Evaluation of the association between insight and symptoms in a large sample of patients with schizophrenia

Background

The objective of the present study was to examine the association of insight into the illness with demographic variables and symptomatology in a sample of 1213 patients with schizophrenia.

Method

Data were collected with the Psychosis Evaluation tool for Common use by Caregivers (PECC), a semi-structured interview evaluating five symptom domains of schizophrenia and the insight items ‘awareness of having a mental disorder’ and ‘attributing symptoms to a mental disorder’.

Results

Insight was positively associated with educational level and inversely with overall symptom severity, and the positive, negative, excitatory and cognitive symptom domains. At symptom level, the items ‘delusions’, ‘grandiosity’, ‘poor rapport’, ‘social withdrawal’ and ‘guilt feelings’ showed the strongest associations with both insight items. Overall, correlations between insight and symptomatology were modest, explaining less than 30% of the variance in insight.

Conclusion

Lack of insight in schizophrenia is partially explained by clinical symptoms and demographic measures.

Sexual dysfunction: The unspoken side effect of antipsychotics

Although only a few studies have been performed and published data are scarce, it seems clear that sexual dysfunctions frequently occur during treatment with antipsychotics in 30–60% of patients with schizophrenia. It is important to evaluate the occurrence of sexual dysfunction and its relation to antipsychotic treatment.

Second-generation antipsychotics and constipation: A review of the literature

Antipsychotics are the cornerstone in the management of psychotic disorders and schizophrenia. They are effective agents but also have a wide range of side effects. In the recent literature constipation as possible side effect has received little attention. A review of the literature concerning constipation associated with antipsychotics was performed. Overall constipation is a rarely studied or reported side effect of antipsychotic medication. Nevertheless constipation is a common side effect. Antipsychotic agents differ in their liability to induce constipation. Constipation can be severe and can lead to serious consequences such as paralytic ileus, bowel occlusion and death. Active screening, monitoring and treatment are recommended. Further research on incidence, prevalence, underlying mechanisms and preventive measures is required.

Oral glucose tolerance tests in treated patients with schizophrenia

Objective

A recent consensus conference has proposed guidelines for the monitoring for diabetes in patients with schizophrenia and also identifies the need of long-term prospective studies.

Methods

A large scale prospective study on metabolic risks of antipsychotic medication is currently ongoing. At baseline, patients get a full laboratory screening, ECG and an oral glucose tolerance test (OGTT). Baseline data on 100 non-diabetic patients at study inclusion and stable on medication for at least 6 months are presented.

Results

Glucose abnormalities are found in 22% of patients at baseline. A monitoring protocol based only on fasting glucose would not have detected 63.6% of these patients with classifiable glucose abnormalities in our sample. Fasting insulin and measures for insulin resistance have a high predictive value for abnormalities late in the OGTT.

Conclusions

Already at baseline, metabolic problems are frequently present in patients with schizophrenia treated with antipsychotics. Adding assessment of fasting insulin in a monitoring protocol improves detection of glucose abnormalities late in an OGTT.

Relationship between prolactin, breast cancer risk, and antipsychotics in patients with schizophrenia: a critical review

OBJECTIVE

A recent meta-analysis showed that breast cancer probably is more common in female patients with schizophrenia than in the general population (effect size = 1.25, P < 0.05). Increasing experimental and epidemiological data have alerted researchers to the influence of prolactin (PRL) in mammary carcinogenesis. We therefore investigated the possible relationship between antipsychotic-induced hyperprolactinemia (HPRL) and breast cancer risk in female patients with schizophrenia.

METHOD

A literature search (1950 until January 2015), using the MEDLINE database, was conducted for English-language published clinical trials to identify and synthesize data of the current state of knowledge concerning breast cancer risk (factors) in women with schizophrenia and its (their) relationship between HPRL and antipsychotic medication.

RESULTS

Although an increasing body of evidence supports the involvement of PRL in breast carcinogenesis, results of human prospective studies are limited, equivocal, and correlative (with risk ratios ranging from 0.70 to 1.9 for premenopausal women and from 0.76 to 2.03 for postmenopausal women). Moreover, these studies equally do not take into account the local production of PRL in breast epithelium, although amplification or overexpression of the local autocrine/paracrine PRL loop may be a more important mechanism in tumorigenesis. Until now, there is also no conclusive evidence that antipsychotic medication can increase the risk of breast malignancy and mortality.

CONCLUSION

Other breast risk factors than PRL, such as nulliparity, obesity, diabetes mellitus, and unhealthy lifestyle behaviours (alcohol dependence, smoking, low physical activity), probably are of greater relevance in individual breast cancer cases within the population of female patients with schizophrenia.

Associative stigma in family members of psychotic patients in Flanders: An exploratory study

AIM: To assess presence and severity of associative stigma in family members of psychotic patients and factors for higher associative stigma.

METHODS: Standardized semi-structured interview of 150 family members of psychotic patients receiving full time treatment. This study on associative stigma in family members of psychotic patients was part of a larger research program on the burden of the family, using “Interview for the Burden of the Family” and the chapters stigma, treatment and attribution from the “Family interview Schedule”. The respondents were relatives, one per patient, either partner or parent. The patients had been diagnosed with schizophrenia or schizo-affective disorder. All contacts with patients and relatives were in Dutch. Relatives were deemed suitable to participate in this research if they saw the patient at least once a week. Recruitment took place in a standardized way: after obtaining the patient’s consent, the relatives were approached to participate. The results were analyzed using SPSS Version 18.0.

RESULTS: The prevalence of associative stigma in this sample is 86%. Feelings of depression in the majority of family members are prominent. Twenty-one point three percent experienced guilt more or less frequent, while shame was less pronounced. Also, 18.6% of all respondents indicated that they tried to hide the illness of their family member for others regularly or more. Three six point seven percent really kept secret about it in certain circumstances and 29.3% made efforts to explain what the situation or psychiatric condition of their family member really is like. Factors with marked significance towards higher associative stigma are a worsened relationship between the patient and the family member, conduct problems to family members, the patients’ residence in a residential care setting, and hereditary attributional factors like genetic hereditability and character. The level of associative stigma has significantly been predicted by the burden of aggressive disruptions to family housemates of the psychotic patient.

CONCLUSION: Family members of psychotic patients in Flanders experience higher associative stigma compared to previous international research. Disruptive behavior by the patient towards in-housing family members is the most accurate predictor of higher associative stigma.

Preliminary study of associative stigma among trainee psychiatrists in Flanders, Belgium

AIM: To study the degree of stigmatization among trainee psychiatrists, individual characteristics potentially leading to higher associative stigma, and coping mechanisms.

