 1st Department of Psychiatry, Athens University Medical School, Athens 12462, Greece.
| | - Eirini Theochari
- Psychiatric Hospital of Attica and Experimental Psychology Laboratory, 1st Department of Psychiatry, Athens University Medical School, Athens 12462, Greece
| | - Eleftheria Tsaltas
- Psychiatric Hospital of Attica and Experimental Psychology Laboratory, 1st Department of Psychiatry, Athens University Medical School, Athens 12462, Greece
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26
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Thomas N, Hayward M, Peters E, van der Gaag M, Bentall RP, Jenner J, Strauss C, Sommer IE, Johns LC, Varese F, García-Montes JM, Waters F, Dodgson G, McCarthy-Jones S. Psychological therapies for auditory hallucinations (voices): current status and key directions for future research. Schizophr Bull 2014; 40 Suppl 4:S202-12. [PMID: 24936081 PMCID: PMC4141318 DOI: 10.1093/schbul/sbu037] [Citation(s) in RCA: 137] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
This report from the International Consortium on Hallucinations Research considers the current status and future directions in research on psychological therapies targeting auditory hallucinations (hearing voices). Therapy approaches have evolved from behavioral and coping-focused interventions, through formulation-driven interventions using methods from cognitive therapy, to a number of contemporary developments. Recent developments include the application of acceptance- and mindfulness-based approaches, and consolidation of methods for working with connections between voices and views of self, others, relationships and personal history. In this article, we discuss the development of therapies for voices and review the empirical findings. This review shows that psychological therapies are broadly effective for people with positive symptoms, but that more research is required to understand the specific application of therapies to voices. Six key research directions are identified: (1) moving beyond the focus on overall efficacy to understand specific therapeutic processes targeting voices, (2) better targeting psychological processes associated with voices such as trauma, cognitive mechanisms, and personal recovery, (3) more focused measurement of the intended outcomes of therapy, (4) understanding individual differences among voice hearers, (5) extending beyond a focus on voices and schizophrenia into other populations and sensory modalities, and (6) shaping interventions for service implementation.
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Affiliation(s)
- Neil Thomas
- Brain and Psychological Sciences Research Centre, Swinburne University, Melbourne, Australia; Monash Alfred Psychiatry Research Centre, The Alfred, Melbourne, Australia;
| | - Mark Hayward
- School of Psychology, University of Sussex, Brighton, UK;,Research & Development Department, Sussex Partnership NHS Foundation Trust, Brighton, UK
| | - Emmanuelle Peters
- Institute of Psychiatry, King’s College London, Department of Psychology, London, UK;,National Institute for Health Research (NIHR) Biomedical Research Centre for Mental Health at South London and Maudsley NHS Foundation Trust (SLaM), London, UK;,Psychological Interventions Clinic for Outpatients With Psychosis (PICuP),SLaM, London, UK
| | - Mark van der Gaag
- VU University and EMGO+ Institute for Health and Care Research, VU University, Amsterdam, The Netherlands;,Parnassia Psychiatric Institute, The Hague, The Netherlands
| | - Richard P. Bentall
- School of Psychological Sciences, University of Liverpool, Liverpool, UK
| | - Jack Jenner
- Jenner Consult, AUDITO, Groningen, The Netherlands
| | - Clara Strauss
- School of Psychology, University of Sussex, Brighton, UK;,Research & Development Department, Sussex Partnership NHS Foundation Trust, Brighton, UK
| | - Iris E. Sommer
- Department of Psychiatry, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Louise C. Johns
- Institute of Psychiatry, King’s College London, Department of Psychology, London, UK;,Psychological Interventions Clinic for Outpatients With Psychosis (PICuP),SLaM, London, UK
| | - Filippo Varese
- School of Psychological Sciences, University of Manchester, Manchester, UK
| | | | - Flavie Waters
- School of Psychiatry and Clinical Neurosciences, University of Western Australia, Perth, Australia;,Clinical Research Centre, North Metro Health Service Mental Health,Perth,Australia
| | - Guy Dodgson
- Early Intervention in Psychosis, Greenacre Centre, Ashington, UK
| | - Simon McCarthy-Jones
- ARC Centre of Excellence in Cognition and Its Disorders, Department of Cognitive Science, Macquarie University, Sydney, Australia;,Department of Psychology, Durham University, Durham, UK
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Corves C, Engel RR, Davis J, Leucht S. Do patients with paranoid and disorganized schizophrenia respond differently to antipsychotic drugs? Acta Psychiatr Scand 2014; 130:40-5. [PMID: 24299424 DOI: 10.1111/acps.12231] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/06/2013] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The aim of this study was to compare the differential response to amisulpride in patients with paranoid versus disorganized schizophrenia. METHOD We reanalyzed the original data from five different randomized drug trials comparing Brief Psychiatric Rating Scale (BPRS) scores in a database containing 427 paranoid and 296 disorganized patients with schizophrenia. RESULTS Both the disorganized and the paranoid group showed a substantial improvement of the BPRS total score within the first 4 weeks. In the paranoid group, mean (±SD) BPRS reduction was 16.9 (±14.6) (t = 24.06, df = 426, P < 0.001) and in the disorganized group 17.0 (±15.9) (t = 18.49, df = 295, P < 0.001). An analysis of covariance (ancova) controlling for BPRS at baseline and the influence of different trial protocols showed significant differences between diagnostic groups (F = 13.47, df = 1, P < 0.001), Cohen's D 0.31 (CI = 0.16-0.46). Paranoid patients improved by 4.8 BPRS points more than disorganized patients (adjusted means 18.90 (CI = 17.33-20.37) for the paranoid and 14.1 (CI = 12.04 - 16.11) for the disorganized group. CONCLUSION We conclude that amisulpride is effective in disorganized as well as in paranoid schizophrenia, but that symptom reduction in the disorganized subtype is less pronounced.
