Placebo effects in adult and adolescent patients with schizophrenia: combined analysis of nine RCTs

OBJECTIVE

To examine characteristics of placebo responders and seek optimal criteria of early improvement with placebo for predicting subsequent placebo response in patients with schizophrenia.

METHOD

Data of 672 patients with schizophrenia randomized to placebo in nine double-blind antipsychotic trials were analyzed. Multiple logistic regression analyses were conducted to examine associations between placebo response at week 6 (i.e., a ≥ 25% reduction in the Positive and Negative Syndrome Scale [PANSS] score) and gender, age, study locations, baseline PANSS total or Marder 5-Factor scores, and per cent PANSS score reduction at week 1. Predictive power of improvement at week 1 for subsequent response was investigated; sensitivity and specificity of incremental 5% cutoff points between 5% and 25% reduction in the PANSS total score at week 1 were calculated.

RESULTS

Per cent PANSS total score reduction at week 1 and lower PANSS Marder disorganized thought scores at baseline were significantly associated with subsequent placebo response. A 10% reduction in a per-protocol analysis or a 15% reduction in last-observation-carried-forward analysis in the PANSS total score at week 1 showed the highest predictive power.

CONCLUSION

These findings are informative to identify potential placebo responders at the earliest opportunity for optimal trial design for schizophrenia.

Religiosity and psychological resilience in patients with schizophrenia and bipolar disorder: an international cross-sectional study

OBJECTIVE

The impact of religious/spiritual activities on clinical outcomes in patients with serious mental illnesses remains controversial, which was addressed in this international cross-sectional study.

METHOD

Three-hundred sixty-nine subjects were recruited from Austria (n = 189) and Japan (n = 180), consisting of 112 outpatients with paranoid schizophrenia, 120 with bipolar I disorder (DSM-IV), and 137 healthy controls. Religiosity was assessed in terms of attendance and importance of religious/spiritual activities, while resilience was assessed using the 25-item Resilience Scale. General linear models were used to test whether higher religiosity will be associated with higher resilience, higher social functioning, and lower psychopathology. The association between levels of spiritual well-being and resilience was also examined.

RESULTS

Attendance of religious services (F_[4,365] = 0.827, P = 0.509) and importance of religion/spirituality (F_[3,365] = 1.513, P = 0.211) did not show significant associations with resilience. Regarding clinical measures, a modest association between higher importance of religion/spirituality and residual manic symptoms was observed in bipolar patients (F_[3,118] = 3.120, P = 0.029). In contrast to the findings regarding religiosity, spiritual well-being showed a strong positive correlation with resilience (r = 0.584, P < 0.001).

CONCLUSION

The protective effect of religiosity in terms of resilience, social functioning, and psychopathology was not evident in our sample. Spiritual well-being appears more relevant to resilience than religiosity.

Emotional intelligence and non-social cognition in schizophrenia and bipolar I disorder

BACKGROUND

The different patterns of Emotional Intelligence (EI) deficits in schizophrenia and bipolar I disorder are are not yet well understood. This study compares EI levels among these groups and highlights the potential impact of non-social cognition on EI.

METHOD

Fifty-eight schizophrenia and 60 bipolar outpatients were investigated using the Mayer-Salovey-Caruso Emotional Intelligence Test (MSCEIT) and the Brief Assessment of Cognition in Schizophrenia (BACS). Analyses of covariance were performed with adjustment for the BACS composite score.

RESULTS

Compared to bipolar subjects, schizophrenia patients showed significantly lower levels in both EI and non-social cognition. After adjustment for the BACS composite score, the difference in EI was lost. The mediation analysis revealed that differences between schizophrenia and bipolar patients in strategic EI are almost fully attributable to the mediating effect of non-social cognition.

CONCLUSIONS

Our findings suggest that in both schizophrenia and bipolar patients EI is strongly influenced by non-social cognitive functioning. This has to be taken into account when interpreting MSCEIT data in comparative studies in serious mental illness and emphasizes the importance of cognitive remediation.

Quality of life in stabilized patients with schizophrenia is mainly associated with resilience and self-esteem

OBJECTIVE

Improving quality of life (QoL) is an important objective in the treatment of schizophrenia. The aim of the current study was to examine to what extent resilience, self-esteem, hopelessness, and psychopathology are correlated with QoL.

METHOD

We recruited 52 out-patients diagnosed with schizophrenia according to DSM-IV criteria and 77 healthy control subjects from the general community. In patients, psychopathology was quantified by the Positive and Negative Syndrome Scale. The following scales were used in both patients and control subjects: the Berliner Lebensqualitätsprofil, the Resilience Scale, the Rosenberg Self-Esteem Scale, and the Beck Hopelessness Scale to assess QoL, resilience, self-esteem, and hopelessness respectively.

RESULTS

Patients with schizophrenia presented with significantly less QoL, resilience, self-esteem, and hope compared to healthy control subjects. In patients, QoL correlated moderately with resilience, self-esteem, and hopelessness and weakly with symptoms. With respect to the latter, particularly depression and positive symptoms were negatively correlated with QoL.

CONCLUSION

Our results highlight the complex nature of QoL in patients suffering from schizophrenia. They underscore that significant efforts are necessary to enhance resilience and self-esteem and to diminish hopelessness as well as affective and positive symptoms in patients with schizophrenia.