METHODS: Two hundred and seven trainee psychiatrists in Flanders (Belgium), all member of the Flemish Association of Trainee Psychiatrists, were approached to participate in the survey. A non-demanding questionnaire that was specifically designed for the purpose of the study was sent by mail. The questionnaire consisted of three parts, each emphasizing a different aspect of associative stigma: devaluing and humiliating interactions, the focus on stigma during medical training, and identification with negative stereotypes in the media. Answers were scored on a Likert scale ranging from 0 to 3. The results were analyzed using SPSS Version 18.0.

RESULTS: The response rate of the study was 75.1%. The internal consistency of the questionnaire was good, with a Cronbach’s α of 0.71. Seventy-five percent of all trainee psychiatrists confirmed hearing denigrating or humiliating remarks about the psychiatric profession more than once. Additionally, more than half of them had had remarks about the incompetence of psychiatrists directed at them. Only 1.3% remembered having stigma as a topic during their psychiatric training. Trainees who had been in training for a longer period of time had experienced a significantly higher level of stigmatization than trainees with fewer years of experience (mean total stigma scores of 16.93 ± SD 7.8 vs 14.45 ± SD 6.1, t = -2.179 and P < 0.05). In addition, senior trainees effectively kept quiet about their profession significantly more often than their junior colleagues (mean item score 0.44 ± SD 0.82 vs 0.13 ± SD 0.48, t = 2.874, P < 0.01). Comparable results were found in trainees working in adult psychiatry as were found in those working in child or youth psychiatry (mean item score 0.38 ± SD 0.77 vs 0.15 ± SD 0.53, t = -2.153, P < 0.05). Biologically oriented trainees were more inclined to give preventive explanations about their profession, which can be seen as a coping mechanism used to deal with this stigma (mean item score 2.05 ± SD 1.05 vs 1.34 ± SD 1.1, t = -3.403, P < 0.01).

CONCLUSION: Associative stigma in trainee psychiatrists is underestimated. More attention should be paid to this potentially harmful phenomenon in training.

The effects of novel and newly approved antipsychotics on serum prolactin levels: a comprehensive review

Since the 1970s, clinicians have increasingly become more familiar with hyperprolactinemia (HPRL) as a common adverse effect of antipsychotic medication, which remains the cornerstone of pharmacological treatment for patients with schizophrenia. Although treatment with second-generation antipsychotics (SGAs) as a group is, compared with use of the first-generation antipsychotics, associated with lower prolactin (PRL) plasma levels, the detailed effects on plasma PRL levels for each of these compounds in reports often remain incomplete or inaccurate. Moreover, at this moment, no review has been published about the effect of the newly approved antipsychotics asenapine, iloperidone and lurasidone on PRL levels. The objective of this review is to describe PRL physiology; PRL measurement; diagnosis, causes, consequences and mechanisms of HPRL; incidence figures of (new-onset) HPRL with SGAs and newly approved antipsychotics in adolescent and adult patients; and revisit lingering questions regarding this hormone. A literature search, using the MEDLINE database (1966-December 2013), was conducted to identify relevant publications to report on the state of the art of HPRL and to summarize the available evidence with respect to the propensity of the SGAs and the newly approved antipsychotics to elevate PRL levels. Our review shows that although HPRL usually is defined as a sustained level of PRL above the laboratory upper limit of normal, limit values show some degree of variability in clinical reports, making the interpretation and comparison of data across studies difficult. Moreover, many reports do not provide much or any data detailing the measurement of PRL. Although the highest rates of HPRL are consistently reported in association with amisulpride, risperidone and paliperidone, while aripiprazole and quetiapine have the most favorable profile with respect to this outcome, all SGAs can induce PRL elevations, especially at the beginning of treatment, and have the potential to cause new-onset HPRL. Considering the PRL-elevating propensity of the newly approved antipsychotics, evidence seems to indicate these agents have a PRL profile comparable to that of clozapine (asenapine and iloperidone), ziprasidone and olanzapine (lurasidone). PRL elevations with antipsychotic medication generally are dose dependant. However, antipsychotics having a high potential for PRL elevation (amisulpride, risperidone and paliperidone) can have a profound impact on PRL levels even at relatively low doses, while PRL levels with antipsychotics having a minimal effect on PRL, in most cases, can remain unchanged (quetiapine) or reduce (aripiprazole) over all dosages. Although tolerance and decreases in PRL values after long-term administration of PRL-elevating antipsychotics can occur, the elevations, in most cases, remain above the upper limit of normal. PRL profiles of antipsychotics in children and adolescents seem to be the same as in adults. The hyperprolactinemic effects of antipsychotic medication are mostly correlated with their affinity for dopamine D2 receptors at the level of the anterior pituitary lactotrophs (and probably other neurotransmitter mechanisms) and their blood-brain barrier penetrating capability. Even though antipsychotics are the most common cause of pharmacologically induced HPRL, recent research has shown that HPRL can be pre-existing in a substantial portion of antipsychotic-naïve patients with first-episode psychosis or at-risk mental state.

Comorbid substance abuse in first-episode schizophrenia: effects on cognition and psychopathology in the EUFEST study

Studies and meta-analyses investigating the influence of substance use disorder (SUD) (substance abuse or dependence) on psychopathology and neurocognitive function in schizophrenia patients have revealed controversial results. Most studies did only have small samples and did not focus exclusively on first-episode schizophrenia patients.

METHOD

In a post-hoc analysis of the European First Episode Schizophrenia Trial (EUFEST) psychopathology and cognitive performances of patients with (FE-SUD, N=119, consisting of N=88 patients with persisting SUD at baseline and N=31 patients with previous SUD) and without SUD (FE-non-SUD, N=204) were compared at baseline and 6 months follow-up. Neurocognitive assessment included the Rey Auditory Verbal Learning Test (RAVLT); Trail Making Tests A and B (TMT), Purdue Pegboard and Digit-Symbol Coding.

RESULTS

In total 31.1% of patients reported SUD, and 22.2% of patients used cannabis. There were no significant differences between patients with and without SUD concerning PANSS scores, extrapyramidal motor symptoms or neurocognitive measures except better performance in psychomotor speed (TMT-A, p=0.033, Cohen's d=0.26) in patients with SUD at 6 months follow-up. Interestingly, SUD patients with ongoing substance use at follow-up showed elevated positive symptoms (PANSS positive score, p=0.008, Cohen's d=0.84) compared to those who abstained. PANSS scores at baseline were increased in patients with an onset of SUD before the age of 16 years. In addition we found a correlation between longer duration of cannabis use and higher cognitive performance as well as reduced symptom improvement and more extrapyramidal motor symptoms in patients with higher frequency of cannabis consumption.

CONCLUSIONS

FE-SUD and FE-non-SUD show similar psychopathology and neuropsychological performances at baseline and during the first 6 months of antipsychotic treatment.

