Cultural competence of mental health practitioners in the Netherlands

BACKGROUND

The importance of providing mental health from a transcultural perspective in establishing a therapeutic alliance is recognized. However, it is currently unknown how many mental health practitioners in the Netherlands feel capable of providing mental healthcare from a transcultural perspective, or if they are familiar with the Cultural Formulation Interview (CFI). The CFI is a tool used in mental health care to gather culturally relevant patient information, enhancing cultural sensitivity in treatment. It is also unknown if there is a difference between psychiatrist and psychiatry residents in terms of their cultural competence.

AIMS

This study aimed to assess the self-appraised cultural competence of Dutch psychiatrist and psychiatry residents, including their knowledge of the CFI, and the need for further training.

METHODS

A cross-sectional study was conducted among psychiatrists and psychiatry residents by means of an online questionnaire.

RESULTS

Ninety-seven mental health practitioners completed the questionnaire. Of the psychiatrists 70% and of the residents 76% reported that treating patients from cultural backgrounds different from their own background is challenging. Only 44% of psychiatrists and 34% of residents considered themselves sufficiently culturally competent, and 56% and 47% respectively, were uninformed about the CFI. The majority of psychiatrists and residents (70 vs 84%) indicated a need for more training in cultural competence.

CONCLUSION

The majority of psychiatrists and residents in The Netherlands considered treating patients from different cultural backgrounds a challenge, reported feeling insufficiently culturally competent, lacked experience with the cultural formulation interview and reported a need for more training in cultural competence.

Sexual dysfunction related to psychiatric disorders: a systematic review

BACKGROUND

Sexual dysfunction is thought to be highly prevalent in patients with psychiatric disorders. Factors such as the use of psychotropic substances (ie, psychopharmaceuticals and drugs), age, or somatic diseases may contribute to sexual problems, but the extent to which psychopathology itself affects sexual functioning is not well understood.

AIM

The study sought to provide an overview of the literature on the prevalence of sexual dysfunction in psychotropic-free and somatic disease-free psychiatric patients.

METHOD

A systematic review (PRISMA [Preferred Reporting Items for Systematic Reviews and Meta-Analyses]) was conducted by 2 authors (TH and AWMP) independently, with the review process being monitored by a third author. Relevant articles on the relationship between sexual dysfunctions and psychopathology were searched in PubMed, Web of Science, and PsycINFO from inception until June 16, 2022. The study methods were entered in the international register of systematic reviews PROSPERO (2021, CRD42021223410).

OUTCOMES

The main outcome measures were sexual dysfunction and sexual satisfaction.

RESULTS

Twenty-four studies were identified, including a total of 1199 patients. These studies focused on depressive disorders (n = 9 studies), anxiety disorders (n = 7), obsessive- compulsive disorder (OCD) (n = 5), schizophrenia (n = 4), and posttraumatic stress disorder (n = 2). No studies on bipolar disorder were found. Reported prevalence rates of sexual dysfunction in psychiatric disorders were 45% to 93% for depressive disorders, 33% to 75% for anxiety disorders, 25% to 81% for OCD, and 25% for schizophrenia. The most affected phase of the sexual response cycle was sexual desire, in both men and women with depressive disorders, posttraumatic stress disorder, and schizophrenia. Patients with OCD and anxiety disorders most frequently reported dysfunction in the orgasm phase, 24% to 44% and 7% to 48%, respectively.

CLINICAL IMPLICATIONS

The high prevalence of sexual dysfunction requires more clinical attention by means of psychoeducation, clinical guidance, sexual anamnesis, and additional sexological treatment.

STRENGTHS AND LIMITATIONS

This is the first systematic review on sexual dysfunction in psychotropic-free and somatic disease-free psychiatric patients. Limitations include the small number of studies, small sample sizes, the use of multiple questionnaires (some not validated), which may contribute to bias.

CONCLUSION

A limited number of studies identified a high prevalence of sexual dysfunction in patients with a psychiatric disorder, with substantial variation between patient groups in frequency and phase of reported sexual dysfunction.

Maternal choline supplementation during pregnancy to promote mental health in offspring

AIM

There is increasing interest in the role of choline in brain development, including its possible role in promoting mental health and preventing mental illness. Choline is an essential micronutrient in fetal brain maturation. In more than 90% of pregnant women, choline intake has been found to be lower than the daily-recommended dose. The aim of this article is to review what is known about the effects of maternal choline supplementation on fetal brain development, early child development and mental health.

METHODS

A narrative review of the literature.

RESULTS

A limited number of studies suggest that maternal choline supplementation during pregnancy may enhance fetal brain development and improve early signs and symptoms that may predispose to mental illness.

CONCLUSION

The general low maternal choline intake during pregnancy, expected health benefits and low risks, make a plea for maternal choline supplementation to promote mental health. Choline supplementation may be especially important for pregnant women with a (family) history of severe mental illness and/or alcohol dependence.

[Muscarinic M1 and/or M4 receptor agonists as potential novel treatments for psychoses]

BACKGROUND

Research suggests that cholinergic muscarinic 1 (M1) and/or muscarinic 4 (M4) receptors may be involved in the pathophysiology of psychotic disorders. Agonistic modulation of these receptors can offer new treatment options.

AIM

To provide an overview of current research on the role of cholinergic M1 and M4 receptors in the development and treatment of psychoses, with special attention to the development of new drugs such as xanomeline and emraclidine.

METHOD

To obtain an overview, we searched for English-language studies published in PubMed, Embase, and PsycInfo up until June 1, 2023. We examined the role and effects of M1 and/or M4 agonists in schizophrenia. Additionally, we consulted clinical trial registers.

RESULTS

Our search strategy resulted in nine published articles on five clinical studies. These studies revealed that reduced presence of M1 receptors, primarily in the frontal cortex, and M4 receptors, primarily in the basal ganglia, are associated with psychoses. M1 and M4 receptors modulate dopaminergic activity in the ventral tegmentum and striatum through various pathways. Several M1 and/or M4 agonists, partial agonists, and positive allosteric modulators (PAMs) have been developed. Drugs exhibiting agonistic activity on M1 and/or M4 receptors, such as xanomeline-trospium (phase 2 and 3 studies) and emraclidine (phase 1b studies), have shown positive effects on cognitive and potentially negative symptoms in patients with schizophrenia.

CONCLUSION

M1 and/or M4 receptor agonists show potential as new treatment strategies for individuals with psychotic disorders. Although initial studies with xanomeline-trospium and emraclidine have shown positive results, further research is needed to assess their long-term efficacy, safety, and tolerability before these new medications can be evaluated.

[The influence of maternal choline supplementation on fetal brain development and the risk of psychotic symptoms]

BACKGROUND

Choline is an essential micronutrient important for fetal brain development. Research suggests that maternal choline supplementation during pregnancy may reduce the risk of developing neuropsychiatric disorders such as psychosis in offspring.