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Affiliation(s)
- C Corves
- Department of Psychiatry and Psychotherapy, Technische Universität München, Munich, Germany; Psychiatrische Klinik und Poliklinik, Klinikum der LMU, Munich, Germany
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Corstens D, Longden E, McCarthy-Jones S, Waddingham R, Thomas N. Emerging perspectives from the hearing voices movement: implications for research and practice. Schizophr Bull 2014; 40 Suppl 4:S285-94. [PMID: 24936088 PMCID: PMC4141309 DOI: 10.1093/schbul/sbu007] [Citation(s) in RCA: 134] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
The international Hearing Voices Movement (HVM) is a prominent mental health service-user/survivor movement that promotes the needs and perspectives of experts by experience in the phenomenon of hearing voices (auditory verbal hallucinations). The main tenet of the HVM is the notion that hearing voices is a meaningful human experience, and in this article, we discuss the historical growth and influence of the HVM before considering the implications of its values for research and practice in relation to voice-hearing. Among other recommendations, we suggest that the involvement of voice-hearers in research and a greater use of narrative and qualitative approaches are essential. Challenges for implementing user-led research are identified, and avenues for future developments are discussed.
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Affiliation(s)
| | - Eleanor Longden
- Institute of Psychological Sciences, University of Leeds, Leeds, UK
| | - Simon McCarthy-Jones
- ARC Centre for Excellence in Cognition and Its Disorders, Macquarie University, Sydney, Australia;,Department of Psychology, Durham University, Durham, UK
| | | | - Neil Thomas
- Brain and Psychological Sciences Research Centre, Swinburne University, Melbourne, Australia;,Monash Alfred Psychiatry Research Centre, Melbourne, Australia
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29
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Affiliation(s)
- Max Birchwood
- Max Birchwood, Professor of Youth Mental Health, Division of Health and Wellbeing, Warwick Medical School, University of Warwick, UK. ; David Shiers, GP Advisor to the National Audit of Schizophrenia (The Royal College of Psychiatrists) and Rethink Mental Illness Trustee; Jo Smith, Visiting Professor in Early intervention and Psychosis, University of Worcester and Consultant Clinical Psychologist, Worcestershire Health and Care NHS Trust
| | - David Shiers
- Max Birchwood, Professor of Youth Mental Health, Division of Health and Wellbeing, Warwick Medical School, University of Warwick, UK. ; David Shiers, GP Advisor to the National Audit of Schizophrenia (The Royal College of Psychiatrists) and Rethink Mental Illness Trustee; Jo Smith, Visiting Professor in Early intervention and Psychosis, University of Worcester and Consultant Clinical Psychologist, Worcestershire Health and Care NHS Trust
| | - Jo Smith
- Max Birchwood, Professor of Youth Mental Health, Division of Health and Wellbeing, Warwick Medical School, University of Warwick, UK. ; David Shiers, GP Advisor to the National Audit of Schizophrenia (The Royal College of Psychiatrists) and Rethink Mental Illness Trustee; Jo Smith, Visiting Professor in Early intervention and Psychosis, University of Worcester and Consultant Clinical Psychologist, Worcestershire Health and Care NHS Trust
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30
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Kidd SA, McKenzie KJ, Virdee G. Mental health reform at a systems level: widening the lens on recovery-oriented care. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2014; 59:243-9. [PMID: 25007277 PMCID: PMC4079144 DOI: 10.1177/070674371405900503] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2014] [Accepted: 02/01/2014] [Indexed: 11/15/2022]
Abstract
This paper is an initial attempt to collate the literature on psychiatric inpatient recovery-based care and, more broadly, to situate the inpatient care sector within a mental health reform dialogue that, to date, has focused almost exclusively on outpatient and community practices. We make the argument that until an evidence base is developed for recovery-oriented practices on hospital wards, the effort to advance recovery-oriented systems will stagnate. Our scoping review was conducted in line with the 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (commonly referred to as PRISMA) guidelines. Among the 27 papers selected for review, most were descriptive or uncontrolled outcome studies. Studies addressing strategies for improving care quality provide some modest evidence for reflective dialogue with former inpatient clients, role play and mentorship, and pairing general training in recovery oriented care with training in specific interventions, such as Illness Management and Recovery. Relative to some other fields of medicine, evidence surrounding the question of recovery-oriented care on psychiatric wards and how it may be implemented is underdeveloped. Attention to mental health reform in hospitals is critical to the emergence of recovery-oriented systems of care and the realization of the mandate set forward in the Mental Health Strategy for Canada.