Hostility in schizophrenia: An integrated analysis of the combined Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) and the European First Episode Schizophrenia Trial (EUFEST) studies

Phase 1 of the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study enrolled a sample of 1493 chronic schizophrenia patients. The European First Episode Schizophrenia Trial (EUFEST) enrolled 498 patients. We have combined these two samples to study the effects of hostility on study discontinuation as well as to examine correlates and predictors of hostility. Individual data from 1154 patients with complete data were used for analyses. Survival analysis demonstrated that higher hostility was associated with earlier all-cause treatment discontinuation. Furthermore, regression analysis indicated that increased hostility was associated with more severe positive symptoms, lower adherence to pharmacological treatment, younger age, impaired insight, and more drug or alcohol consumption. The clinical implications of the results point to the importance of establishing therapeutic alliance while managing patient's symptoms of hostility with antipsychotics such as olanzapine combined with psychosocial interventions to improve insight and reduce substance use.

Differential effects of antipsychotic drugs on insight in first episode schizophrenia: Data from the European First-Episode Schizophrenia Trial (EUFEST)

Although antipsychotics are widely prescribed, their effect of on improving poor illness insight in schizophrenia has seldom been investigated and therefore remains uncertain. This paper examines the effects of low dose haloperidol, amisulpride, olanzapine, quetiapine, and ziprasidone on insight in first-episode schizophrenia, schizoaffective disorder, or schizophreniform disorder. The effects of five antipsychotic drugs in first episode psychosis on insight were compared in a large scale open randomized controlled trial conducted in 14 European countries: the European First-Episode Schizophrenia Trial (EUFEST). Patients with at least minimal impairments in insight were included in the present study (n=455). Insight was assessed with item G12 of the Positive and Negative Syndrome Scale (PANSS), administered at baseline and at 1, 3, 6, 9, and 12 months after randomization. The use of antipsychotics was associated with clear improvements in insight over and above improvements in other symptoms. This effect was most pronounced in the first three months of treatment, with quetiapine being significantly less effective than other drugs. Effects of spontaneous improvement cannot be ruled out due to the lack of a placebo control group, although such a large spontaneous improvement of insight would seem unlikely.

Hyperprolactinemia in antipsychotic-naive patients with first-episode psychosis

BACKGROUND

Hyperprolactinemia is frequent in patients with schizophrenic psychoses. It is usually regarded as an adverse effect of antipsychotics but has recently also been shown in patients without antipsychotic medication. Our objective was to test whether hyperprolactinemia occurs in antipsychotic-naive first-episode patients (FEPs).

METHOD

In the framework of the European First Episode Schizophrenia Trial (EUFEST), 249 out of 498 FEPs were eligible for this study, of whom 74 were antipsychotic naive. All patients were investigated regarding their serum prolactin levels with immunoassays standardized against the 3rd International Reference Standard 84/500.

RESULTS

Twenty-nine (39%) of the 74 antipsychotic-naive patients showed hyperprolactinemia not explained by any other reason, 11 (50%) of 22 women and 18 (35%) of 52 men.

CONCLUSIONS

Hyperprolactinemia may be present in patients with schizophrenic psychoses independent of antipsychotic medication. It might be stress induced. As enhanced prolactin can increase dopamine release through a feedback mechanism, this could contribute to explaining how stress can trigger the outbreak of psychosis.

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.

Pharmacological treatment of schizophrenia: a critical review of the pharmacology and clinical effects of current and future therapeutic agents

Since the introduction of chlorpromazine and throughout the development of the new-generation antipsychotic drugs (APDs) beginning with clozapine, the D(2) receptor has been the target for the development of APDs. Pharmacologic actions to reduce neurotransmission through the D(2) receptor have been the only proven therapeutic mechanism for psychoses. A number of novel non-D(2) mechanisms of action of APDs have been explored over the past 40 years but none has definitively been proven effective. At the same time, the effectiveness of treatments and range of outcomes for patients are far from satisfactory. The relative success of antipsychotics in treating positive symptoms is limited by the fact that a substantial number of patients are refractory to current medications and by their lack of efficacy for negative and cognitive symptoms, which often determine the level of functional impairment. In addition, while the newer antipsychotics produce fewer motor side effects, safety and tolerability concerns about weight gain and endocrinopathies have emerged. Consequently, there is an urgent need for more effective and better-tolerated antipsychotic agents, and to identify new molecular targets and develop mechanistically novel compounds that can address the various symptom dimensions of schizophrenia. In recent years, a variety of new experimental pharmacological approaches have emerged, including compounds acting on targets other than the dopamine D(2) receptor. However, there is still an ongoing debate as to whether drugs selective for singe molecular targets (that is, 'magic bullets') or drugs selectively non-selective for several molecular targets (that is, 'magic shotguns', 'multifunctional drugs' or 'intramolecular polypharmacy') will lead to more effective new medications for schizophrenia. In this context, current and future drug development strategies can be seen to fall into three categories: (1) refinement of precedented mechanisms of action to provide drugs of comparable or superior efficacy and side-effect profiles to existing APDs; (2) development of novel (and presumably non-D(2)) mechanism APDs; (3) development of compounds to be used as adjuncts to APDs to augment efficacy by targeting specific symptom dimensions of schizophrenia and particularly those not responsive to traditional APD treatment. In addition, efforts are being made to determine if the products of susceptibility genes in schizophrenia, identified by genetic linkage and association studies, may be viable targets for drug development. Finally, a focus on early detection and early intervention aimed at halting or reversing progressive pathophysiological processes in schizophrenia has gained great influence. This has encouraged future drug development and therapeutic strategies that are neuroprotective. This article provides an update and critical review of the pharmacology and clinical profiles of current APDs and drugs acting on novel targets with potential to be therapeutic agents in the future.