AIM

To provide a narrative review of evidence from the literature for the possible prevention of neuropsychiatric problems such as psychosis by maternal choline supplementation.

METHOD

A narrative review of the literature obtained after searches in PubMed, Embase and PsycINFO.

RESULTS

Nutritional studies indicate that most pregnant women do not receive sufficient dietary choline. This may have adverse effects on fetal brain development. A total of 8 studies were identified; 4 animal and 4 clinical studies. Beneficial effects of maternal choline supplementation were found on fetal brain development, including cognitive and psychosocial functioning of children. No evidence of (serious) side effects was found. Due to the relatively short duration and limited size of the studies, no conclusions could be drawn about the role of maternal choline supplementation in the prevention of neuropsychiatric problems such as psychosis.

CONCLUSION

Maternal choline supplementation and/or a choline-rich diet during pregnancy should be further investigated because of evidence of beneficial effects on infant mental functioning, low cost and few side effects. There is no evidence that maternal choline supplementation can prevent psychotic symptoms in offspring.

[Brexpiprazole for treatment of schizophrenia: a critical literature study]

Background Brexpiprazole has been registered in the Netherlands and Belgium for the treatment of schizophrenia since 2019. It is a third-generation antipsychotic drug with a number of pharmacological similarities to aripiprazole and cariprazine. Aim To critically evaluate the pharmacology, effectiveness and side effects of brexpiprazole in the treatment of schizophrenia using the hitherto available double-blind, placebo-controlled study. Method A clinically oriented study of the literature. Results Brexpiprazole is effective in the treatment of schizophrenia and has few extrapyramidal side effects, metabolic side effects and moderate weight gain, no QTc prolongation, no sedation, and little influence on blood prolactin levels. Limited dose titration is required when initiated on brexpiprazole. Conclusion Brexpiprazole is a treatment option for schizophrenia, with a relatively favorable side effect profile. The position of brexpiprazole within the current treatment algorithm should become clear through future research and clinical experience. Tijdschrift voor Psychiatrie 63(2021)1, 48-55.

[An antipsychotic without dopamine receptor blockade?]

BACKGROUND

Current antipsychotic treatment is suboptimal. There is an urgent need for new antipsychotics with new mechanisms of action. SEP-363856 is a trace amine-associated receptor 1 (TAAR1) agonist and a serotonin 5-HT1a agonist with potential antipsychotic properties.

AIM

To describe the rationale for the development of SEP-363856, the pharmacology of TAAR1/5-HT1a agonists, and the clinical efficacy of SEP-363856.

METHOD

A narrative review of the literature using PubMed, Embase and PsychINFO.

RESULTS

Six publications were identified, one of which was a phase 2 clinical trial with SEP-363856. This phase 2 study shows that SEP-363856 is an effective and well-tolerated antipsychotic; positive, but also negative symptoms decreased; motor side effects (akathisia) and prolactin increase did not occur, while metabolic side effects hardly occurred. Reported side-effects were somnolence and nausea. The antipsychotic activity of SEP-363856 appears to be (pre)clinical not based on D2 antagonism, but on TAAR1 and 5-HT1a agonism.

CONCLUSION

TAAR1 and 5-HT1a agonists such as SEP-363856 may be a treatment option for psychosis. Hopefully they can be further developed into an antipsychotic with a favorable effectiveness and tolerability profile.

[Cariprazine for acute and maintenance treatment of schizophrenia]

Since 2018, cariprazine has been available for the treatment of schizophrenia on the Dutch and Belgian markets.<br/> AIM: To give an overview of the indications, effectiveness and side effects of cariprazine. To make an inventory of the advantages and disadvantages of this new antipsychotic drug.<br/> METHOD: A clinically oriented literature review of published clinical studies and pharmacodynamic and -kinetic publications.<br/> RESULTS: Cariprazine is unique because of its preferential D3 receptor partial agonist affinity and has, in theory, a beneficial effect on negative symptoms. The antipsychotic has two active metabolites: desmethylcariprazine and didesmethylcariprazine. The long half-life of cariprazine indicates that, in theory, the drug should not be given daily. Cariprazine is metabolized by cyp3a4 and to a lesser extent by cyp2d6 enzymes. Extrapyramidal symptoms and akathisia are relatively frequent side effects. In contrast, metabolic side effects and weight gain have been reported rarely.<br/> CONCLUSION: Cariprazine can be an effective treatment option for schizophrenia. The final positioning of this antipsychotic drug will have to be based on future research.

[Decision aid for the treatment of psychotic illness: development of TReatment E-AssisT (TREAT)]

Use of decision aids in mental health care is increasing and will also be introduced in the Dutch mental healthcare system. We describe the context of this development and discuss how decision aids could facilitate evidence-based psychiatry.<br/> AIM: To describe the development of the decision aid TReatment E-Assist (TREAT) in the Dutch mental healthcare system that aims to optimize treatment of people with a psychotic illness.<br/> METHOD: We describe how the TREAT application works and discuss its potential contribution to the treatment of people with a psychotic illness.<br/> RESULTS: In a pilot study TREAT was judged as user friendly and useful. TREAT seemed to increase the integration of ROM-results in treatment and the advice offered new view points for practioners.<br/> CONCLUSION: TREAT is a novel application which combines routine outcome monitoring results with current treatment guidelines and standards of care in order to generate personalised treatment recommendations in the context of a psychiatric treatment trajectory. A multicentre study is being conducted in different provinces in the Netherlands to investigate the effectiveness of TREAT.

Relation of inflammatory markers with symptoms of psychotic disorders: a large cohort study

AIMS

Immunological mechanisms may play a role in symptomatology of patients with a psychotic disorder. Besides metabolic problems and medication use, inflammatory processes that may occur due to the disorder may cause increased inflammatory markers and concurrent psychiatric symptoms. The aim of this study is to investigate whether levels of C-reactive protein (CRP) and white blood cell count (WBC) are related to positive and negative symptoms of psychotic disorders, and whether age, gender, duration of illness, smoking behavior, haloperidol equivalents, mediation use, body mass, and metabolic syndrome affect this relation.

METHODS

CRP and WBC values of 2123 patients with a psychotic disorder were related to positive and negative symptoms measured with a psychiatric interview. CRP was analyzed by survival analysis accounting for detection limit and WBC by linear mixed model analysis. In case of a significant association, the confounding factors were added to the model.

RESULTS

Both WBC and CRP were related to both positive and negative symptoms, even after correction for age, gender, smoking, use of medication and metabolic problems. Of the covariates, gender, metabolic problems, smoking and statins also showed a strong association with inflammatory markers.