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Affiliation(s)
- Sean A Kidd
- Assistant Professor, Department of Psychiatry, University of Toronto, Toronto, Ontario; Head, Psychology Service, Complex Mental Illness Program, Schizophrenia Division, Centre for Addiction and Mental Health (CAMH), Toronto, Ontario
| | - Kwame J McKenzie
- Professor, Department of Psychiatry, University of Toronto, Toronto, Ontario; Medical Director, Underserved Populations Program, Centre for Addiction and Mental Health, Toronto, Ontario
| | - Gursharan Virdee
- Student, City University, Department of Psychology, London, England; Research Analyst, Complex Mental Illness Program, Schizophrenia Division, Centre for Addiction and Mental Health, Toronto, Ontario
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31
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Morrison AP, Turkington D, Pyle M, Spencer H, Brabban A, Dunn G, Christodoulides T, Dudley R, Chapman N, Callcott P, Grace T, Lumley V, Drage L, Tully S, Irving K, Cummings A, Byrne R, Davies LM, Hutton P. Cognitive therapy for people with schizophrenia spectrum disorders not taking antipsychotic drugs: a single-blind randomised controlled trial. Lancet 2014; 383:1395-403. [PMID: 24508320 DOI: 10.1016/s0140-6736(13)62246-1] [Citation(s) in RCA: 137] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Antipsychotic drugs are usually the first line of treatment for schizophrenia; however, many patients refuse or discontinue their pharmacological treatment. We aimed to establish whether cognitive therapy was effective in reducing psychiatric symptoms in people with schizophrenia spectrum disorders who had chosen not to take antipsychotic drugs. METHODS We did a single-blind randomised controlled trial at two UK centres between Feb 15, 2010, and May 30, 2013. Participants aged 16-65 years with schizophrenia spectrum disorders, who had chosen not to take antipsychotic drugs for psychosis, were randomly assigned (1:1), by a computerised system with permuted block sizes of four or six, to receive cognitive therapy plus treatment as usual, or treatment as usual alone. Randomisation was stratified by study site. Outcome assessors were masked to group allocation. Our primary outcome was total score on the positive and negative syndrome scale (PANSS), which we assessed at baseline, and at months 3, 6, 9, 12, 15, and 18. Analysis was by intention to treat, with an ANCOVA model adjusted for site, age, sex, and baseline symptoms. This study is registered as an International Standard Randomised Controlled Trial, number 29607432. FINDINGS 74 individuals were randomly assigned to receive either cognitive therapy plus treatment as usual (n=37), or treatment as usual alone (n=37). Mean PANSS total scores were consistently lower in the cognitive therapy group than in the treatment as usual group, with an estimated between-group effect size of -6.52 (95% CI -10.79 to -2.25; p=0.003). We recorded eight serious adverse events: two in patients in the cognitive therapy group (one attempted overdose and one patient presenting risk to others, both after therapy), and six in those in the treatment as usual group (two deaths, both of which were deemed unrelated to trial participation or mental health; three compulsory admissions to hospital for treatment under the mental health act; and one attempted overdose). INTERPRETATION Cognitive therapy significantly reduced psychiatric symptoms and seems to be a safe and acceptable alternative for people with schizophrenia spectrum disorders who have chosen not to take antipsychotic drugs. Evidence-based treatments should be available to these individuals. A larger, definitive trial is needed. FUNDING National Institute for Health Research.