A prospective, multicentre, open-label study to evaluate the effectiveness of aripiprazole in the treatment of a broad range of patients with schizophrenia

PURPOSE

The aim of this study is to evaluate the effectiveness of 12-week treatment with aripiprazole in a broad range of patients suffering from schizophrenia by using a variety of physicians, caregivers and patients scales.

SUBJECTS AND METHODS

A total of 361 in- or outpatients who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for schizophrenia received open-label aripiprazole (10-30 mg per day) in this 12-week, prospective, multicentre, uncontrolled study. The primary endpoint was the Clinical Global Impression-Improvement (CGI-I) scale which measured effectiveness of study medication, including efficacy, safety and tolerability. A variety of physician-, patient- and caregiver-rated parameters were measured to gain a complete view of the effectiveness of aripiprazole.

RESULTS

The effectiveness of aripiprazole treatment was demonstrated in a broad range of schizophrenia patients (CGI-I score of 3.0; 95% confidence interval: 2.8, 3.2: last observation carried forward [LOCF]) as the upper bound of the 95% CI was less than 4 (score of "no change"). Both patient and caregiver PGI-I scores (LOCF: 95% CI: 2.79, 3.09 and, 95% CI: 2.74, 3.17, respectively) corroborate this finding. Aripiprazole had a positive effect on disease severity by study end, as assessed by an increase of the (physician-rated) CGI-S scores, with 57.3% of patients having improved disease, one-third maintaining their condition (30.8%) and 11.3% with worsening symptoms (LOCF). The Investigator Assessment Questionnaire (IAQ) showed a great improvement (>50% of patients). Patients reported significantly improved quality of life and overall, 71% of patients and 67% of caregivers preferred aripiprazole to their previous antipsychotic medication (LOCF; P<0.0001 over time).

CONCLUSION

Aripiprazole was effective in a broad range of patients with schizophrenia.

Familial sinistrality and handedness in patients with first episode schizophrenia: the EUFEST study

The population with schizophrenia is characterised by a leftward shift in handedness-sinistrality. However, findings are inconsistent in chronic patients, and familial sinistrality (FS), defined as the presence of left-handed close relatives, might contribute to the discrepancies. Therefore the aim of this study was to investigate the strength of manual lateralisation in patients with first episode schizophrenia, taking into account familial sinistrality. The Edinburgh Inventory (EI) allowed us to categorise 179 patients from the EUFEST study and 189 controls presenting "strong handedness" (SH: EI absolute value between ∣81∣ and ∣100∣) or "weak-handedness" (WH: EI value between -80 and +80). The nominal logistic regression did not show an FS effect, but a nearly significant interaction between illness and FS (p =.07). There were fewer participants without FS presenting SH among patients (99/151: 65.6%) than among controls (134/164: 81.7%, p =.001). In contrast, the number of participants with FS presenting SH was similar between controls (68%) and patients (75%, p =.57). The presence of left-handed relatives (FS + ) tended to reduce manual lateralisation, but only in controls. This supports the notion that reduced manual lateralisation in schizophrenia is related to the illness rather than to familial left-handedness.

Guidelines for screening and monitoring of cardiometabolic risk in schizophrenia: systematic evaluation

BACKGROUND

Metabolic and cardiovascular health problems have become a major focus for clinical care and research in schizophrenia.

AIMS

To evaluate the content and quality of screening guidelines for cardiovascular risk in schizophrenia.

METHOD

Systematic review and quality assessment of guidelines/recommendations for cardiovascular risk in people with schizophrenia published between 2000 and 2010, using the Appraisal of Guidelines for Research and Evaluation (AGREE).

RESULTS

The AGREE domain scores varied between the 18 identified guidelines. Most guidelines scored best on the domains 'scope and purpose' and 'clarity of presentation'. The domain 'rigour of development' was problematic in most guidelines, and the domains 'stakeholder involvement' and 'editorial independence' scored the lowest. The following measurements were recommended (in order of frequency): fasting glucose, body mass index, fasting triglycerides, fasting cholesterol, waist, high-density lipoprotein/low-density lipoprotein, blood pressure and symptoms of diabetes. In terms of interventions, most guidelines recommended advice on physical activity, diet, psychoeducation of the patient, treatment of lipid abnormalities, treatment of diabetes, referral for advice and treatment, psychoeducation of the family and smoking cessation advice. Compared across all domains and content, four European guidelines could be recommended.

CONCLUSIONS

Four of the evaluated guidelines are of good quality and should guide clinicians' screening and monitoring practices. Future guideline development could be improved by increasing its rigour and assuring user and patient involvement.

Setting new standards in schizophrenia outcomes: symptomatic remission 3 years before versus after the Andreasen criteria

Symptomatic remission is often mentioned as one of the treatment goals for schizophrenia. However, the consistently with which this is documented in the schizophrenia literature since the introduction of the consensus criteria proposed by Andreasen and colleagues in 2005 has yet to be investigated. Similarly, additional treatment goals which are being discussed include improved functioning and quality of life, but whether these goals are being increasingly documented in the literature alongside symptomatic remission is as yet unknown. The objective of this article is therefore to review the use of the term 'remission' in the schizophrenia literature from Europe, U.S.A. and the rest of the world from 2002 to 2007, before and after the introduction of the Andreasen criteria. A second objective is to determine whether these manuscripts documenting symptomatic remission are also addressing other concepts such as functioning, quality of life and relationships. This literature review indicates that the use of the Andreasen criteria is indeed increasing, although there are manuscripts documenting alternative remission criteria or using the term remission without documentation of specific remission criteria. From 2004 to 2007 the number of manuscripts mentioning remission without documenting specific criteria has fallen by approximately 50%. Within these manuscripts there is increasing awareness of functioning and quality of life as outcome measures, in particular in manuscripts generated in Europe and the U.S.A. This review highlights the growing importance of co-assessment of symptomatic remission and functional outcomes, and calls for further consideration of the most appropriate and consistent way to evaluate functioning of schizophrenia patients.

How are we assessing functioning in schizophrenia? A need for a consensus approach

Efforts to improve everyday living skills are important in schizophrenia. What constitutes appropriate functioning is however difficult to evaluate. Several instruments were tested in different settings throughout Europe (EGOFORS initiative), including two new questionnaires (FROGS, PSRS), to provide directions on domains to be assessed and tools to be used.

Quality: A non-interventional study evaluating quality of life in schizophrenic patients treated with atypical antipsychotics in the ambulatory setting

Objectives

The QUALITY study evaluated Quality-of-Life in schizophrenic patients treated with atypical antipsychotics (AAPs) in the ambulatory setting.