CONCLUSIONS

This study in a large patient-group confirmed that inflammatory markers are related to psychotic disorders, particularly negative symptoms. Future studies could use more precise measures of inflammatory markers and measure symptomatic state at specific moments in illness progression.

[The three-monthly paliperidone palmitate depot in the treatment of schizophrenia]

A three-monthly formulation of intramuscular paliperidone palmitate has been available on the Dutch and Belgian markets since 2016.<br/> AIM: To provide an overview of the indication, effectiveness and side-effects of this injectable three-monthly formulation of paliperidone and to offer considerations for clinical practice.<br/> METHOD: A clinically-oriented literature study.<br/> RESULTS: Three-monthly paliperidone palmitate depot appears to be as effective as the monthly paliperidone depot and has the same profile of side-effects. <br/> CONCLUSION: Three-monthly paliperidone palmitate is an effective treatment option for schizophrenia. However, future research and clinical practice need to clarify the position of this depot in the treatment trajectory.

Exploring the use of Routine Outcome Monitoring in the treatment of patients with a psychotic disorder

BACKGROUND

Routine Outcome Monitoring (ROM) has become part of the treatment process in mental health care. However, studies have indicated that few clinicians in psychiatry use the outcome of ROM in their daily work. The aim of this study was to explore the degree of ROM use in clinical practice as well as the explanatory factors of this use.

METHODS

In the Northern Netherlands, a ROM-protocol (ROM-Phamous) for patients with a psychotic disorder has been implemented. To establish the degree of ROM-Phamous use in clinical practice, the ROM results of patients (n=204) were compared to the treatment goals formulated in their treatment plans. To investigate factors that might influence ROM use, clinicians (n=32) were asked to fill out a questionnaire about ROM-Phamous.

RESULTS

Care domains that were problematic according to the ROM-Phamous results were mentioned in the treatment plan in 28% of cases on average (range 5-45%). The use of ROM-Phamous in the treatment process varies considerably among clinicians. Most of the clinicians find ROM-Phamous both useful and important for good clinical practice. In contrast, the perceived ease-of-use is low and most clinicians report insufficient time to use ROM-Phamous.

CONCLUSIONS

More frequent ROM use should be facilitated in clinicians. This could be achieved by improving the fit with clinical routines and the ease-of-use of ROM systems. It is important for all stakeholders to invest in integrating ROM in clinical practice. Eventually, this might improve the diagnostics and treatment of patients in mental health care.

[Non-invasive brain stimulation in schizophrenia: hallucinations and negative symptoms]

New approaches are needed in the treatment of characteristic symptoms of schizophrenia such as hallucinations and negative symptoms. Non-invasive brain stimulation can make a useful contribution.<br/> AIM: To discuss the published evidence regarding efficacy and safety of repetitive transcranial magnetic stimulation (rtms) and transcranial direct current stimulation (tdcs) when used in the treatment of auditory verbal hallucinations and negative symptoms.<br/> METHOD: We review and discuss recent meta-analyses and we analyse relevant factors.<br/> RESULTS: On average, when compared to sham-stimulation, rtms was found to have a significant effect on hallucinations and negative symptoms. Nevertheless, the results of some studies were variable and some studies did not report any improvement. There are indications that some factors such as age and distance between scalp and cortex may influence efficiency. There were only a few studies relating to the use of tdcs and none of these reported a clear effect.<br/> CONCLUSION: There is reasonable evidence that rtms is an efficient treatment for hallucinations and negative symptoms, although some variable results have been reported. There is insufficient evidence for conclusions to be drawn about the efficacy of tdcs for the treatment of hallucinations and negative symptoms. However, both simulation methods are safe and largely without side-effects.

[Clinical application of ROM in psychosis]

AIM

The use of 'routine outcome monitoring' (ROM) in mental health care has increased widely during the past decade. However, little is known about the use of ROM outcome in daily clinical practice. We investigated to what extent ROM results were reflected in psychotic patients' treatment plans.

DESIGN

Cross-sectional study.

METHOD

The ROM-Phamous, a ROM-protocol for patients with psychotic disorders in which data is collected on the basis of interviews, questionnaires and physical examination was implemented in the northern Netherlands. A random sample of 100 patients was extracted from the 2010 ROM database (n = 1040), from which we determined the prevalence of a number of problem areas. We then investigated whether these problems were reflected in patients' treatment plans.

RESULTS

The sample consisted of 63 men and 37 women, with a mean age of 44 years and a mean duration of illness of 18 years. The prevalence of symptoms and psychosocial problems was 13-37%; the prevalence of cardiovascular risk factors was 11-86%. The majority of problems identified with ROM were not reflected in patients' treatment plans; the opposite also occurred: psychosocial problems, in particular, mentioned in the treatment plans were not always identified with ROM.

CONCLUSION

ROM and treatment should ideally be integrated in mental-health services, but currently appear to be separate processes. If improvement of integration of ROM and clinical practice succeeds it could lead to improvement of care for psychiatric patients. Further investigation is warranted. Conflict of interest and financial support: ICMJE forms provided by the authors are available online along with the full text of this article.

[Differences in non-native resident psychiatrists and native residents psychiatrists in completion of the psychiatry residency training programmes]

A relatively small number of psychiatrists in the Netherlands have a non-Dutch origin. We suspect that resident psychiatrists who do not have Dutch as their first language are less likely than native Dutch speakers to complete the psychiatry residency training programmes.<br/> AIM: To find out how often and for what reasons resident psychiatrists do not complete the psychiatry residency training programmes. <br/> METHOD: All course coordinators in the Netherlands were asked to participate in a survey to provide information about the residents who had started but had abandoned the psychiatry residency training programmes between the years 2008 and 2015. They were also asked about factors that had influenced residents to abandon the course.<br/> RESULTS: We were able to obtain data on 37% of the trainees. The data revealed that the number of non-native resident psychiatrists who failed to complete the training course was almost four times higher than the number of native trainee psychiatrists who dropped out before the end of the course. According to the coordinators, possible reasons for this discrepancy are lack of proficiency in Dutch, communication problems and cultural differences.<br/> CONCLUSION: The results of our survey could possibly be used to adjust the training programmes.

The prevalence of visual hallucinations in non-affective psychosis, and the role of perception and attention

BACKGROUND

Little is known about visual hallucinations (VH) in psychosis. We investigated the prevalence and the role of bottom-up and top-down processing in VH. The prevailing view is that VH are probably related to altered top-down processing, rather than to distorted bottom-up processing. Conversely, VH in Parkinson's disease are associated with impaired visual perception and attention, as proposed by the Perception and Attention Deficit (PAD) model. Auditory hallucinations (AH) in psychosis, however, are thought to be related to increased attention.