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Affiliation(s)
- Anthony P Morrison
- School of Psychological Sciences, University of Manchester, Manchester, UK; Greater Manchester West Mental Health NHS Foundation Trust, Manchester, UK.
| | - Douglas Turkington
- Newcastle University, Newcastle-upon-Tyne, UK; Northumberland, Tyne and Wear NHS Mental Health Foundation Trust, Newcastle-upon-Tyne, UK
| | - Melissa Pyle
- School of Psychological Sciences, University of Manchester, Manchester, UK; Greater Manchester West Mental Health NHS Foundation Trust, Manchester, UK
| | - Helen Spencer
- Newcastle University, Newcastle-upon-Tyne, UK; Northumberland, Tyne and Wear NHS Mental Health Foundation Trust, Newcastle-upon-Tyne, UK
| | - Alison Brabban
- University of Durham, Durham, UK; Tees, Esk, and Wear Valley NHS Mental Health Foundation Trust, County Durham, UK
| | - Graham Dunn
- Centre for Biostatistics, University of Manchester, Manchester, UK
| | - Tom Christodoulides
- Northumberland, Tyne and Wear NHS Mental Health Foundation Trust, Newcastle-upon-Tyne, UK
| | - Rob Dudley
- Newcastle University, Newcastle-upon-Tyne, UK; Northumberland, Tyne and Wear NHS Mental Health Foundation Trust, Newcastle-upon-Tyne, UK
| | - Nicola Chapman
- School of Psychological Sciences, University of Manchester, Manchester, UK; Greater Manchester West Mental Health NHS Foundation Trust, Manchester, UK
| | - Pauline Callcott
- Northumberland, Tyne and Wear NHS Mental Health Foundation Trust, Newcastle-upon-Tyne, UK
| | - Tim Grace
- Tees, Esk, and Wear Valley NHS Mental Health Foundation Trust, County Durham, UK
| | - Victoria Lumley
- Tees, Esk, and Wear Valley NHS Mental Health Foundation Trust, County Durham, UK
| | - Laura Drage
- Greater Manchester West Mental Health NHS Foundation Trust, Manchester, UK
| | - Sarah Tully
- School of Psychological Sciences, University of Manchester, Manchester, UK; Greater Manchester West Mental Health NHS Foundation Trust, Manchester, UK
| | - Kerry Irving
- Greater Manchester West Mental Health NHS Foundation Trust, Manchester, UK
| | - Anna Cummings
- Newcastle University, Newcastle-upon-Tyne, UK; Northumberland, Tyne and Wear NHS Mental Health Foundation Trust, Newcastle-upon-Tyne, UK
| | - Rory Byrne
- Greater Manchester West Mental Health NHS Foundation Trust, Manchester, UK
| | - Linda M Davies
- Centre for Health Economics, Institute of Population Health, University of Manchester, Manchester, UK
| | - Paul Hutton
- School of Psychological Sciences, University of Manchester, Manchester, UK; Greater Manchester West Mental Health NHS Foundation Trust, Manchester, UK
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32
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Patel MX, Arista IA, Taylor M, Barnes TRE. How to compare doses of different antipsychotics: a systematic review of methods. Schizophr Res 2013; 149:141-8. [PMID: 23845387 DOI: 10.1016/j.schres.2013.06.030] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2013] [Revised: 05/20/2013] [Accepted: 06/14/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND The ability to calculate equivalent dosage is important when comparing or switching between doses of different antipsychotics in the treatment of schizophrenia. It is also necessary when designing antipsychotic comparator trials which control for dosage. METHOD A systematic review to identify and critically evaluate the methods available for the estimation of antipsychotic dose equivalence was conducted. Electronic searches were carried out using Medline and PubMed and additional information was requested from pharmaceutical companies. The identified methods were evaluated against specific criteria regarding scientific rigour, quality of source data underpinning the method, clinical applicability and utility. RESULTS Eleven articles were identified that described methodologies for antipsychotic dose equivalence. Seven of these referred to calculated methods, including chlorpromazine equivalence, maximum dose and daily-defined dose, and relied on an evidence base from both fixed and flexible dosing data. The remaining four described consensus methods which were based on the knowledge and experience of experts. Chlorpromazine was used as the standard comparator drug in the majority of the calculated equivalence studies, whereas risperidone was used for most consensus methods. CONCLUSIONS Comparison of methods for calculating antipsychotic dose equivalence suggests that different methods yield different equivalencies and the evidence is not sufficiently robust for any of these to be considered as a gold standard method. Thus, choice of method may introduce bias, either an over or underestimate of equivalent dosage, when designing head-to-head, antipsychotic, fixed-dose trials. Consequently, clinical trial reports should routinely include justification of the choice of method for calculating dose equivalence.