Methods

This study was a 9-month, observational, multicentre prospective study. Patients (18–65 years-old) diagnosed with schizophrenia and treatment started with one AAP before visit-1 (minimum: 4-weeks, maximum: 8-weeks) were enrolled into this Belgian study. At visit-1 patients’ demographics and medical history were recorded with follow-up visits after 3-, 6- and 9-months. At each visit, patients completed the Subjective Well-being under Neuroleptic treatment short form (SWN-K), while investigators assessed the Positive and Negative Symptom Scale (PANSS-8) and Global Assessment of Functioning.

Results

121 patients were enrolled: 91 male, mean age 36.7 ± 10.8years. The main AAPs were risperidone (38/121), apripirazole (28/121) and quetiapine (25/121). On average, most mean changes from baseline in SWN-K-subscale scores were positive (between −0.5 and +0.5, range −1.8–1.6) suggesting patients felt better, although there were no treatment-group differences. The associations between baseline SWN-K-subscales and age were small (RC [regression co-efficient] range: −0.03–0.01). PANSS-8-score changes were slightly negative (means between −0.77 and −0.43) suggesting decreased symptom severity. Patients with more severe negative symptoms considered their mental- and physical-functioning to be better throughout the study, indicated by significant correlations between these SWN-K-subscale scores and negative PANSS-scores (RC = 0.19, p = 0.0282; RC = 0.15, p = 0.0258). The associations between SWN-K-scores and positive PANSS-scores were small (RC: 0.01–0.14). The number of hospitalizations decreased during the study (9.6% between visit-1 and 2 vs. 7.5% visit-3 and −4).

Conclusions

Quality-of-life for all patients seemed to improve slightly, without any differences between treatment-groups.

Ziprasidone vs olanzapine in recent-onset schizophrenia and schizoaffective disorder: results of an 8-week double-blind randomized controlled trial

INTRODUCTION

Head-to-head comparisons of antipsychotics have predominantly included patients with chronic conditions. The aim of the present study was to compare the efficacy and tolerability of ziprasidone and olanzapine in patients with recent-onset schizophrenia.

METHODS

The study was an 8-week, double-blind, parallel-group, randomized, controlled multicenter trial (NCT00145444). Seventy-six patients with schizophreniform disorder, schizophrenia or schizoaffective disorder (diagnosis < 5 y), and a maximum lifetime antipsychotic treatment < 16 weeks participated in the study. Efficacy of ziprasidone (80-160 mg/d) and olanzapine 10-20 mg was measured using the Positive and Negative Syndrome Scale (PANSS), the Clinical Global Impression (CGI) Scale, the Calgary Depression Scale for Schizophrenia (CDSS), and the Heinrich Quality of Life Scale (HQLS); tolerability assessments included laboratory assessments, body weight, and electroencephalogram.

RESULTS

Olanzapine (n = 34) and ziprasidone (n = 39) showed equal efficacy as measured by the PANSS, CDSS, CGI, and HQLS. However, mean weight gain was significantly higher in the olanzapine group (6.8 vs 0.1 kg, P < .001). Ziprasidone was associated with decreasing levels of triglycerides, cholesterol, and transaminases, while these parameters increased in the olanzapine group (all P values < .05). There were no significant differences in fasting glucose and prolactin levels or in cardiac or sexual side effects. Patients on ziprasidone used biperiden for extrapyramidal side effects more frequently (P < .05).

DISCUSSION

The results of this study indicate that ziprasidone and olanzapine have comparable therapeutic efficacy but differ in their side effect profile. However, there is a risk of a type II error with this sample size. Clinically significant weight gain and laboratory abnormalities appear early after initiating treatment and are more prominent with olanzapine, while more patients on ziprasidone received anticholinergic drugs to treat extrapyramidal symptoms.

A systematic evaluation and comparison of the guidelines for screening and monitoring of cardiometabolic risk in people with schizophrenia

Metabolic and cardiovascular health problems have become a major focus for clinical care and research in schizophrenia. To evaluate the content and quality of screening guidelines for cardiovascular risk in schizophrenia we performed a systematic review and quality assessment of guidelines/recommendations published between 2000–2010, using the Appraisal of Guidelines for Research and Evaluation (AGREE). AGREE domain scores varied between 18 identified guidelines. Most guidelines scored best on the domains ‘Scope and Purpose’ and ‘Clarity of Presentation’. The domain ‘Rigour of Development’ was problematic in most guidelines, while the domains ‘Stakeholder Involvement’ and ‘Editorial Independence’ scored the lowest. The following parameters were recommended, in order of frequency: fasting glucose, BMI, fasting triglycerides, fasting cholesterol, waist, HDL/LDL, blood pressure, symptoms of diabetes. In terms of interventions most guidelines recommended advise on physical activity, advise on diet psycho-education of the patent, treatment of lipid abnormalities, treatment of diabetes, referral for advise and treatment, psycho-education of family and smoking cessation advice. Compared across all domains and content, 4 European guidelines could be recommended. Four of the evaluated guidelines are of good quality and should guide clinicians’ screening and monitoring practices. Future guideline development could be improved by increasing its rigour and assuring user and patient involvement. Although good guidelines are available research shows that the implementation in daily clinical practice remains poor.

Improvement in patient symptoms and functioning during long-term treatment with olanzapine long-acting injection (OLAI)

Introduction, objectives and aims

To evaluate the outcome of patients with schizophrenia during maintenance treatment with OLAI.

Methods

Data from three studies with OLAI were pooled and patients classified according to a cluster analysis [Lipkovich, Psychiatry Res, 2009] into five categories according severity of psychiatric symptoms (sx) and functional impairment (imp):A

Improvement was defined as a change from B or C to A, or from D or E to A, B or C. Changes between the categories in the 6 months were analyzed. Stepwise logistic regression modeling was done to determine factors associated with improvement.

Results

1182 patients were classified. Patients who remained in the studies at 6 months had lower baseline CGI-S (3.04 vs 3.28, p < 0.001), lower PANSS (61.38 vs 64.05, p = 0.012) and higher QLS (1.76 vs 1.39, p = 0.001). (Table 1) As patients in category A couldn’t improve and in category D&E couldn’t worsen, 261(39%) patients from categories B, C, D and E improved and only 55(10%) from categories A, B and C got worse during 6 months. Baseline factors associated with improvement were: baseline category (p < 0.001), CGI-S score (p = 0.022), and PANSS positive (p = 0.003)

Conclusions

Majority of patients with schizophrenia who stay on 6 months treatment with OLAI improve or maintain their symptoms and functioning level. The strongest factor associated with a higher chance of improvement was poor baseline category.

Impact of the “puente project” on the public disease expenditure of a patient with schizophrenia in belgium

Introduction

The “Puente project”, rises up the adherence rate with 38% (1). The aim of the study was to analyse the economic impact of this disease management prgramme of patients with a schizophrenic disorder.