METHOD

Our retrospective database study included 1119 patients with non-affective psychosis and 586 controls. The Community Assessment of Psychic Experiences established the VH rate. Scores on visual perception tests [Degraded Facial Affect Recognition (DFAR), Benton Facial Recognition Task] and attention tests [Response Set-shifting Task, Continuous Performance Test-HQ (CPT-HQ)] were compared between 75 VH patients, 706 non-VH patients and 485 non-VH controls.

RESULTS

The lifetime VH rate was 37%. The patient groups performed similarly on cognitive tasks; both groups showed worse perception (DFAR) than controls. Non-VH patients showed worse attention (CPT-HQ) than controls, whereas VH patients did not perform differently.

CONCLUSIONS

We did not find significant VH-related impairments in bottom-up processing or direct top-down alterations. However, the results suggest a relatively spared attentional performance in VH patients, whereas face perception and processing speed were equally impaired in both patient groups relative to controls. This would match better with the increased attention hypothesis than with the PAD model. Our finding that VH frequently co-occur with AH may support an increased attention-induced 'hallucination proneness'.

[A study of cost-effectiveness of treating serious mental illness: challenges and solutions]

BACKGROUND People with serious mental illness (SMI) often suffer high healthcare costs and enduring loss of quality of life. Increasing our understanding of the cost-effectiveness of people with SMI is important when striving for optimal health at affordable costs. AIM To describe aspects that can be important for cost-effectiveness research targeting people with SMI. METHOD These aspects are demonstrated by considering pro-active care, rehabilitation and involuntary treatment RESULTS The possible involvement of a large number of stakeholders outside of healthcare requires cost-effectiveness research to also map the costs and benefits outside of healthcare, preferably for each stakeholder specifically. Availability of data, the possibility to combine datasets, and ways to deal with dropouts require extra attention. CONCLUSION Cost-effectiveness research targeting people with SMI could be enhanced when solutions are found for the availability of data inside and outside of healthcare and when dropout can be compensated for by other sources of data, such that costs and benefits for each stakeholder can be estimated more reliably.

[Mindfulness training for psychiatrists in residency: a pilot study]

Medical students and psychiatrists in residency run a high risk for burnout. Furthermore, while at medical school, students seem to experience a reduction in empathy; this seems to be linked to a high level of stress. Interventions based on mindfulness training appear to reduce stress and increase empathy in medical students. Trainees in psychiatric residency might also benefit from mindfulness training.<br/> AIM: To assess the effects that a mindfulness course has on perceived stress and empathy in psychiatrists in residency.<br/> METHOD: In this pilot study 13 trainees in psychiatric residency participated in an eight-week course in mindfulness. Before and after the training, 11 of the participants completed questionnaires relating to their empathy, perceived stress and mindfulness.<br/> RESULTS: Participants reported experiencing considerably more empathy after their course than before it. Perceived stress also diminished, but not significantly.<br/> CONCLUSION: The results support our suggestion that mindfulness training can be a valuable part of the curriculum for trainees in psychiatric residency.

Efficacy of bilateral repetitive transcranial magnetic stimulation for negative symptoms of schizophrenia: results of a multicenter double-blind randomized controlled trial

BACKGROUND

Few studies have investigated the efficacy of repetitive transcranial magnetic stimulation (rTMS) treatment for negative symptoms of schizophrenia, reporting inconsistent results. We aimed to investigate whether 10 Hz stimulation of the bilateral dorsolateral prefrontal cortex during 3 weeks enhances treatment effects.

METHOD

A multicenter double-blind randomized controlled trial was performed in 32 patients with schizophrenia or schizo-affective disorder, and moderate to severe negative symptoms [Positive and Negative Syndrome Scale (PANSS) negative subscale ⩾15]. Patients were randomized to a 3-week course of active or sham rTMS. Primary outcome was severity of negative symptoms as measured with the Scale for the Assessment of Negative Symptoms (SANS) and the PANSS negative symptom score. Secondary outcome measures included cognition, insight, quality of life and mood. Subjects were followed up at 4 weeks and at 3 months. For analysis of the data a mixed-effects linear model was used.

RESULTS

A significant improvement of the SANS in the active group compared with sham up to 3 months follow-up (p = 0.03) was found. The PANSS negative symptom scores did not show a significant change (p = 0.19). Of the cognitive tests, only one showed a significant improvement after rTMS as compared with sham. Finally, a significant change of insight was found with better scores in the treatment group.

CONCLUSIONS

Bilateral 10 Hz prefrontal rTMS reduced negative symptoms, as measured with the SANS. More studies are needed to investigate optimal parameters for rTMS, the cognitive effects and the neural basis.

[Cost-effectiveness in Dutch mental health care: future because of ROM?]

BACKGROUND

The document reporting Dutch mental health care negotiations for 2014-2017 calls for a cost decrease based on cost-effectiveness. Thanks to ROM, the Dutch mental health care seems well prepared for cost-effectiveness research.

AIM

Evaluate how valid cost-effectiveness research should be established in mental health care and the role of rom therein.

METHOD

Evaluation of requirements of cost-effectiveness research, trends, and a translation to Dutch mental health care.

RESULTS

Valid cost-effectiveness research in mental health care requires the application of a societal perspective, a long time-horizon and an adequate evaluation of quality of life of patients. Healthcare consumption, outcome of care and characterisation of the patient population should be measured systematically and continuously. Currently, rom-data are not suitable to serve as a basis for cost-effectiveness research, although a proper basis is present. Further development of rom could lead to a situation in which mental health care is purchased on the basis of cost-effectiveness. However, cost-effectiveness will only really be improved if quality of care is rewarded, rather than rewarding activities that are not always related to outcome of care.

CONCLUSION

Cost-effectiveness research in mental health care should focus on societal costs and benefits, quality of life and a long time-horizon. If developed further, rom has the potential to be a basis for cost-effectiveness research in the future.

[Trauma treatment in a patient with a psychotic disorder]

Until recently, patients suffering from both a psychotic disorder and a post-traumatic stress disorder (PTSD) were hardly ever treated for their PTSD. Many clinicians considered that the reliving of the trauma during treatment could increase the risk of psychotic decompensation. We describe a trauma-focused cognitive behavioural therapy that was used to treat a 43-year-old patient diagnosed with both schizoaffective disorder and comorbid PTSD. After five sessions the patient no longer experienced PTSD symptoms.