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Affiliation(s)
- Maxine X Patel
- Institute of Psychiatry, King's College London, Dept of Psychosis Studies PO68, 16 DeCrespigny Park, London SE5 8AF, UK.
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33
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[Can long-term treatment with antipsychotic drugs lead to structural brain damage? Pro]. DER NERVENARZT 2013; 84:1117-9. [PMID: 23868706 DOI: 10.1007/s00115-013-3815-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Leucht S, Fennema H, Engel R, Kaspers-Janssen M, Lepping P, Szegedi A. What does the HAMD mean? J Affect Disord 2013; 148:243-8. [PMID: 23357658 DOI: 10.1016/j.jad.2012.12.001] [Citation(s) in RCA: 137] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2012] [Revised: 11/30/2012] [Accepted: 12/01/2012] [Indexed: 11/25/2022]
Abstract
Little is known about the clinical relevance of the Hamilton Rating Scale for Depression (HAMD-17) total scores. It is unclear how total scores translate into clinical severity, or what commonly used measures for response (reduction from baseline of ≥ 50% in the total score) and remission (total HAMD-17 score ≤ 7) mean from a clinical perspective. We therefore compared: (a) the percentage and absolute change in the HAMD-17 total scores with Clinical Global Impression-Improvement (CGI-I); (b) the absolute and percentage change in the HAMD-17 total scores with Clinical Global Impression-Severity (CGI-S) absolute change; and (c) the percentage and absolute change in the HAMD-17 total scores with CGI-I in the subgroups of patients with ≤ median and > median HAMD-17 total scores at baseline. The method used was equipercentile linking of HAMD-17 and CGI ratings from 43 drug trials in patients with Major Depressive Disorder (MDD) (n = 7131). Our results confirm the validity of the commonly used measures for remission and response in MDD trials: a CGI-I score of 2 ('much improved') corresponded to a reduction from baseline of > 50% and < 60%, and a CGI-I score of 1 ('very much improved') to a reduction of > 75% and < 85%. The CGI-S score of 1 ('normal., not at all ill') corresponded to the HAMD-17 total score of < 5 and the CGI-S score of 2 ('borderline mentally ill') to the score between 6 and 8. An effect of baseline illness severity was observed.
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Affiliation(s)
- Stefan Leucht
- Klinik für Psychiatrie und Psychotherapie der TU-München Klinikum rechts der Isar Ismaningerstr. 22, 81675 München, Germany.
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Bracken P, Thomas P, Timimi S, Asen E, Behr G, Beuster C, Bhunnoo S, Browne I, Chhina N, Double D, Downer S, Evans C, Fernando S, Garland M, Hopkins W, Huws R, Johnson B, Martindale B, Middleton H, Moldavsky D, Moncrieff J, Mullins S. Una psichiatria al di là dell'attuale paradigma. PSICOTERAPIA E SCIENZE UMANE 2013. [DOI: 10.3280/pu2013-001002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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36
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Corstens D, Longden E, Rydinger B, Bentall R, Os JV. Treatment of hallucinations: A comment. PSYCHOSIS-PSYCHOLOGICAL SOCIAL AND INTEGRATIVE APPROACHES 2013. [DOI: 10.1080/17522439.2012.740069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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37
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Morrison AP, Wardle M, Hutton P, Davies L, Dunn G, Brabban A, Byrne R, Drage L, Spencer H, Turkington D. Assessing Cognitive Therapy Instead Of Neuroleptics: Rationale, study design and sample characteristics of the ACTION trial. PSYCHOSIS-PSYCHOLOGICAL SOCIAL AND INTEGRATIVE APPROACHES 2013. [DOI: 10.1080/17522439.2012.756539] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Metacognitive therapy in treatment-resistant psychosis: a multiple-baseline study. Behav Cogn Psychother 2013; 42:166-85. [PMID: 23286558 DOI: 10.1017/s1352465812001026] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND More effective psychological treatments for psychosis are required. Case series data and pilot trials suggest metacognitive therapy (MCT) is a promising treatment for anxiety and depression. Other research has found negative metacognitive beliefs and thought-control strategies may be involved in the development and maintenance of hallucinations and delusions. The potential of MCT in treating psychosis has yet to be investigated. AIMS Our aim was to find out whether a short number of MCT sessions would be associated with clinically significant and sustained improvements in delusions, hallucinations, anxiety, depression and subjective recovery in patients with treatment-resistant long-standing psychosis. METHOD Three consecutively referred patients, each with a diagnosis of paranoid schizophrenia and continuing symptoms, completed a series of multiple baseline assessments. Each then received between 11 and 13 sessions of MCT and completed regular assessments of progress, during therapy, post-therapy and at 3-month follow-up. RESULTS Two out of 3 participants achieved clinically significant reductions across a range of symptom-based outcomes at end-of-therapy. Improvement was sustained at 3-month follow-up for one participant. CONCLUSIONS Our study demonstrates the feasibility of using MCT with people with medication-resistant psychosis. MCT was acceptable to the participants and associated with meaningful change. Some modifications may be required for this population, after which a controlled trial may be warranted.