Subjects and methods

“Puente” stands for a programme of LAAP with active outreaching of patients with schizophrenia. The details of the data collection and the subjects have been described elsewhere (1).The hospitalisation rate and the length of stay of the 117 case control pairs have been compared. The cost of hospitalisation in Belgium, recently adjusted by De Ridder et al. (2), have been used in order to map the differences.

Results

The number of hospital days totalised by 23 cases, was 2,152 days, in comparison to 6,371 realised by 42 controls,wich gives 18,6 hospital days per year for the cases and 38.9 days for the controls. Given an hospital cost per day in Belgium of 163.8 € per day, a crude saving of 3,328.5 € per case per year can be realised, correespondng with a net diminution of 2,428.5 € per patient year. Enrolling 1,675 cases per year, creates a saving of 4,066,533 € per year, an equivalent of 24,826 hospital days, or the cost of a psychiatric hospital of 85 beds occupied at 80%.

Conclusion

The Puente programme realised a substantial drop in public patient expenditure of 3,328.5 € per patient year. This is a very strong argument to implement, to finance and to support “Puente” like disease programmes in Belgium.

[Aripiprazole-induced parkinsonism in a 64-year-old female patient diagnosed with bipolar disorder]

A 64-year-old female patient, diagnosed with bipolar disorder, developed parkinsonism 18 days after aripiprazole had been initiated. Twenty-six days after the patient had stopped taking aripiprazole the parkinson syndrome disappeared completely. Aripiprazole is usually associated with a low incidence of extrapyramidal symptoms. So far, little is known about the pathophysiology of parkinsonism and the possible role of aripiprazole. The case-study includes some hypotheses and recommendations.

[Clinical assessment of the ultra high risk of developing a a psychotic disorder; review and critical reflection]

BACKGROUND

It may be possible to improve the prognosis of psychotic disorders by the timely recognition and treatment of the early stages of these disorders. Since the first psychotic episode is often preceded by a period of non-specific symptoms and functional decline, it could be worthwhile investigating whether this early phase can be detected.

AIM

To review existing diagnostic approaches and clinical instruments that are currently used for prospective identification of the prodromal phase.

METHOD

We searched the literature between 1995 and 2009 using the search terms 'prodromal' or 'ultra high risk' in combination with 'psychosis' or 'schizophrenia' and 'assessment'.

RESULTS

In international literature we found four diagnostic approaches to ultra high risk of psychosis: the attenuated positive symptom approach, the basic symptom approach, the clinical high risk approach and the strictly phenomenological approach. Within each of these approaches specific screening instruments had been developed and tested with regard to their ability to correctly predict a first psychotic episode.

CONCLUSION

None of the current diagnostic approaches produces a sufficiently reliable prediction of the risk of a first psychotic episode. Within the group of persons assumed, based on screening, to be at very high risk, only a small percentage will actually develop a psychotic disorder.

[Body-directed techniques on psychomotor therapy for people with schizophrenia: a review of the literature]

BACKGROUND

Patients with schizophrenia frequently undergo a disturbance of body experience. This can occur during an acute psychotic phase or during a period of remission.

AIM

To investigate the scientific evidence of the effects of introducing body-directed techniques into psychomotor therapy for patients with schizophrenia.

METHOD

PubMed, PEDro, CINAHL, psycINFO and SPORTDiscus were searched form 1 January, 2000, tot 1 January 2011, for reports of randomised controlled trials, controlled clinical trials and for studies wit a different design. The Tijdschrift voor Psychiatrie (the Dutch Journal of Psychiatry), the Tijdschrift voor Vaktherapie (The Journal for Special therapies) and Actuele Themata (Actual Themes) in psychomotor therapy were also screened. The quality of the methodology was assessed with the help of a checklist. Evidence for the efficacy of the interventions was summarised on the basis of a best-evidence synthesis.

RESULT

Eleven studies satisfied our inclusion and exclusion criteria. There was a strong evidence for the reduction of psychiatric symptoms after yoga and reduced feelings of anxiety and stress after progressive muscle relaxation. There is limited evidence for yoga in reducing feelings of anxiety and stress and for body-directed group techniques in reducing negative symptoms. Qualitative research reported that mindfulness – and massage-techniques were able to considerably reduce feelings of stress. There is no evidence for the beneficial effects of dancing techniques.

CONCLUSION

A body-directed approach can be effective an deserves to be included in the multidisciplinary treatment of schizophrenia.

Physical health management in psychiatric settings

Severe mental disorders have a chronic course associated with a high risk for co-morbid somatic illnesses and premature mortality, but despite this increased risk, general health care needs in this population are often neglected. Over recent years, several groups have developed screening and monitoring guidelines for metabolic and cardiovascular risk assessment in patients treated with antipsychotics. The psychiatrist needs to be aware of the potential metabolic side-effects of antipsychotic medication and to include them in the risk/benefit assessment when choosing a specific antipsychotic. He should also be responsible for the implementation of the necessary screening assessments and referral for treatment of any physical illness. Multidisciplinary assessment of psychiatric and medical conditions is needed. The somatic treatments offered to people with severe and enduring mental illness should be at par with general health care in the non-psychiatrically ill population. In our University Centre, a structured and elaborate screening and monitoring protocol was introduced in late 2003. This paper describes the practical aspects of this monitoring protocol and the results obtained 4 years after its implementation.

Effects on cognitive functioning after olanzapine-ziprasidone crossover in recent-onset schizophrenia

INTRODUCTION

To enhance functional outcome in schizophrenia improvement of cognitive symptoms is crucial.

EXPERIMENTAL PROCEDURES

Using a comprehensive test battery, this follow-up examines cognitive effects in patients with recent-onset schizophrenia after a change of medication following insufficient clinical response and intolerance.

RESULTS

After eight weeks cognitive outcomes had not improved in the patients having switched from olanzapine to ziprasidone (n=11; mean dose 136 mg) nor in those having switched from ziprasidone to olanzapine (n=10; mean 16 mg), while the symptoms of patients maintaining olanzapine (n=18; mean 10.9 mg) or ziprasidone (n=18; mean 88.9 mg) treatment had not improved further.

DISCUSSION

The findings suggest that also in early-stage schizophrenia the antipsychotics tested affect cognitive symptoms similarly.

Safety of sertindole versus risperidone in schizophrenia: principal results of the sertindole cohort prospective study (SCoP)

OBJECTIVE

To explore whether sertindole increases all-cause mortality or cardiac events requiring hospitalization, compared with risperidone.

METHOD

Multinational randomized, open-label, parallel-group study, with blinded classification of outcomes, in 9858 patients with schizophrenia.