Unmet needs in patients with first-episode schizophrenia: a longitudinal perspective

BACKGROUND

This study aimed to identify the course of unmet needs by patients with a first episode of schizophrenia and to determine associated variables.

METHOD

We investigated baseline assessments in the European First Episode Schizophrenia Trial (EUFEST) and also follow-up interviews at 6 and 12 months. Latent class growth analysis was used to identify patient groups based on individual differences in the development of unmet needs. Multinomial logistic regression determined the predictors of group membership.

RESULTS

Four classes were identified. Three differed in their baseline levels of unmet needs whereas the fourth had a marked decrease in such needs. Main predictors of class membership were prognosis and depression at baseline, and the quality of life and psychosocial intervention at follow-up. Depression at follow-up did not vary among classes.

CONCLUSIONS

We identified subtypes of patients with different courses of unmet needs. Prognosis of clinical improvement was a better predictor for the decline in unmet needs than was psychopathology. Needs concerning social relationships were particularly persistent in patients who remained high in their unmet needs and who lacked additional psychosocial treatment.

Symptomatic remission and neurocognitive functioning in patients with schizophrenia

BACKGROUND

A cross-sectional study was conducted in participants with schizophrenia to explore a potential association between the patients' remission status and neurocognitive functioning and to examine whether these factors have an impact on functional outcome.

METHOD

Psychopathological symptoms were rated by means of the Positive and Negative Syndrome Scale with symptom remission being assessed by applying the severity component of the recently proposed remission criteria. Tests for the cognitive battery were selected to cover domains known to be impaired in patients with schizophrenia. Next to pre-morbid intelligence, attention performance, executive functioning, verbal fluency, verbal learning and memory, working memory and visual memory were assessed. The joint effect of remission status and neurocognitive functioning on treatment outcome was investigated by logistic regression analysis.

RESULTS

Out of 140 patients included in the study, 62 were symptomatically remitted. Mean age, education and sex distribution were comparable in remitted and non-remitted patients. Remitted patients showed significantly higher values on tests of verbal fluency, alertness and optical vigilance. Both symptomatic remission as well as performance on tests of working memory and verbal memory had a significant effect on the patients' employment status.

CONCLUSIONS

In the present study neuropsychological measures of frontal lobe functioning were associated with symptomatic remission from schizophrenia. In addition, both symptomatic remission and performance on tests of working memory and verbal memory had a significant effect on the patients' employment status. Longitudinal follow-up data are needed to determine how the associations of these determinants of functional outcome interact and change over time.

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.

Neutropenia induced by second generation antipsychotics: a prospective investigation

BACKGROUND

Clozapine is known to induce neutropenia as well as agranulocytosis. Some cases of olanzapine- and risperidone-induced neutropenia and agranulocytosis have also been reported. We prospectively investigated schizophrenia patients treated with second generation antipsychotics with respect to alterations of white blood cell counts.

METHODS

In an analysis of our drug monitoring program, we studied white blood cell counts in 104 patients receiving different second generation antipsychotics other than clozapine for at least six months and compared them with those of 28 patients receiving clozapine.

RESULTS

We found neutropenia (neutrophils <2 000/microL) in the mixed group in 17.6% and in 11.8% of patients treated with clozapine during the first 6 months. There was no statistically significant difference between those groups with respect to the risk to develop neutropenia during the investigation period. There was no case of agranulocytosis. Neutropenia was transient in all patients. Eosinophilia occurred in some patients that developed neutropenia later on but had no significant predictive value.

Subjective response and attitudes toward antipsychotic drug therapy during the initial treatment period: a prospective follow-up study in patients with schizophrenia

OBJECTIVE

In this prospective study, patients with schizophrenia were followed up for 3 months to investigate the impact of sociodemographic factors, psychopathology, change in psychopathology and side effects on subjective response and attitudes toward antipsychotics during the initial treatment period.

METHOD

We investigated 42 patients starting treatment with a new-generation antipsychotic. Next to the registration of demographic data various rating scales were used: the Positive and Negative Syndrome Scale (PANSS), the Udvalg for Kliniske Undersogelser (UKU) Side Effect Rating Scale and the Drug Attitude Inventory (DAI).

RESULTS

Two patients experienced a first episode of the illness and were neuroleptic naïve, and 40 had suffered from at least one prior episode of schizophrenia. Longer duration of illness as well as the amelioration of psychopathological symptoms had a positive impact on subjective response to treatment. Correlations between antipsychotic-induced side effects and drug attitude tended to be weak.

CONCLUSION

Our results emphasize the necessity of improving psychopathological symptoms during the initial treatment period to improve attitudes toward and compliance with treatment.