[Good clinical practice and the maintenance of ethical standards in medical research: advice for junior researchers working in mental health care]

BACKGROUND

In mental health care, more and more research is being done, particularly in the field of educational programmes. Unfortunately, junior researchers are often not fully informed about the rules and regulations relating to research and about medical ethics. Therefore, they are not in a position to make considered judgements that conform to good clinical practice and acceptable medical ethics.<br/>

AIM

To give practical advice to trainees, stimulating them to think carefully about ethical standards in patient-related research in mental health care. METHODS The article provides a practice-based overview of practical advice and ethical considerations.<br/>

RESULTS

We stress that before beginning their research, researchers should think very carefully about the ethics of medical research. Instructions and guidelines relating to medical and ethical standards are to be found in: directive for good clinical practice compiled by the central committee for human research (CCMO) with the accompanying e-learning module and in the basic course 'rules and organisation for clinical researchers' (BROK). Practical tips, illustrated with examples, provide a framework for stimulating thoughts on medical ethics. Finally, it is important to improve the ways in which research is embedded in the organisational structure of teaching programmes.<br/>

CONCLUSION

Basic information about GCP and the upholding of medical and ethical standards in patient-related research can be obtained from various sources. The main challenge is to ensure that GCP is firmly embedded in patient-related research undertaken by junior researchers.

Amélioration fonctionnelle sous palmitate de paliperidone à doses flexibles chez des patients aigus ou non aigus atteints de schizophrénie, après échec d’un traitement par antipsychotiques oraux

Objectifs

Évaluer l’amélioration fonctionnelle chez des patients atteints de schizophrénie sous palmitate de paliperidone (PP) à doses flexibles après échec d’un traitement par antipsychotiques oraux.

Méthodes

Analyse menée dans deux sous-groupes de patients atteints de schizophrénie : aigus (n = 202) et non aigus (n = 593) après échec d’un traitement par antipsychotiques oraux, inclus dans une étude internationale, prospective, de six mois.

Critères d’évaluation

Changement du score total à la PANSS (Positive and Negative Syndrome Scale), à la PSP (Personal and Psychosocial Performance scale), et à la Mini-ICF-APP (Mini International Classification of Functionality, Disability and Health Rating for Activity and Participation Disorders in Psychological Illnesses).

Résultats

Les deux sous-groupes ont présenté une amélioration significative du score total à la PANSS : de 98,5 ± 20,1 à l’inclusion à 67,4 ± 24,0 à la fin de l’étude (diminution moyenne = −31,0 ± 29,0) chez les patients aigus et de 71,5 ± 14,6 à 59,7 ± 18,1 (diminution moyenne = −11,7 ± 15,9) chez les patients non aigus. Cette réponse thérapeutique était associée à une augmentation significative du score total à la PSP de 43,9 ± 15,0 à 62,9 ± 17,1 (amélioration moyenne = 19,0 ± 18,7, p <0,0001) chez les patients aigus, et de 58,1 ± 13,4 à 66,1 ± 15,7 (amélioration moyenne =8,0 ± 14,0, p < 0,0001) chez les patients non aigus. Il existait une amélioration significative du score à la Mini-ICF-APP qui diminuait de 26,8 ± 8,5 à 18,5 ± 9,8 (diminution moyenne = −8,0 ± 10,4, p < 0,0001) chez les patients aigus et de 19,8 ± 7,9 à 15,9 ± 8,8 (diminution moyenne = −4,0 ± 7,5, p < 0,0001) chez les patients non aigus.

Conclusions

L’amélioration symptomatique sous PP à doses flexibles chez des patients aigus ou non-aigus atteints de schizophrénie après échec d’un traitement par antipsychotique oral s’est accompagnée d’une amélioration fonctionnelle cliniquement significative.

[Dutch guideline on Schizophrenia 2012: basic care within the areas of psychosocial interventions and nursing care]

BACKGROUND

An updated version of the Dutch multidisciplinary guideline on schizophrenia was published in 2012.

AIM

We aim to provide an overview of the psychosocial interventions and nursing care which, according to the guideline, should be included in basic care programmes for patients with schizophrenia. We consider which interventions are effective and which are optional. In addition, we argue for continuous updating of the guideline so that it reflects current developments.

METHOD

We conducted a systematic review on the basis of specific predefined search terms. We included articles published up to February 2010. We used the method for evidence-based guideline development in order to formulate treatment recommendations.

CONCLUSION

Cognitive behavioural therapy and family interventions are scientifically proven interventions that should be included in the care programmes. Although there is no clear evidence that psycho-education is effective, it is nevertheless recommended. Optional interventions are peer support groups and, in the case of negative symptoms, psychomotor therapy. Although scientific evidence concerning nursing care is limited, we do make some recommendations. We are strongly in favour of a living guideline & rsquo; that is constantly developed and updated.

A systematic review of instruments to measure depressive symptoms in patients with schizophrenia

BACKGROUND

Depressive symptoms require accurate recognition and monitoring in clinical practice of patients with schizophrenia. Depression instruments developed for use in depressed patients may not discriminate depressive symptoms from negative psychotic symptoms.

OBJECTIVE

We reviewed depression instruments on their reliability and validity in patients with schizophrenia.

METHODOLOGY

A systematic literature search was carried out in three electronic databases. Psychometric properties were extracted for those instruments of which reliability, divergent, concurrent and predictive validity were reported in one or more publications.

RESULTS

Forty-eight publications described the reliability and validity of six depression instruments in patients with schizophrenia. The only self-report was the Beck Depression Inventory (BDI). The Brief Psychiatric Rating Scale-Depression subscale (BPRS-D), Positive and Negative Syndrome Scale-Depression subscale (PANSS-D), Hamilton Rating Scale for Depression (HAMD), Montgomery Asberg Depression Rating Scale (MADRS) and Calgary Depression Scale for Schizophrenia (CDSS) were clinician rated. All instruments were reliable for the measurement of depressive symptoms in patients with schizophrenia. The CDSS most accurately differentiated depressive symptoms from other symptoms of schizophrenia (divergent validity), correlated well with other depression instruments (concurrent validity), and was least likely to miss cases of depression or misdiagnose depression (predictive validity).

CONCLUSIONS

We would recommend to use the CDSS for the measurement of depressive symptoms in research and in daily clinical practice of patients with schizophrenia. A valid self-report instrument is to be developed for the use in clinical practice.

[Neurotoxicity in elderly patients being treated with lithium: is there a reason to adjust the dosage administered?]

BACKGROUND

Neurotoxicity can occur in patients being treated with lithium. Features are cognitive dysfunctioning and motor symptoms. Some results of research performed on adults up to the age of 65 indicate that lithium can cause mild cognitive dysfunctioning. It is not clear, however, whether elderly patients are more susceptible than young adults to this form of neurotoxicity or, if this is the case, whether the dosage of lithium should be reduced.

AIM

To determine whether elderly patients treated with lithium run an increased risk of neurotoxicity, and to discuss the pharmacodynamic aspects of lithium use in the elderly which may cause neurotoxicity.

METHOD

Literature review in Cochrane (all EBM), Embase, PsycINFO, Medline and PubMed, with cross-checked references.

RESULTS

Few studies described possible neurotoxic effects of lithium. We found no indications for cognitive dysfunctioning in elderly patients being treated with lithium. However, a lithiumassociated tremor was seen more often in elderly patients than in younger adults. Pharmacodynamic effects of aging, such as an increase in the lithium concentration in the brain with no change in the serum level, may give rise to side-effects. More research is needed into the relationship between the serum level and the neurotoxic effects of lithium in the elderly.