RESULTS

After 14147 person-years, there was no effect of treatment on overall mortality (sertindole 64, risperidone 61 deaths, Hazard Ratio (HR) = 1.12 (90% CI: 0.83, 1.50)) or cardiac events requiring hospitalization [sertindole 10, risperidone 6, HR = 1.73 (95% CI: 0.63, 4.78)]: Of these, four were considered arrhythmia-related (three sertindole, one risperidone). Cardiac mortality was higher with sertindole (Independent Safety Committee (ISC): 31 vs. 12, HR=2.84 (95% CI: 1.45, 5.55), P = 0.0022; Investigators 17 vs. 8, HR=2.13 (95% CI: 0.91, 4.98), P = 0.081). There was no significant difference in completed suicide, but fewer sertindole recipients attempted suicide (ISC: 68 vs. 78, HR=0.93 (95% CI: 0.66, 1.29), P = 0.65; Investigators: 43 vs. 65, HR=0.67 (95% CI: 0.45, 0.99), P = 0.044).

CONCLUSION

Sertindole did not increase all-cause mortality, but cardiac mortality was higher and suicide attempts may be lower with sertindole.

[Validity of nonaffective functional psychosis of the DSM IV in a Congolese population. A transversal clinical trial]

BACKGROUND

The fourth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM IV) distinguishes schizophrenia, schizophreniform disorder and brief psychotic disorder only according to the duration of the illness. Thus, the validity of these nosological concepts sounds uncertain.

AIM

The aim of this study was to evaluate the validity of the DSM IV concepts schizophrenia, schizophreniform disorder and brief psychotic disorder.

POPULATION AND METHODS

Seventy schizophrenics, 68 patients with brief psychotic disorder and 50 with schizophreniform disorder, all Congolese people, selected from the 'Telema' Mental Health Centre and the 'Neuropsychopathological centre of the University of Kinshasa, from 5(th) August 2003 to 14(th) March 2005 were compared with respect to the following clinical parameters: family schizophrenia and brief psychoses history, precipitating psychosocial factors, mode of onset of the disease, clinical syndromes linked to psychoses and general functioning. Statistical analyses included analysis of variances 'one way' (Anova), post hoc Tukey's test, discriminant analysis, and analysis of covariances.

RESULTS

Brief psychotic disorder differed from schizophrenia and schizophreniform Disorder in respect with positive syndrome (F=8.76, df=2; 179, p=0.0002), cognitive syndrome (F=3.79, df=2; 179, P=0.024), syndrome of excitement (F=3.23, df=2; 179, P=0.042), general functioning (F=13.73, df=2; 179, P<0.0001), family history of schizophrenia (χ(2)=8.65; P=0.013), precipitating psychosocial factors (χ(2)=19.82; P<0.0001), and mode of onset of the disease (χ(2)=91.3; P<0.0001). Schizophreniform disorder differered from schizophrenia only by a more frequent acute onset and a better general functioning. Two nosological realities were thus distinguishable: brief psychotic disorder and schizophrenia-schizophreniform disorder complex. Surprisingly, negative syndrome could not distinguish brief psychotic disorder from schizophrenia and schizophreniform (F=2.80, df=2; 179, P=0.063). Data of the discriminant analysis based on scores on general functioning, positive, negative, depressive, cognitive and excitement syndromes was conclusive (F=6.41, df=2; 185, P<0.0001) and allowed correct classification rates of 75% for brief psychotic disorder, 48% for schizophreniform disorder, 54% for schizophrenia. Schizophreniform disorder was thus the less distinguishable group; this is in the line with longitudinal studies, which demonstrated the lowest diagnostic stability of this affection, compared with the two other diseases. Total error rate was 41%.

CONCLUSIONS

Brief psychotic disorder could constitute a distinct affection from schizophrenia and schizophreniform disorder, whereas schizophreniform disorder and schizophrenia could be the same affection; the first being an acute and "good functioning" form of the second. However, these viewpoints need to be confirmed by data on long-term course. The data of this study validate ultimately a binary model of the major nonaffective functional psychoses, like that of the tenth edition of the International classification of mental and behavioural disorders (ICD-10).

The prevention of deep venous thrombosis in physically restrained patients with schizophrenia

BACKGROUND

Physical restraint and seclusion are associated with several risks. Antipsychotic drug use increases this risk.

OBJECTIVE

To evaluate whether the risk of thromboembolism in physical restraint and seclusion of patients with psychosis, treated with antipsychotic medication, was considered by taking preventive measures.

METHOD

Anonymous data on all consecutively admitted patients with schizophrenia, treated with antipsychotic medication, between 2002 and 2009, were analysed. Diagnostic information and data about seclusion procedures and medication were collected. Preventive measures of thromboembolism in patients in physical restraint were assessed by reviewing case notes and the medication prescribed at the time of seclusion.

RESULTS

Seclusion of patients with psychosis is common. Out of 679 identified patients, 170 had been secluded (472 events). Physical restraint use was not a rare event (N seclusions with restraint use 296, 62.7%). Pharmacological preventive measures (use of heparine drugs) were taken frequently to prevent deep vein thrombosis (DVT) by physical restraint or isolation. Sixty-five (38.2%) out of 170 secluded patients, including a majority of patients who had been under physical restraint, had been administered anticoagulants at the time of seclusion. No cases of DVT occurred.

CONCLUSIONS

Preventive measures were routinely administered in clinical practice and were effective in the prevention of DVT. For a clinical setting, it is important to establish a clear and detailed management plan on seclusion and fixation taken into account in all possible risks of physical restraint.

Randomized comparison of ultra-brief bifrontal and unilateral electroconvulsive therapy for major depression: cognitive side-effects

OBJECTIVE

The cognitive side-effects of bifrontal (BF) and right unilateral (UL) ultra-brief pulse (0.3 ms) electroconvulsive therapy (ECT) were compared, in the treatment of patients with a depressive episode.

METHOD

Neuropsychological functioning in patients with a medication refractory depressive episode, that were treated with a course of BF ultra-brief ECT at 1.5 times seizure threshold (ST) or UL ultra-brief ECT at 6 times ST, by random assignment, was assessed before treatment, and 1 and 6 weeks after the treatment course, by a blinded rater.

RESULTS

Of the 64 patients that were included, 32 (50%) received BF ECT, and 32 (50%) received UL ECT, by random assignment. Neuropsychological testing 1 and 6 weeks after treatment was performed by 30 (93.75%) and 19 (59.37%) patients, respectively, in the BF-group and 29 (90.62%) and 20 (62.50%), respectively, in the UL-group. There was no deterioration in any of the neuropsychological measures. Patients rated their memory as clearly improved after treatment. There were no significant differences between the patients given BF ECT and those given UL ECT.

CONCLUSIONS

Ultrabrief pulse ECT, used either in combination with a UL electrode position and a stimulus of 6 times ST, or a BF electrode position with a stimulus of 1.5 times ST, are effective antidepressant techniques, that do not have a deleterious effect on cognitive function.