Metabolic side effects of antipsychotic medication

The use of second-generation antipsychotics (SGAs) is associated with metabolic side effects including weight gain, diabetes mellitus and an atherogenic lipid profile. These adverse effects are not only the risk factors for cardiovascular disease, insulin resistance and diabetes mellitus leading to increased morbidity and mortality but may also impair the patient's adherence to treatment. SGAs in particular are associated with significant weight gain with clozapine and olanzapine carrying the highest risk, whereas newer agents, such as risperidone and aripiprazole, are considered to be less prone to cause weight gain. Consequently, a consensus development conference convened issuing recommendations on patient monitoring when treated with SGAs. The metabolic effects of antipsychotic drugs should be of concern when planning a patient's treatment strategy. Baseline screening and regular follow-up monitoring whose intervals should depend on the individual predisposition are advised. Possible therapeutical strategies for the management of drug-induced obesity include therapeutic approaches, such as life style change and pharmaceutical intervention. Drugs with a weight reducing effect become more important because of the lack of compliance with behavioural intervention. Topiramate, histamine-antagonists, dopaminergic- and serotoninergic agents have shown positive results in the management of psychotropic medication induced weight gain. However, further trials are required to support a specific therapeutical approach as well as studies to investigate the underlying mechanisms for future drug development.

Patterns of social distance towards people suffering from schizophrenia in Austria: a comparison between the general public, relatives and mental health staff

OBJECTIVE

The aims of this study were to identify the different aspects of the attitudes towards people suffering from schizophrenia and to find factors influencing these attitudes -- especially the willingness to contact people suffering from schizophrenia -- as well as to obtain information on how to reduce stigma and discrimination.

METHOD

We conducted a study to investigate these attitudes in Austria. A representative sample of the general public, different professional groups working in the field and relatives of mentally ill people were interviewed. The public, relatives and people working in the mental health field were asked a number of the same questions, to allow for comparisons between groups.

RESULTS

We found great differences in key dimensions of the attitude towards people suffering from schizophrenia between groups: these included different causal attributions to schizophrenia, different attitudes concerning the perceived success of the treatment of schizophrenia, different fears concerning perceived dangerousness and a different willingness to interact voluntarily with schizophrenia patients.

CONCLUSION

The factors influencing the distance towards people suffering from schizophrenia differ between groups. Our findings should help to optimize campaigns fighting against stigma and discrimination.

Outcomes in Schizophrenia Outpatients Treated with Amisulpride or Olanzapine

INTRODUCTION

We compared stable patients with schizophrenia who were treated with either amisulpride or olanzapine in terms of symptomatic outcome, neurocognitive functioning, functionality, and subjective outcome.

METHODS

Sixty outpatients with chronic schizophrenia who had been treated with either amisulpride or olanzapine for at least six months were investigated.

RESULTS

The scores of positive, negative, and cognitive symptoms did not differ between the two groups, but patients treated with olanzapine had significantly lower scores on the excitement and depression/anxiety components of the PANSS. With regard to cognitive variables, patients treated with amisulpride showed significantly lower values regarding verbal fluency and significantly better verbal memory than patients treated with olanzapine. Both treatment groups were comparable with respect to functional and subjective outcome variables.

DISCUSSION

These observations add to the evidence that continuous treatment with different second-generation antipsychotics with relatively few side effects leads to comparable outcomes in patients with schizophrenia.

Pharmakotherapie der Schizophrenie

The management of schizophrenia patients remains one of the great challenges in psychiatry. Despite the undisputed effectiveness of antipsychotic drugs, patients and their physicians still face considerable difficulties mainly related to incomplete or lacking treatment response and the inability to predict the individual efficacy and tolerability. In this manuscript we review the key elements of pharmacological treatment of this disorder, encompassing acute and long-term management as well as specific management problems ranging from acutely violent patients to treatment-resistant subjects. Along with general treatment principles, the document provides specific information regarding efficacy and safety features of antipsychotics. Many of the currently available treatment recommendations/guidelines are based on the evidence reviewed here. This review is meant to serve as a guide for clinicians involved in managing schizophrenia, whether in a psychiatric hospital setting or as family physicians in private practice.

[Pathophysiology of schizophrenia and its impact on pharmacotherapy]

Schizophrenia is a severe psychiatric illness with a lifetime morbidity risk of around 1 %. Symptoms include hallucinations, delusions, poverty of thought and emotion and social withdrawal and cognitive deficits. Although newer antipsychotics affecting multiple neurotransmitter receptors facilitate therapy, many patients still do not achieve full response. Despite intensive study, the molecular etiology of schizophrenia remains enigmatic in many ways. The dopamine hypothesis of schizophrenia still plays an important role, although pharmacological studies, brain imaging analyses and genetic research indicate additional dysfunctions of glutamate, GABA and serotonin transmission. This article reviews the pathophysiological background of the disorder, its implications for pharmacological treatment and possible directions for future research.

Olanzapine impairs glycogen synthesis and insulin signaling in L6 skeletal muscle cells

Second-generation antipsychotic agents (SGAs) are increasingly replacing first-generation antipsychotic agents due to their superior activity against the negative symptoms of schizophrenia, decreased extrapyramidal symptoms and better tolerability. However, some SGAs are associated with adverse metabolic effects as significant weight gain, lipid disorders and diabetes mellitus. The pathogenesis of SGA-induced disturbances of glucose homeostasis is unclear. In vivo studies suggest a direct influence of SGAs on peripheral insulin resistance. To this end, we analyzed whether olanzapine might alter glycogen synthesis and the insulin-signaling cascade in L6 myotubes. Glycogen content was diminished in a dose- and time-dependent manner. Within the insulin-signaling cascade IRS-1 tyrosine phosphorylation was induced several fold by insulin and was diminished by preincubation with olanzapine. IRS-1-associated PI3K activity was stimulated by insulin three-fold in L6 myotubes. Olanzapine inhibited insulin-stimulated IRS-1-associated PI3K activity in a dose-dependent manner. Protein mass of AKT, GSK-3 and GS was unaltered, whereas phosphorylation of AKT and GSK-3 was diminished, and pGS was increased. Finally, we compared olanzapine with amisulpride, an SGA clinically not associated with the induction of diabetes mellitus. Glycogen content was diminished in olanzapine-preincubated L6 cells, whereas this effect was not observed under the amisulpride conditions. We conclude that olanzapine impairs glycogen synthesis via inhibition of the classical insulin-signaling cascade and that this inhibitory effect may lead to the induction of insulin resistance in olanzapine-treated patients.