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Hunter N. Distortion, Bias, and Ethical Informed Consent: Presentations of Etiological and Treatment Factors in Abnormal Psychology Textbooks. ACTA ACUST UNITED AC 2013. [DOI: 10.1891/1559-4343.15.3.160] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Concerns have been made highlighting the need for true informed consent and choice when patients and/or parents are confronted with seeking treatment for severe emotional states and crises. Yet, psychosocial treatments are often derided or recommended only in conjunction with psychotropic medications because of the assumed biological basis of mental distress. At the same time, the benefits of medications are often inflated, whereas the harmful effects are drastically minimized or not reported at all. This misinformation is distributed to the public, and to patients, in part through the education of students and trainees. Early educational experiences can shape the thinking of trainees as they begin to formulate their respective approaches to clinical populations, and textbooks are a fundamental part of this education. The purpose of this study was to analyze popular abnormal psychology textbooks to evaluate their representation of the current scientific literature regarding psychopathology. Content areas that were explored were those related to depression, attention-deficit/hyperactivity disorder, and schizophrenia. Misrepresentations of the literature were pervasive in areas associated with biological findings. In addition, there were multiple omissions or biased statements related to psychosocial findings, distortions regarding the efficacy of and adverse effects of various treatments, and a lack of reports of the existence of effective alternative approaches to standard mental health care. Concerns regarding the dissemination of distorted and false information in higher education as it pertains to ethics and informed consent are discussed.
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Bracken P, Thomas P, Timimi S, Asen E, Behr G, Beuster C, Bhunnoo S, Browne I, Chhina N, Double D, Downer S, Evans C, Fernando S, Garland MR, Hopkins W, Huws R, Johnson B, Martindale B, Middleton H, Moldavsky D, Moncrieff J, Mullins S, Nelki J, Pizzo M, Rodger J, Smyth M, Summerfield D, Wallace J, Yeomans D. Psychiatry beyond the current paradigm. Br J Psychiatry 2012. [PMID: 23209088 DOI: 10.1192/bjp.bp.112.109447] [Citation(s) in RCA: 165] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
A series of editorials in this Journal have argued that psychiatry is in the midst of a crisis. The various solutions proposed would all involve a strengthening of psychiatry's identity as essentially 'applied neuroscience'. Although not discounting the importance of the brain sciences and psychopharmacology, we argue that psychiatry needs to move beyond the dominance of the current, technological paradigm. This would be more in keeping with the evidence about how positive outcomes are achieved and could also serve to foster more meaningful collaboration with the growing service user movement.
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Affiliation(s)
- Pat Bracken
- Centre for Mental Health Care and Recovery, Bantry General Hospital, Bantry, Co Cork, Ireland.