Treatment retention with risperidone long-acting injection: 24-month results from the Electronic Schizophrenia Treatment Adherence Registry (e-STAR) in six countries

OBJECTIVE

To assess treatment retention on risperidone long-acting injection (RLAI) and outcomes in schizophrenia patients for whom 24 months of follow-up data in the electronic Schizophrenia Treatment Adherence Registry (e-STAR) were available.

RESEARCH DESIGN AND METHODS

e-STAR is an ongoing, international, multicenter, prospective, observational registry assessing use of antipsychotics in patients with schizophrenia or schizoaffective disorder in a normal clinical practice setting. Parameters were assessed prior to and post-initiation of RLAI. Data presented are from six European countries that enrolled patients in e-STAR after they initiated treatment with RLAI.

MAIN OUTCOME MEASURES

Clinical and demographic information were collected at baseline and treatment-related data, including RLAI discontinuation, psychiatric hospitalization and medication utilization, were collected prospectively every 3 months. Data collection continued for 24 months, even for patients who discontinued RLAI therapy. Hospitalization and medication utilization were also collected retrospectively by chart review for the 12-month period prior to RLAI initiation.

RESULTS

A total of 1659 patients (mean age, 39.2; 18.3% inpatients) completed the study. Twenty-four months after initiating therapy (initial RLAI dose = 33.6 mg) 85% of patients (n = 1410) remained on RLAI (completers) while 15% discontinued therapy. The main reasons for discontinuation were insufficient response (28.5%), patient/family choice (26.1%), adverse events (9.6%) and unacceptable tolerability (6.0%). At baseline, compared to completers, discontinuers were younger (37.4 vs. 39.6 years, p = 0.01), had schizophrenia for a shorter time (10.2 vs. 11.9 years, p = 0.02), had lower Global Assessment of Functioning (GAF) scores (43.5 vs. 48.0, p = 0.0001), higher utilization of benzodiazepines (56.5 vs. 43.3%) and more initiated therapy as inpatients (30 vs. 16%). With RLAI therapy GAF scores improved significantly (p < 0.001) for both groups but the 24-month value for discontinuers was lower than that of completers (55.4 vs. 67.2). Compared to the pre-RLAI initiation period, at 12 months post-initiation completers had greater reductions than discontinuers in the percent of patients hospitalized (66.2% reduction vs. 29.2%) and in the length (68% reduction vs. 0%) and number (80.0 vs. 14.3%) of hospital stays, differences that remained at 24 months. The most common adverse events while patients were taking RLAI were nervous system disorders (6.8%), psychiatric disorders (5.6%), weight increase (3.2%), reproductive system and breast disorders (2.5%) and gastrointestinal disorders (2.1%).

CONCLUSIONS

These observational data confirm that RLAI is an effective treatment in schizophrenia and high levels of adherence to therapy offers an opportunity for effective long-term disease management and significant sustained decreases in hospitalization.

[The therapeutic value of physical exercise for people with schizophrenia]

BACKGROUND

Only about 25% of people with schizophrenia follow the public health recommendations for a minimum of 150 minutes per week of moderate physical exercise. In their leisure time people diagnosed with schizophrenia take considerably less exercise than their healthy counterparts.

AIM

To collect scientific evidence of movement-related interventions in patients with schizophrenia.

METHOD

PubMed, PEDro, CINAHL, PsychINFO and Sport Discus were searched for the period from 2003 up to April 2009 for reports of randomised controlled trials (RCTs) on the basis of the search terms ‘schizophrenia', ‘exercise' and ‘physical activity'. Relevant literature was also traced by means of the reference lists for selected articles.

RESULTS

Eight RCTs were selected. Physical exercise was reported to bring about significant improvements in cardiovascular and metabolic parameters and in psychiatric symptomatology. A physical exercise also has social advantages; it helps patients to cope with stress and improves their quality of life.

CONCLUSION

Physical exercise as part of psychomotor therapy should play an important role within the multidisciplinary treatment of schizophrenia. More research is needed into the effect of physical activity on cognitive functioning.

Clinical and resource-use outcomes of risperidone long-acting injection in recent and long-term diagnosed schizophrenia patients: results from a multinational electronic registry

BACKGROUND

Non-adherence to pharmacological treatment leading to frequent relapses and rehospitalizations is a major issue of concern among schizophrenia patients, especially those who are recently diagnosed. Risperidone long-acting injection (RLAI) has been shown to be efficacious, improve compliance, and increase long-term retention rate on therapy.

OBJECTIVE

To determine clinical outcomes and hospitalizations before and after the initiation of RLAI among schizophrenia patients with recent (< or =2 years) diagnosis relative to those who had long-term (> 2 years) diagnosis.

RESEARCH DESIGN AND METHODS

The electronic Schizophrenia Treatment Adherence Registry (e-STAR) is an observational study of patients with schizophrenia who start treatment with RLAI. Data were recorded at baseline, retrospectively for the 12 months prior to baseline, and prospectively every 3 months for 24 months. Data on patients with a defined length of diagnosis were pooled from eight countries.

MAIN OUTCOME MEASURES

Clinical Global Impression of Illness Severity (CGI-S), Global Assessment of Functioning (GAF) scores, and hospitalization data were key outcomes.

RESULTS

The magnitude of improvement in CGI-S scores was greater in the recent versus long-term diagnosis group [Delta -1.48 vs. Delta -0.95 (12 months); Delta -1.6 vs. Delta -1.09 (24 months)]. There were parallel improvements in GAF scores [Delta 19.4 vs. Delta 13.7 (12 months); Delta 22.3 vs. Delta 16.8 (24 months)]. The decline in the proportion of patients hospitalized from the retrospective to the prospective period was greater in the recent versus long-term diagnosis group (Delta -36.0 vs. Delta -19%, respectively) at 12 months. This was also true for the number of hospital stays (Delta -0.6 vs. Delta -0.3, respectively) and length of stay (days) (Delta -20.9 vs. Delta -6.9, respectively) at 12 months. Common adverse events in both groups included psychiatric, gastrointestinal, musculoskeletal and reproductive system and breast disorders.

CONCLUSIONS

Treatment with RLAI is associated with improved outcomes in recently diagnosed and chronic patients. However, the magnitude of improvement was higher in recently diagnosed patients.