Brain activation pattern during a verbal fluency test in healthy male and female volunteers: a functional magnetic resonance imaging study

Sex differences in executive speech tasks, favoring women, have been noted in behavioral studies and functional imaging studies. In the present study ten female and ten male volunteers underwent functional magnetic resonance imaging in a conventional block design. All subjects were selected on the basis of high performance on the verbal fluency task. Regions of activation were detected after performance of a covert lexical verbal fluency task inside the scanner. Men and women who did not differ significantly in verbal fluency task performance showed a very similar pattern of brain activation. Our data argue against genuine between-sex differences in cerebral activation patterns during lexical verbal fluency activities when confounding factors like performance differences are excluded.

New developments in the pharmacotherapy of schizophrenia

This review summarizes current key research strategies and the most prominently pursued new potential treatments for schizophrenia. First, new routes of administration for second generation antipsychotics are presented. These include rapidly dissolving tablets, drops and sirups as well as new intramuscular formulations. Newly available short acting and long acting (depot) antipsychotics complement oral antipsychotics so that the full spectrum of routes of administration is now available for second generation antipsychotics. Next to antipsychotic polypharmacy, in which two or more antipsychotics are combined, pharmacological add-on treatments, mainly with benzodiazepines, antidepressants and mood stabilizers enjoy increasing popularity. Most of this practice is driven by personal preferences, clinical experience and marketing rather than evidence based medicine. New pharmacological mechanisms currently utilized in advanced states of development include partial dopamine D2-receptor agonism, supplementation with glutamatergic agents, estrogen and omega-3-fatty acids. While the concept of partial D1-agonism has already led to the successful launch of a new antipsychotic, aripiprazole, the other attempts to improve therapeutic response in schizophrenia patients have so far provided equivocal results. It is argued that they may be helpful for certain subgroups or specific symptoms of schizophrenia patients. In conclusion, many exciting new pharmacological leads are currently pursued and this will very likely augment the options for treating patients with schizophrenia.

Sex differences in brain activation pattern during a visuospatial cognitive task: a functional magnetic resonance imaging study in healthy volunteers

Sex differences in mental rotation tasks, favoring men, have been noted in behavioral studies and functional imaging studies. In the present study ten female and ten male volunteers underwent functional magnetic resonance imaging in a conventional block design. Regions of activation were detected after performance of a mental rotation task inside the scanner. In contrast to previous studies, confounding factors such as performance differences between genders or high error rates were excluded. Men showed significantly stronger parietal activation, while women showed significantly greater right frontal activation. Our results point to gender specific differences in the neuropsychological processes involved in mental rotation tasks.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

The impact of hemoglobin levels on fatigue and quality of life in cancer patients

BACKGROUND

Although fatigue is a commonly reported symptom in cancer patients its etiology is still poorly understood. The objective of the present study was to investigate the relationship between hemoglobin (Hb) levels and the subjective experience of fatigue and quality of life in cancer patients with mild or no anemia undergoing chemotherapy.

PATIENTS AND METHODS

Sixty-eight cancer patients (25 colorectal, 26 lung and 17 ovarian cancer) presently undergoing chemotherapy participated in the study. Fatigue was measured with the Multidimesional Fatigue Inventory (MFI-20), quality of life with The European Organization for Research and Treatment of Cancer QLQ-C30. In order to provide normative data for fatigue levels, the MFI-20 was also completed by a sex- and age-matched sample of 120 healthy controls.

RESULTS

Compared with healthy subjects, cancer patients experienced significantly higher levels of subjective fatigue. Correlations between Hb values and subscales of the MFI-20 were moderate with a tendency to increase during chemotherapy. Hb values alone, however, do not fully account for the observed fatigue. Other symptoms, especially pain, dyspnea and sleep disturbances, also showed an association with perceived fatigue.

CONCLUSIONS

Despite significant correlations, these results indicate that Hb values only partially explain subjectively experienced fatigue and quality of life in cancer patients. It is suggested therefore that the treatment of fatigue must be multidimensional and involve all areas which contribute to the syndrome.

Quality of life measurement in oncology--a matter of the assessment instrument?

Two widely used quality of life questionnaires, European Organization for Research and Treatment of Cancer Core (EORTC QLQ-C30) & Functional Assessment of Cancer Therapy-General (FACT-G), were examined for their comparability using four different groups of cancer patients. During a follow-up investigation, 418 cancer patients (Hodgkin's disease, breast cancer, bone marrow transplantation (BMT), chronic lymphatic leukaemia (CLL)) completed both the EORTC QLC-C30 and the FACT-G during the same session. For an illustration of the differences between the two Quality of Life (QoL) instruments, pairs of diagnostic groups were formed and their QoL scores using the EORTC QLQ-C30 and FACT-G compared. The corresponding subscales of the EORTC-QLC-C30 and the FACT-G show only low to moderate intercorrelations across all four groups of cancer patients studied. In particular, a comparison of pairs, namely Hodgkin's disease versus breast cancer patients and BMT versus CLL patients, highlights substantial differences in the corresponding subscales of the EORTC QLQ-C30 and the FACT-G. The results of the QoL investigations should not be interpreted independently of the instrument used and an interpretation of results must be based on the contents of items of the respective questionnaires.