CONCLUSION

There are no indications that lithium causes more neurotoxicity in the elderly than in younger adults. If the use of lithium is indicated, it can be safely prescribed for the elderly, provided age-related pharmacodynamics are taken into account.

[The relationship between antipsychotic-induced hyperprolactinemia and menstrual disorders in women with schizophrenia; a systematic review]

BACKGROUND

Menstrual disorders are common among women with schizophrenia, particularly when they are being treated with antipsychotics. The occurrence of menstrual disorders is often attributed to the use of prolactin-elevating antipsychotics, although menstrual disorders also occur in patients not using antipsychotics. Therefore we need to find out whether menstrual disorders in schizophrenia are drug-related or whether they have some other connection with schizophrenia.

AIM

To identify and discuss studies that investigate the relationship between antipsychotics-induced hyperprolactinemia and menstrual disorders in women with schizophrenia.

METHOD

We reviewed the literature systematically using PubMed, Psyc, info and the Cochrane Central Register of Controlled Trials.

RESULTS

Very few studies have investigated the connection between antipsychotic-induced hyperprolactinemia and menstrual disorders and most have serious methodological limitations. Only one study was able to demonstrate such a connection.

CONCLUSION

On the basis of current research no firm conclusions can be drawn about the relationship between the increased frequency of menstrual disorders in women with schizophrenia and elevated prolactin levels resulting from the use of antipsychotics.

An open randomized pilot trial on the differential effects of aripiprazole versus risperidone on anhedonia and subjective well-being

INTRODUCTION

Negative symptoms of schizophrenia often predict an unfavorable clinical outcome. Disturbed dopamine transmission in different brain parts may underlie different aspects of negative symptoms, and the effect of antipsychotics on them may also differ. This pilot study investigated the potentially therapeutic effects of the partial dopamine agonist aripiprazole on different negative symptoms.

METHODS

This pilot study randomly assigned patients with schizophrenia (N=40) to either aripiprazole or risperidone. After 6 weeks of treatment, the severity of negative symptoms was determined by the PANSS. Subscales of self-report questionnaires were used to assess differences in initiative, anhedonia, social functioning and subjective well-being.

RESULTS

Patients treated with aripiprazole showed a significant improvement on measures for anhedonia and subjective wellbeing. Negative symptoms in general, lack of initiative and social inhibition were also lower in the aripiprazole treated group, but without reaching statistical significance.

DISCUSSION

According to this pilot study, aripiprazole appears to specifically improve anhedonia and subjective wellbeing compared to risperidone. This may be caused by a specific effect of aripiprazole on the limbic branch of the dopamine system. Future studies should replicate this finding with a larger sample size.

The course of depressive symptoms and prescribing patterns of antidepressants in schizophrenia in a one-year follow-up study

BACKGROUND

Antidepressants are frequently prescribed in patients with psychotic disorders, but little is known about their effects in routine clinical practice. The objective was to investigate the prescribing patterns of antidepressants in relation to the course of depressive symptoms in patients with psychotic disorders.

METHODS

A cohort of 214 Dutch patients with psychotic disorders received two assessments of somatic and psychiatric health, including a clinician-rated screening for depressive symptoms, as part of annual routine outcome monitoring.

RESULTS

Depressive symptoms were prevalent among 43% (93) of the patients. Antidepressants were prescribed for 40% (86) of the patients and the majority 83% (71) continued this therapy after one year. Multivariable analysis showed that patients with more severe psychopathology had a higher risk to develop depressive symptoms the following year (OR [95% CI]=0.953 [0.912-0.995]). For patients with depressive symptoms at baseline, polypharmacy was a potential risk factor to keep having depressive symptoms (OR [95% CI]=1.593 [1.123-2.261]). Antidepressant use was not an independent predictor in both analyses.

CONCLUSIONS

Routine outcome monitoring in patients with psychotic disorders revealed a high prevalence of depressive symptoms. Antidepressants were frequently prescribed and continued in routine clinical practice.

Economic aspects of peer support groups for psychosis

Peer support groups are rarely available for patients with psychosis, despite potential clinical and economic advantages of such groups. In this study, 106 patients with psychosis were randomly allocated to minimally guided peer support in addition to care as usual (CAU), or CAU only. No relevant differences between mean total costs of both groups were found, nor were there significant differences in WHOQoL-Bref outcomes. Intervention adherence had a substantial impact on the results. It was concluded that minimally guided peer support groups for psychosis do not seem to affect overall healthcare expenses. Positive results of additional outcomes, including a significant increase in social contacts and esteem support, favour the wider implementation of such groups.

[Depot antipsychotics in the year 2011]

BACKGROUND

People suffering from a psychotic disorder show limited compliance with the prescribed regimen of antipsychotics. Insufficient compliance and insufficient insight into their illness are important contributing factors predicting recurrence of psychotic symptoms.

AIM

To discuss what contribution long-acting, mainly intramuscular (depot) antipsychotics can make in reducing the chance of a psychotic relapse. Also, we suggest procedures for switching from oral to depot antipsychotics.

METHOD

The currently available depot antipsychotics in the Netherlands are compared with each other, desired and undesired treatment effects are discussed. Also, the possible role of depot antipsychotics in limiting compliance problems is discussed. Expected developments in depot antipsychotics in the near future are presented.

RESULTS

A review of the literature shows that there are insufficient studies supporting an evidence-based choice for oral versus depot antipsychotics in different clinical situations. A choice for depot antipsychotics does not solve all compliance problems, but it does make them manifest.

CONCLUSION

The choice for oral or depot administration of an antipsychotic will have to be based on the patient's particular circumstances, including the medical history and insight in his/ her illness, risks to patients and others and the personal preferences of both patient and clinician. The choice for switching to depot antipsychotics in order to reduce compliance problems needs to be part of an overall treatment plan that includes psychosocial support.

Schizophrenia care and the Dutch community pharmacy: the unmet needs

Background

Schizophrenia is a severe psychiatric disease with a prevalence of 0.6% both worldwide and in the Netherlands. Without proper treatment, schizophrenia will be increasingly incapacitating for up to 70% of patients. Management consists of drug treatment and education and can include cognitive therapy. Information about antipsychotic drugs and the importance of treatment compliance are most often given to the patient by the treating psychiatrist.

Method

Structured postal questionnaires to patients and relatives - 250 members of Anoiksis, a Dutch patients' association for people suffering from psychotic illnesses and 250 members of Ypsilon, a Dutch support network for relatives of patients suffering from schizophrenia or psychosis. Face to face, semi-structured interviews with 25 community pharmacists randomly selected from different parts of the Netherlands.