Outcome and outcome trajectories of personality disordered patients during and after a psychoanalytic hospitalization-based treatment

This study aims to identify different outcome trajectories in a psychoanalytic hospitalization-based treatment in a sample of 70 patients with personality disorders using a naturalistic 12 month follow-up design. Trajectory analysis identified four groups of patients, i.e., patients showing (a) high initial symptom levels and considerable and consistent improvement late in treatment (High-Low group; HL), (b) medium initial symptom levels and a quick and sustained response (Medium-Low group; ML), (c) medium initial symptom levels but without substantial improvement (Medium-Medium group; MM), and (d) low initial symptom levels without substantial further improvement during and after treatment (Low-Low group; LL). Further, data suggested that these four trajectories were related in theoretically meaningful ways to pre-treatment variables, such as anaclitic and introjective personality styles and trauma. Results are discussed in the context of other studies showing the need for differential treatment approaches based on pretreatment characteristics.

Belgian Schizophrenia Outcome Survey - results of a 2-year naturalistic study in patients stabilised on monotherapy with olanzapine, risperidone or haloperidol

OBJECTIVES

This Schizophrenia Outcome Survey compared medical costs, psychopathology and adverse events in outpatients for 2 years following hospitalisation for an acute schizophrenic episode.

METHODS

Adults stabilised with haloperidol, olanzapine or risperidone entered this observational study <or=1 month after discharge and were assessed at baseline, 3, 6, 12, 18 and 24 months using Brief Psychiatric Rating Scale (BPRS), Clinical Global Impression (CGI), Global Assessment of Functioning and adverse events reporting.

RESULTS

Among 323 patients (haloperidol 32, olanzapine 149, risperidone 142), baseline characteristics were similar in the olanzapine and risperidone groups, except for more first episodes in the risperidone group (p=0.01). Haloperidol patients were more often single and institutionalised, less educated, had more residual schizophrenia, were longer hospitalised in the previous year, took more corrective and psychotropic drugs and had more extrapyramidal symptoms (EPS) and gynaecomastia (all significantly). Sixty-eight percent of patients completed a 2-year follow-up. In all groups, CGI and GAF improved during the first 3 months (both p<0.0001) while BPRS deteriorated in the first year (all within group changes p<0.05, between group changes NS) before it stabilised. There were no significant differences in hospitalisations and no change in social profile. At the last visit, 66% of haloperidol (p<0.01), 35% of olanzapine (NS) and 39% (NS) of risperidone patients had >or=1 EPS; 69% (p<0.013), 40 and 44%, respectively, had >or=1 sexual problem (NS). Mean weight gain was 0.4 (NS), 2.6 (p<0.05) and 2.6 kg (p<0.05), respectively.

CONCLUSIONS

In this naturalistic study, treatment allocation might have introduced a bias in the interpretation of efficiency results, but olanzapine and risperidone caused less EPS than haloperidol during 2 years of outpatient follow-up.

State anxiety and subjective well-being responses to acute bouts of aerobic exercise in patients with depressive and anxiety disorders

OBJECTIVE

Acute aerobic exercise is associated with a reduction in state anxiety and an improvement in subjective well-being. The objective of the present study was to contrast the effects of aerobic exercise at self-selected intensity versus prescribed intensity on state anxiety and subjective well-being (negative affect, positive well-being and fatigue) in patients with depressive and/or anxiety disorders. In addition, the potential impact of heart rate feedback was assessed.

METHODS

Nineteen men and 29 women performed three test conditions on a bicycle ergometer during 20 minutes: two tests at self-selected intensity; one with and another without heart rate feedback, and a third test at the prescribed intensity of 50% of the maximal heart rate reserve according to Karvonen. Tests were executed in random order. State anxiety and subjective well-being were evaluated using the state anxiety inventory and the subjective exercise experiences scale.

RESULTS

After 20 minutes cycling, patients showed significantly decreased state anxiety and negative affect in the three conditions. The magnitude of the reduction did not differ significantly between the three conditions. Only cycling at self-selected intensity enhanced positive well-being. Cycling at 50% of the maximal heart rate reserve decreased fatigue, whereas cycling at self-selected intensity increased fatigue.

CONCLUSIONS

The response in state anxiety and negative affect was unaffected by the type of aerobic exercise. Self-selected intensity influenced exercise-induced changes in positive well-being and fatigue in a positive and negative way, respectively.

Delineating psychomotor slowing from reduced processing speed in schizophrenia

INTRODUCTION

Psychomotor slowing is an intrinsic feature of schizophrenia that is poorly delineated from generally reduced processing speed. Although the Symbol Digit Substitution Test (SDST) is widely used to assess psychomotor speed, the task also taps several higher-order cognitive processes. Recording motor performance on copying tasks using a digitising tablet allows a more precise measurement of psychomotor speed.

METHODS

A group of 75 schizophrenic inpatients were compared to 26 healthy controls in their performance on the SDST and two copying tasks.

RESULTS

Factor analyses showed that the copying tasks were found to capture both a cognitively loaded factor and the motor component of psychomotor slowing better, which latter aspect is not properly assessed by the SDST.

CONCLUSIONS

In schizophrenia psychomotor slowing seems to exist alongside reduced processing speed.

Evidence that the COMT(Val158Met) polymorphism moderates sensitivity to stress in psychosis: an experience-sampling study

Gene-environment interactions involving the catechol-O-methyltransferase Val(158)Met polymorphism (COMT(Val158Met)) have been implicated in the causation of psychosis. Evidence from general population studies suggests that Met/Met subjects are sensitive to stress, a trait associated with psychosis. We hypothesized that the Met allele would moderate the effects of stress on negative affect (NA) in controls, and on NA and psychosis in patients with a psychotic disorder. Thirty-one patients with a psychotic disorder and comorbid cannabis misuse and 25 healthy cannabis users were studied with the experience sampling method (ESM), a structured diary technique assessing current context and emotional and psychotic experiences in daily life. A significant interaction between COMT(Val158Met) genotype and ESM stress in the model of NA was found for patients (interaction chi(2) = 7.4, P = 0.02), but not for controls (interaction chi(2) = 3.8, P = 0.15). In the model of ESM psychosis, a significant interaction between COMT(Val158Met) genotype and ESM stress was also apparent (interaction chi(2) = 11.6, P < 0.01), with Met/Met patients showing the largest increase in psychotic experiences as well as NA in reaction to ESM stress. The findings suggest that the COMT(Val158Met) polymorphism moderates affective and psychotic responses to stress in patients with psychosis, providing evidence for gene-environment interaction mechanisms in the formation of psychotic symptoms.

[Clozapine-induced agranulocytosis and Sweet's syndrome in a 74-year-old female patient. A case study]

A 74-year-old psychotic female patient who was treated with clozapine developed Sweet's syndrome followed by agranulocytosis from which she later died. A link between these two conditions seems unlikely. Sweet's syndrome is characterised by an acute onset of fever, leukocytosis and erythematous plaques with dense neutrophilic infiltrates. Frequent counting of the numbers of neutrophiles is advisable when skin disorders appear during treatment with clozapine.