Association of olanzapine-induced weight gain with an increase in body fat

OBJECTIVE

The goal of this study was to explore the pathophysiology of weight gain during treatment with olanzapine for schizophrenia.

METHOD

The authors used a prospective, controlled, open study comparing body weight, body mass index, and related biological measures in mentally and physically healthy volunteers and olanzapine-treated patients with schizophrenia. Weight, eating behavior, leptin serum levels, body mass index, and body composition were assessed over an 8-week observation period.

RESULTS

A significant increase in body weight, leptin serum levels, and percentage of body fat was seen in patients treated with olanzapine, but the drug-free comparison group did not show any significant changes. The weight gain during antipsychotic treatment with olanzapine was mainly attributable to an increase in body fat; patients' lean body mass did not change.

CONCLUSIONS

In addition to the original finding that an increase in body fat is mainly responsible for olanzapine-induced weight gain, these findings confirm results obtained in other studies showing increases in body weight and serum leptin levels during treatment with second-generation antipsychotics.

Differential regulation of chromogranin A, chromogranin B and secretogranin II in rat brain by phencyclidine treatment

Chromogranin A, chromogranin B and secretogranin II belong to the chromogranin family which consists of large protein molecules that are found in large dense core vesicles. Chromogranins are endoproteolytically processed to smaller peptides. This study was designed to elucidate the regulation of chromgranin expression by acute and subchronic phencyclidine administration. The behavioral syndrome produced by phencyclidine represents a pharmacological model for some aspects of schizophrenia [Jentsch and Roth (1999) Neuropsychopharmacology 20, 201-225]. Tissue concentrations of chromogranins were measured with specific radioimmunoassays. Alterations in secretogranin II gene expression were investigated by in situ hybridization. A single dose of phencyclidine (10mg/kg) led to a transient decrease in secretoneurin tissue levels in the prefrontal cortex after 4h followed by an increase in secretoneurin tissue levels after 12h. Repeated phencyclidine treatment (10mg/kg/day) for five days resulted in elevated secretoneurin levels in cortical areas whereas chromogranin A and chromogranin B tissue levels were unchanged. After the same treatment, a significant increase in the number of secretoneurin containing neurons was found in cortical layers II-III, and V-VI as revealed by immunocytochemistry. The increases in secretoneurin levels were paralleled by an increased number of secretogranin II messenger RNA containing neurons as well as by an increased expression of secretogranin II by individual neurons. The present study shows that secretoneurin II tissue concentration and secretogranin II messenger RNA expression is distinctly altered after acute and subchronic phencyclidine application. From these results we suggest that phencyclidine may induce synaptic alterations in specific brain areas and may contribute to a better understanding of synaptic dysfunction which may also occur in schizophrenia.

Use of alternative/complementary therapy in breast cancer patients--a psychological perspective

The objectives of this study were to assess the additional use of alternative (complementary) therapies in patients with breast cancer who were receiving conventional treatment and to compare patients using alternative therapies with patients receiving only conventional treatment with special reference to psychological adaptation, causal attribution and quality of life. A sample of 117 female out-patients with a diagnosis of breast cancer filled in the following assessment instruments: FQCI (Freiburg Questionnaire for Coping with Illness), PUK (Causal Attribution Questionnaire), EORTC QLQ-C30 (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire), POMS (Profile of Mood States), and a self-developed questionnaire on alternative therapies. Nearly half the patients (47%, n = 55) reported that they had used alternative therapies in addition to conventional treatment. The methods applied most frequently were nutrition-related measures (special drinks, vitamin preparations and whole-foods - each applied by about 50% of users), mistletoe preparations (49%), trace elements (47%), and homeopathy (31%). Compared with patients receiving only conventional treatment, the users of alternative therapy were younger and better educated. Users developed a more active style of illness coping than nonusers and showed more religious involvement. Patients using a large number of alternative therapies (>3) tended to adopt a more depressive coping style than those using only a small number (< or =3). For a substantial proportion of cancer patients alternative therapies apparently fulfil an important psychological need. However, a subgroup of patients using many alternative therapies seem to have considerable adjustment problems. In dealing with cancer patients the treatment team should be aware of both these groups.

Compliance with antipsychotic treatment

OBJECTIVE

Despite the demonstrated efficacy of antipsychotics the relapse rate among patients with schizophrenia remains high. One major reason for this is non-compliance. In this article we review different factors influencing compliance and discuss possibilities to enhance compliance among schizophrenic patients.

METHOD

This review is based on a systematic literature search in Medline.

RESULTS

We summarize the four main factors (patient-, environment-, physician- and treatment-related) that influence compliance and discuss possible measures to enhance compliance. Next to many other variables discussed in more detail, it is crucial to ensure a positive doctor-patient relationship and to provide sufficient information about the benefit/risk ratio of the medication as well as about the illness itself to build up and sustain compliance. Significant others should be included into the therapeutic alliance whenever possible.

CONCLUSION

Despite many published reports on compliance, it remains to be a problem of eminent clinical relevance. Clinicians must not underestimate it in order to optimize the treatment of patients with schizophrenia.