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41
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Zhang Y, Dai G. Efficacy and metabolic influence of paliperidone ER, aripiprazole and ziprasidone to patients with first-episode schizophrenia through 52 weeks follow-up in China. Hum Psychopharmacol 2012; 27:605-14. [PMID: 24446539 DOI: 10.1002/hup.2270] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND There are no direct comparisons of paliperidone extended-release (ER), aripiprazole and ziprasidone in efficacy and metabolic influence in patients with first-episode schizophrenia. OBJECTIVE The present study examined the efficacy and metabolic influence of paliperidone ER, aripiprazole and ziprasidone in patients with first-episode schizophrenia in China. METHODS Subjects were recruited from outpatient and 254 patients entered the trial. These patients received treatment randomly with paliperidone ER, aripiprazole and ziprasidone and were assessed at baseline, 13, 26 and 52 weeks, respectively with Positive and Negative Syndrome Scale (PANSS), 7-item Clinical Global Impressions-Severity (CGI-S), anthropometric (weight, body mass index and waist circumference) and metabolic (fasting blood glucose, HbA1c, cholesterol, high density lipoproteins (HDL), low density lipoproteins and triglycerides) measures. RESULTS A total of 203 patients completed the trial. Paliperidone group had significant greater reduction in PANSS than aripiprazole group and ziprasidone group from 13 weeks, although the a reduction in PANSS of each group was more than 20%. There was no difference in CGI-S among the three groups, and all three groups had a significant reduction from baseline in CGI-S. Aripiprazole group increased in weight and body mass index despite no statistical change in waist circumference. Other two groups showed no changes in anthropometric measure. At the end of the study, two glucose metabolic indices (fasting blood glucose and HbA1c) of aripiprazole group were significantly higher than that of baseline. In lipid metabolism, aripiprazole group reduced triglycerides significantly and had no changes in other indices. Paliperidone group reduced HDL and increased triglycerides despite no changes in glucose metabolism. Ziprasidone group also had no significant changes in glucose metabolism, but reduced cholesterol, low density lipoproteins and increased HDL. Furthermore, 22 subjects in three groups reached the diagnostic criteria of metabolic syndrome. CONCLUSIONS Paliperidone ER, aripiprazole and ziprasidone are effective in treating first-episode schizophrenia, and the ranking of efficacy from high to low is paliperidone ER > aripiprazole > ziprasidone. Paliperidone ER can impair lipid metabolism potentially but had no influence on glucose metabolism. Aripiprazole can damage glucose metabolism and has little influence on lipid metabolism. Ziprasidone is considered an atypical antipsychotic with no evidence of harm to glucose and lipid metabolism.
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Affiliation(s)
- Yinbo Zhang
- Chengdu Mental Health Center, Fourth People's Hospital, Chengdu, China.
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42
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Morrison AP, Hutton P, Shiers D, Turkington D. Antipsychotics: is it time to introduce patient choice? Br J Psychiatry 2012; 201:83-4. [PMID: 22859572 DOI: 10.1192/bjp.bp.112.112110] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Evidence regarding overestimation of the efficacy of antipsychotics and underestimation of their toxicity, as well as emerging data regarding alternative treatment options, suggests it may be time to introduce patient choice and reconsider whether everyone who meets the criteria for a schizophrenia spectrum diagnosis requires antipsychotics in order to recover.
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43
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Lyne JP, Kinsella A, O'Donoghue B. Can we combine symptom scales for collaborative research projects? J Psychiatr Res 2012; 46:233-8. [PMID: 22056401 DOI: 10.1016/j.jpsychires.2011.10.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2011] [Revised: 09/04/2011] [Accepted: 10/10/2011] [Indexed: 11/26/2022]
Abstract
Collaborative research projects have the potential to answer important research questions, which may otherwise require huge resources, funding, and time to complete. There are several scales for measuring psychotic symptoms in schizophrenia and other psychotic disorders, with the Scale for Assessment of Positive Symptoms (SAPS), Scale for Assessment of Negative Symptoms (SANS), Positive and Negative Symptom Scale (PANSS), and the Brief Psychiatric Rating Scale (BPRS) being among the most commonly used. High quality research efforts have used these three scales in different projects, and in order to merge study efforts, some means of combining data from these scales may be necessary. We reviewed correlations in published studies for these three scales, finding them to be highly correlated, however on comparison of the three scales there were considerable clinical differences between them. The paper discusses potential methods for combining the scales in collaborative research, including use of the recently developed standardised remission criteria for schizophrenia.
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Affiliation(s)
- John P Lyne
- DETECT Services, Avila House, Block 5 Blackrock Business Park, Co. Dublin, Ireland.
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Yanagi M, Southcott S, Lister J, Tamminga CA. Animal models of schizophrenia emphasizing construct validity. PROGRESS IN MOLECULAR BIOLOGY AND TRANSLATIONAL SCIENCE 2012; 105:411-44. [PMID: 22137438 DOI: 10.1016/b978-0-12-394596-9.00012-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Achieving animal models of schizophrenia which are representative of clear aspects of the illness is critical to understanding pathophysiology and developing novel treatments for the complex syndrome. This chapter reviews the various approaches that have been used in the past to create animal models of schizophrenia, including pharmacological approaches, environmental risk conditions and schizophrenia risk genes. In addition, we present a new animal model which derives directly from human tissue and brain imaging data used to develop a human schizophrenia model. This chapter emphasizes the crucial need for construct validity and of modeling discrete elements of schizophrenia's illness presentation as the way to successful advances.