Key findings

Patients and their relatives were unaware of the possible information-giving and support roles of the community pharmacist. More than 60% of patients and relatives agreed that they would have liked to receive more information about drug treatment. Two-thirds of patients and relatives thought that an active reminder to collect refill medication would be a valuable service. However, the community pharmacists were unaware of patients' unmet needs and of the support they could offer to patients with schizophrenia.

Conclusion

Patients and their relatives have needs for medication information and support that are not currently being met. Dutch community pharmacists do not currently perceive that they have a contribution to make to the care of patients with schizophrenia. As the first stage in developing future community pharmacy services, the findings of this study should be disseminated to pharmacists.

Objective

To investigate the role of the Dutch community pharmacist in schizophrenia care.

[Pharmacological treatment of negative symptoms in schizophrenia; research and practice]

BACKGROUND

Negative symptoms in patients with schizophrenia predict a worse social outcome. The treatment options for negative symptoms are extremely limited. Various treatment strategies have been studied in which several types of medication were added to antipsychotics in order to alleviate negative symptoms.

AIM

To review the types of medication that have been used to supplement antipsychotic treatment in order to alleviate negative symptoms in patients with schizophrenia.

METHOD

By means of PubMed we were able to perform a systematic review of all randomised controlled trials and relevant meta-analyses published up to and including May 2009.

RESULTS

The pharmacological mechanisms that were studied in connection with the treatment of negative symptoms were as follows: the modulation of the glutamate system, the modulation of the serotonergic system, the histaminergic system and the dopaminergic system and the influencing by means of antioxidants and hormones. Despite all the methodological problems the modulation of the glutamate system and the blocking of serotonin 5-HT-3/2a receptors may be able to bring about a limited reduction of negative symptoms. The therapeutic results of the pharmacological treatments studied which may be effective is only moderate.

CONCLUSION

For the time being the pharmacological addition strategies do not lead us to recommend their use in current clinical practice but they can certainly serve as a basis for further research. medication, negative symptoms, schizophrenia.

The effectiveness of peer support groups in psychosis: a randomized controlled trial

OBJECTIVE

To investigate the effect of a (minimally) guided peer support group (GPSG) for people with psychosis on social network, social support, self-efficacy, self-esteem, and quality of life, and to evaluate the intervention and its economic consequences.

METHOD

In a multi-center randomized controlled trial with 56 patients in the peer support group and 50 patients in the control condition, patients were assessed at baseline and after the last meeting at 8 months.

RESULTS

The experimental group showed GPSG to have a positive effect on social network and social support compared with the control condition. In the experimental condition, high attenders favored over low attenders on increased social support, self-efficacy, and quality of life. Economic evaluation demonstrated groups to be without financial consequences. The GPSG-intervention was positively evaluated.

CONCLUSION

Peer support groups are a useful intervention for people suffering from psychosis by improving their social network.

[Antipsychotics and sexual functioning in persons with psychoses]

BACKGROUND

So far little research has been done into sexual dysfunctions that develop during the use of antipsychotics. However, over the last 10 years a great deal of new and clinically useful information has become available.

AIM

To provide information about the frequency, nature and pathogenesis of sexual dysfunctions that arise during treatment with antipsychotics and to suggest some ways of tackling such problems in clinical practice.

RESULTS

In 30 to 60% of cases the use of antipsychotics is linked to sexual dysfunctions such as loss of libido, erectile and/or lubrication problems and orgasm and ejaculation disorders. If sexual dysfunctions are not actively addressed by clinicians they are likely to be underreported. The most frequent sexual dysfunctions are a result of treatment with antipsychotics with a high affinity for dopamine receptors and/or that cause a marked rise in the prolactin level. Antipsychotic-induced sexual dysfunctions are probably linked to a lower quality of life and lower treatment compliance. Possible mechanisms that underlie the influence of antipsychotics on sexual functioning are discussed. Also discussed are possible interventions designed to reduce sexual dysfunction.

CONCLUSIONS

During treatment with antipsychotics sexual dysfunctions occur frequently, depending on the type of antipsychotics prescribed. If clinicians actively address the problems of sexual dysfunction, they may often be able to arrive at a solution by giving information, by prescribing a different antipsychotic, by reducing the dose and/or by prescribing appropriate supplementary medication.

A randomized open-label comparison of the impact of olanzapine versus risperidone on sexual functioning

The objective of this study was to compare sexual functioning in patients treated with olanzapine or risperidone. This open-label trial included 46 patients randomized to olanzapine (5-15 mg/d) or risperidone (1-6 mg/d) for 6 weeks. We used sexual dysfunction was assessed by a semistructured interview based on the items of the UKU side effect rating scale. Three olanzapine-treated patients (12.0%), compared with 11 risperidone-treated patients (52.4%), reported sexual dysfunctions (p = .008) in the semistructured interview. Only 4 patients (8.7%) spontaneously reported sexual dysfunction. The mean dose was 9.4 mg/d for olanzapine and 3.4 mg/d for risperidone. The mean (+/-SD) prolactin levels (ng/mL) in olanzapine-and risperidone-treated patients were 25.1 (+/- 23.5) and 43.5 (+/- 26.1), respectively. Less sexual dysfunction occurred in the group treated with olanzapine compared with the risperidone group. Direct questioning about sexual functioning is necessary to avoid underestimating the frequency of sexual side effects in patients with schizophrenia and related psychotic disorders.

Low essential fatty acid and B-vitamin status in a subgroup of patients with schizophrenia and its response to dietary supplementation

We assessed essential fatty acid (EFA) and B-vitamin status, together with their determinants, in 61 patients with schizophrenia and established whether those with poor status responded biochemically to the appropriate dietary supplements. As a group, the patients had high erythrocyte saturated fatty acids (FAs), monounsaturated FA and low polyunsaturated FA of the omega3 and omega6 series. Patients reporting not to take vitamin supplements had low vitamin B12 and high homocysteine. Homocysteine variance proved best explained by folate in both the total group and male patients, and by vitamins B12 and B6 in females. Alcohol consumption and duration of illness are risk factors for low polyunsaturated FA status (< P2.5 of reference range), while male gender and absence of fish consumption predict hyperhomocysteinemia (> P97.5 of reference range). Two patients exhibited biochemical EFA deficiency and seven showed biochemical signs of omega3/docosahexaenoic acid (DHA) marginality. Four patients exhibited moderate hyperhomocysteinemia with plasma values ranging from 57.5 to 74.8 micromol/L. None of the five patients with either moderate hyperhomocysteinemia, biochemical EFA deficiency, or both, was predicted by their clinicians to have poor diets. That diet was nevertheless at the basis of these abnormalities became confirmed after supplementing 4 of them with B vitamins and with soybean and fish oils. We conclude that a subgroup of patients with schizophrenia has biochemical EFA deficiency, omega3/DHA marginality, moderate hyperhomocysteinemia, or combinations. Correction seems indicated in view of the possible relation of poor EFA and B-vitamin status with some of their psychiatric symptoms, but notably to reduce their high risk of cardiovascular disease.