The clinical implications of weight gain in schizophrenia

The tendency of most of the second generation antipsychotics to induce weight gain to a larger extent than that of traditional neuroleptics has renewed the interest in weight problems of patients with schizophrenia. Drug-induced weight gain has been identified as a major risk factor for various medical disorders that might be responsible for the increased morbidity and mortality rates of patients suffering from schizophrenia. Also, it has a major impact on compliance. This article focuses on the clinical relevance of increased body weight in schizophrenia. It outlines screening and management options to prevent and/or manage weight gain associated with schizophrenia in everyday clinical practice. The first strategies should be to identify obesity-prone patients at the beginning of treatment and provide information (to patients and caregivers) about the risks of weight gain and its consequences. Additionally, the possibility of weight gain calls for a regular monitoring of weight and weight-related laboratory parameters. The patients should also be offered dietary advice as well as regular exercise and behavior modification programs. Physicians must be aware of the problem of weight gain associated with schizophrenia and choose antipsychotic medication carefully, especially in patients at high risk for weight gain.

A qualitative assessment of the neurological safety of antipsychotic drugs; an analysis of a risperidone database

BACKGROUND

Neurological side effects of antipsychotic agents limit the use of these drugs, and development of newer antipsychotic agents has been focused on a reduced risk of extrapyramidal symptoms (EPS) as well as effective symptom control.

METHODS

A qualitative analysis of EPS was performed using Extrapyramidal Symptom Rating Scale (ESRS) data from 11 double-blind risperidone trials. An ESRS factor analysis and maximum changes in ESRS scores were compared for the risperidone, haloperidol, and placebo groups.

RESULTS

The factor analysis revealed five factors. Between-group comparisons showed no differences between placebo and 1 to 2 mg/day-risperidone groups. Parkinsonism, tremor, akathisia, and sialorrhea were more likely to occur with haloperidol than with placebo or risperidone at 1 to 6 mg/day. Similar results were noted by maximum changes in ESRS scores. At risperidone doses of more than 8 mg/day, acute EPS severity lay between that of the placebo and haloperidol groups. The severity of tardive dyskinesia was greater in patients receiving placebo than in those receiving either active treatment.

CONCLUSIONS

As the results described above were derived from a post hoc analysis of an existing database, conclusions must remain tentative. To provide more definitive answers, EPS assessments in future studies should be refined to more accurately predict the type of EPS expected with a given agent in clinical practice.

Quality of life in breast cancer patients--not enough attention for long-term survivors?

In a study of breast cancer survivors, the authors used the European Organization for Research and Treatment of Cancer core questionnaire + breast module (EORTC QLQ-C30/+BR23) and the Functional Assessment of Cancer Therapy-Breast (FACT-B)for the assessment of quality of life (QoL). The main focus of this study was to look at the effect of time elapsed since initial treatment on the patients' QoL. Eighty-seven female patients (average age of 53.9 +/- 8.7 years) were included in the study. All women had received curative cancer therapy. The average time elapsed since start of initial treatment was 4.7 +/- 4.3 years. Reduced QoL, especially in the areas of emotional, social, and sexual functioning, was found not only after initial treatment (1-2 years) but also after long posttreatment survival (> 5 years). From these findings, needs for specific psycho-oncological interventions are derived. The findings imply that besides recovering from the acute consequences of cancer therapy, long-term survivors of breast cancer (> 5 years after initial treatment) still may have a special need for psycho-oncological support.

Selection bias in clinical trials with antipsychotics

Although the selection of patients is known to be a powerful factor affecting the results of clinical trials, little is known about recruitment issues. Many patients with schizophrenia who are screened for a clinical trial of an investigational antipsychotic are ultimately not included in the study. Therefore, the question arises of whether the results obtained by studying a selected group of patients are really representative of the general population of patients with schizophrenia. The authors studied possible reasons for selective sampling in 200 patients who were consecutively admitted to inpatient units of Innsbruck's Department of Psychiatry with a diagnosis of schizophreniform or schizophrenic disorder over a time period of 33 months. Apart from demographic data and a psychopathologic rating (using the Brief Psychiatric Rating Scale), the authors recorded whether or not a patient was included in a phase III study and whether or not those were not included would have theoretically been eligible for such a study. Twenty-seven patients were finally recruited for a clinical trial. These patients were younger, on average, had a more recent onset of illness, and had experienced fewer psychotic episodes in the past. A history of noncompliance with previous treatment and the refusal of consent were the most common reasons for not including theoretically eligible patients in a clinical trial.

Off-label use of antipsychotic drugs

Despite the fact that most antipsychotics have only been formally evaluated for the treatment of schizophreniform disorder, schizophrenia, mania, and schizoaffective disorder (defined as "classical indications"), antipsychotics are widely used for the treatment of a broad range of symptoms and disorders. In this study, 173 patients who were having their prescriptions for antipsychotics filled at local pharmacies were interviewed. In 115 patients (66.5%), an antipsychotic was prescribed for off-label indications. Patients most often stated that they took antipsychotics as a tranquilizer or an anxiolytic. Neither gender, education, duration of treatment, nor efficacy of treatment showed an influence on the prescription practices for antipsychotics. In contrast, family status and side effects showed a significant influence. A classical indication was more often found in married and widowed patients than in unmarried or divorced ones. Patients in whom antipsychotics were prescribed for the treatment of schizophrenia, schizophreniform disorder, mania, or schizoaffective disorder experienced side effects more often than others. Age was also important for the indication of antipsychotics. Classical indications of antipsychotics were most often found in patients aged 30 to 49 years. In older patients (49-70 years), antipsychotics were almost exclusively used for off-label indications. In classical indications, clozapine was used more frequently (50%) than other antipsychotics. Melperone was primarily prescribed for off-label use.