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Affiliation(s)
- Masaya Yanagi
- Department of Psychiatry, UT Southwestern Medical School, Dallas, Texas, USA
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Suzuki T, Remington G, Mulsant BH, Rajji TK, Uchida H, Graff-Guerrero A, Mamo DC. Treatment resistant schizophrenia and response to antipsychotics: a review. Schizophr Res 2011; 133:54-62. [PMID: 22000940 DOI: 10.1016/j.schres.2011.09.016] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2011] [Revised: 08/24/2011] [Accepted: 09/17/2011] [Indexed: 10/16/2022]
Abstract
BACKGROUND There remains a lack of agreement regarding criteria for treatment-resistant schizophrenia (TRS) and definition of response. METHOD A literature search was conducted to identify clinical studies of antipsychotics in TRS using PubMed, EMBASE and PsycINFO (last search 31 July 2011). Psychopharmacological studies with the number of participants of ≥ 40 were evaluated in terms of definitions for TRS and subsequent treatment response. RESULTS Thirty-three studies of antipsychotics in TRS were reviewed. TRS has been defined mainly by severity in symptoms. Many studies based TRS with at least 2 failed adequate antipsychotic trials (at chlorpromazine equivalent doses of ≥ 1000 mg/day for ≥ 6 weeks), but some studies adopted prospective treatment arm to be certain of sample refractoriness. Treatment response has been defined by a relative change in the representative scales (most commonly ≥ 20% decrease in the Positive and Negative Syndrome Scale), but it sometimes included the absolute criteria such as post-treatment score of ≤ 35 in the Brief Psychiatric Rating Scale or Clinical Global Impression-severity score of ≤ 3 (mild or less severe). Social functioning has not been a primary outcome measure in past pivotal trials, and other important domains of the illness such as cognition and subjective perspectives have not been incorporated into definitions of treatment resistance or response. However, adopting various assessment scales can be time-consuming and complicated, with an additional possibility of disagreement among raters. CONCLUSION Defining outcomes in schizophrenia is a challenging task. It is imperative that the field agrees on how this population is better defined and what constitutes treatment response.
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Affiliation(s)
- Takefumi Suzuki
- Centre for Addiction and Mental Health, Geriatric Mental Health Program, Toronto, Ontario, Canada.
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Antipsychotic medication and mortality: a clarification. Schizophr Res 2011; 133:261; author reply 262-3. [PMID: 21945128 DOI: 10.1016/j.schres.2011.08.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2011] [Revised: 08/28/2011] [Accepted: 08/28/2011] [Indexed: 11/23/2022]
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Gahr M, Kölle MA, Schönfeldt-Lecuona C, Lepping P, Freudenmann RW. Paliperidone extended-release: does it have a place in antipsychotic therapy? Drug Des Devel Ther 2011; 5:125-46. [PMID: 21448450 PMCID: PMC3063117 DOI: 10.2147/dddt.s17266] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2011] [Indexed: 01/23/2023] Open
Abstract
Paliperidone (9-hydroxy-risperidone), the active metabolite of risperidone, was approved for treating schizophrenia worldwide in 2006 as paliperidone extended-release (PER), and became the first second-generation antipsychotic specifically licensed for treating schizoaffective disorder in 2009. However, at the same time, its comparatively high cost gave rise to concerns about the cost-effectiveness of PER as compared with its precursor, risperidone. This paper reviews the existing knowledge of the pharmacology, kinetics, efficacy, tolerability, and fields of application of PER, and compares PER with risperidone in order to determine whether it has a place in antipsychotic therapy. An independent assessment of all relevant publications on PER published until July 2010 was undertaken. PER has a unique pharmacological profile, including single dosing, predominantly renal excretion, low drug-drug interaction risk, and differs from risperidone in terms of mode of action and pharmacokinetics. High-level evidence suggests that PER is efficacious and safe in schizophrenia, schizoaffective disorder, and acute manic episodes. There is a striking lack of published head-to-head comparisons between PER and risperidone, irrespective of indication. Low-level evidence shows a lower risk for hyperprolactinemia and higher patient satisfaction with PER than with risperidone. PER adds to the still limited arsenal of second-generation antipsychotics. In the absence of direct comparisons with risperidone, it remains difficult to come to a final verdict on the potential additional therapeutic benefits of PER which would justify its substantially higher costs as compared with risperidone. However, in terms of pharmacology, the available evidence cautiously suggests a place for PER in modern antipsychotic therapy.
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Affiliation(s)
- Maximilian Gahr
- Department of Psychiatry and Psychotherapy, University of Ulm, Ulm, Germany.
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