Sex differences in concomitant medication with benzodiazepines or antidepressants in first-break schizophrenic patients treated with antipsychotic medication

During a first episode of psychosis, treatment with antipsychotic drugs can improve both positive and negative symptoms. If sufficient amelioration does not occur, adding psychotropic comedication may result in a favorable outcome. To establish sex differences in psychotropic comedication use, we conducted an exploratory retrospective study among first-break patients diagnosed with schizophrenia or schizophreniform disorder. Concerning patient characteristics, no difference in age or antipsychotic drug use was established. At admission, men significantly more often had comorbid substance abuse. Analysis showed that significantly more women than men received benzodiazepines after the onset of psychosis (OR 1.92, 95% CI 1.13-1.27). No sex difference was found in antidepressant comedication (OR 1.22, 95% CI 0.48-3.11). We established a definite sex difference in concomitant benzodiazepine use in first-break patients with schizophrenia. Since women have a better prognosis, we suggest further research to evaluate the efficacy and safety of early benzodiazepine use in the course of schizophrenia. Furthermore, we recommend investigating the possible correlation between benzodiazepine use and substance abuse as a way of treating premorbid symptoms of schizophrenia.

What are the effects of antipsychotics on sexual dysfunctions and endocrine functioning?

The literature is reviewed and preliminary results of new studies are presented showing that treatment with classical antipsychotics, as well as risperidone, induces sexual dysfunctions in 30-60% of the patients. These antipsychotics also frequently induce amenorrhoea and galactorrhoea. Although comparative studies are rare, it is likely that prolactin-sparing antipsychotics, as recently shown in a randomized trial of olanzapine versus risperidone, induce less sexual side effects.From these studies, it becomes apparent that prolactin elevation induced by classical antipsychotics and risperidone is probably a factor in inducing sexual dysfunctions, amenorrhoea and galactorrhoea. The role of other factors inducing sexual dysfunctions like sedation, proportional, variant -blockade, testosterone, dopamine, and serotonin is discussed. Finally, it is concluded that sexual and hormonal effects of antipsychotics, although clearly important, are often neglected in research as in clinical practice. Lowering the dosage or switching to a prolactin-sparing antipsychotic often reduces sexual side effects, amenorrhoea, and galactorrhoea.

Reporting sexual function disorders caused by antipsychotic drugs: is there a role for the community pharmacy?

Sexual function disorders are frequent adverse effects of antipsychotic use. These effects can lead to non-compliance to medication, which dramatically worsen the outcome of the psychotic disease. Detecting sexual dysfunction by the carers may be difficult, since feelings of embarrassment may occur in both care-taker as in patient. In order to prevent underreporting, strategies to recognise sexual dysfunction should be developed, based upon collaboration between care providers of the psychotic patient. Community pharmacies in many countries can detect non-compliance to medication in prescription data and report this to psychiatric services of the patient. Exchanging information by cross-sectoral networks may optimise the disease management of the psychotic patient.

Component structure of the positive and negative syndrome scale (PANSS) in patients with recent-onset schizophrenia and spectrum disorders

RATIONALE

Earlier studies have examined the symptom dimensions of the PANSS (Positive And Negative Syndrome Scale) in patients with chronic schizophrenia. Results have suggested that three to eight component solutions best explain underlying symptom dimensions.

OBJECTIVES

To examine the component structure of the PANSS and the MADRS (Montgomery Asberg Depression Rating Scale) in young patients with recent-onset schizophrenia and related disorders and the correlations between the components of both instruments.

METHODS

Symptomatology was measured in 138 patients with recent-onset schizophrenia, by administering the PANSS and the MADRS.

RESULTS

Principal component analysis of the PANSS revealed five components: a positive, negative, depression, agitation-excitement and disorganisation component. The MADRS only showed one component. A high correlation was found between the depression component of the PANSS and the overall score of the MADRS (p=0.87, P<0.001). A moderate correlation was found between the PANSS negative component and the overall score of the MADRS (p=0.51, P<0.001).

CONCLUSIONS

The data suggest a five component structure of the PANSS. The depression component of the PANSS seems to be a valid way of assessing depression in patients with recent-onset schizophrenia.

Tranylcypromine in narcolepsy

The narcolepsy syndrome consists of excessive daytime somnolence, cataplexy, hallucinations, and sleep paralysis. Data on the effects of tranylcypromine are scant. We report on a patient with severe narcolepsy in whom administration of tranylcypromine led to freedom from hallucinations, nightmares, sleep paralysis, and rapid eye movements (REM), with considerable amelioration of cataplexy and increased daytime alertness. Muscle atonia and low-voltage desynchronized cortical activity during REM sleep did not change. Tranylcypromine warrants further study in narcolepsy.

Effects of antidepressants on cognitive functioning of elderly patients. A review

The influence of antidepressants on cognitive performance in elderly patients has been investigated in 18 studies. More than 70 different psychological tests or batteries of tests could be identified in these studies. The tentative conclusions that can be drawn are as follows. Monoamine oxidase (MAO) inhibitors hardly influence cognitive performance. Amitriptyline, dothiepin, mianserin and trazodone impair attention and ability to concentrate. Drugs with anticholinergic properties, such as nortriptyline, maprotiline and amitriptyline, might impair aspects of memory. For nortriptyline, higher plasma concentrations correlate with greater cognitive impairment. Cognitive impairment induced by nortriptyline during treatment might not be a transient effect, but may last as long as treatment continues. Data regarding the effects of selective serotonin (5-hydroxytryptamine) reuptake inhibitors on cognitive performance in the elderly indicate no detrimental effect. A consensus on the use of instruments evaluating cognitive performance is needed to allow better comparison of future studies. As these conclusions can only be provisional, more study is needed.

Predictors of (non-) response in depressed outpatients treated with a three-phase sequential medication strategy

The predictive value of eight domains or sets of variables including sociodemographic aspects, premorbid history, symptomatology, personality, social and diagnostic data are evaluated in depressed outpatients with a Hamilton Rating Scale for Depression (HRSD) score of at least 14. Patients were treated using a three-phase sequential treatment strategy. Of the 119 patients, 88 completed the trial. The HRSD-score at the end of phases I, II or III was used as an outcome measure. Patients with an initially high HRSD-score and an obsessive-compulsive personality had a greater chance of recovery, while patients with somatization and a passive-aggressive personality had less of a chance of recovery. Variables involving psychiatric history, premorbid history or symptomatology of the depression, were not significantly related to outcome. The endogenous/non-endogenous distinction was not a predictor of response.