In-patient suicide in psychiatric hospitals

OBJECTIVE

In-patient suicides continue to be a matter of concern in hospital psychiatry. In-patients at risk for suicide need to be identified.

METHOD

In-patient suicides in two psychiatric hospitals were assessed over a time-span of 8 years. Cases were detected by comparing police suicide data with the hospitals' admission and discharge records. Further information was then gathered from patients' records.

RESULTS

During the period under investigation 44 in-patients committed suicide, the majority of them being diagnosed with affective disorders (45.4%) or schizophrenia (27.3%). The most commonly used method was 'jumping in front of a vehicle' (34.1%); 79.5% were treated in an open ward at the time of their suicide, 15.9% in a locked unit. The majority of open ward suicides happened outside the hospital; 39.4% of patients had left the ward without giving notice.

CONCLUSION

Additional cautionary measures are warranted especially for patients in open wards.

Intravenous versus oral administration of amitriptyline in patients with major depression

Antidepressants can be administered by different routes. Advantages for either the oral or the intravenous administration have been suggested from pharmacokinetic as well as from clinical points of view. Controlled comparison studies of the two routes do not provide unequivocal recommendations. In this investigation, amitriptyline was studied over a 4-week period consisting of a 2-week, double-blind/double-dummy phase with either oral (150 mg/day), high-dose intravenous (150 mg/day), or medium-dose intravenous (100 mg/day) treatment and a 2-week phase of open oral treatment in 80 patients with major depression. A psychopathologic assessment was made using the Hamilton Rating Scale for Depression, the Clinical Global Impressions Scale, the von Zerssen's "Befindlichkeitsskala," an adjective checklist, and a Visual Analog Scale. No significant differences were found concerning the mean scores of the rating scales or time of onset of action in the physicians' ratings. In the patients' self-ratings, there was an earlier therapeutic effect in the high-dose intravenous group. The number of improvers after 7 days was significantly higher in the high-dose intravenous group compared with both other groups. After 14 days, no significant differences in the numbers of improvers and responders between groups were detected. The results of this study do not clearly favor one of the tested options. The main differences found in this study seem to be dose-related rather than differentiating between oral and intravenous routes of administration.

EORTC QLQ-C30 and FACT-BMT for the measurement of quality of life in bone marrow transplant recipients: a comparison

The purpose of the study was to compare two different quality-of-life self-rating instruments, namely the EORTC QLQ-C30, developed by the quality-of-life study group of the European Organisation for Research and Treatment of Cancer, and the FACT-BMT (version 3), the Functional Assessment of Cancer Therapy - Bone Marrow Transplantation scale, which is the FACT-G(eneral measure) in combination with a module developed specifically for evaluating quality of life of bone marrow transplant (BMT) patients. Fifty-six BMT recipients completed both the EORTC QLQ-C30 and the FACT-BMT (German language version) during the same session. Questionnaire data were analyzed on a subscale basis using correlation analysis and multiple linear regression. Correlations between corresponding subscales of EORTC QLQ-C30 and the FACT-BMT ranged from r=0.30 for the emotional domain (poor agreement) to r=0.77 for global QOL (good agreement). This suggests that the instruments, despite considerable overlap, possibly focus on different aspects of QOL, in particular in addressing emotional and social issues of BMT patients. It appears that the FACT-BMT gives a more comprehensive overview regarding the multidimensional construct of quality of life. The EORTC QLQ-C30 gives more insight into the physical aspects of quality of life and helps to identify symptoms which effectively decrease quality of life from the patient's perspective. The QLQ-C30 might be improved by the incorporation of a BMT-specific module currently under development. We therefore conclude that neither of the two instruments can be replaced by the other in the assessment of QOL of BMT patients and that a direct comparison of results obtained with the two instruments is likely to be misleading.

Further evidence that behavioral tests and neuropeptide mRNA and tissue level alterations can differentiate between typical and atypical antipsychotic drugs

This study was designed to compare some behavioral and biochemical effects of chronic treatment with a range of antipsychotic drugs. Gene expression of enkephalin, chromogranin A, chromogranin B, and secretogranin II and their respective peptide products were studied with in situ hybridization and radioimmunoassays after daily oral administration of haloperidol, clozapine, risperidone, or zotepine for 21 days. In behavioral tests, significant catalepsy was induced by haloperidol only. All four antipsychotic drugs increased hind paw retraction time but only haloperidol also increased forelimb retraction time. In the caudate putamen, haloperidol increased both enkephalin mRNA expression and enkephalin tissue levels. Neither of these parameters was altered by the other three drugs. In the prefrontal cortex, antipsychotic drugs generated a distinct pattern of gene expression in two regards. First, the dopamine D(2) receptor antagonist, haloperidol, did not significantly alter synaptic protein levels or their encoding mRNAs. Secondly, there was a differential change in tissue levels and mRNA expression since secretogranin II was not affected by any tested antipsychotic drug. This study shows that different types of antipsychotic drug induce distinct behavioural effects as well as differential changes in the biosynthesis of synaptic proteins and their encoding mRNAs. The data reinforce the notion that haloperidol can be classed as a typical antipsychotic drug whilst clozapine, zotepine, and risperidone reflect their atypical classification.