Showing papers in "Clinical Schizophrenia & Related Psychoses in 2009"

The Five-Factor Structure of the PANSS: A Critical Review of its Consistency Across Studies

Abstract: General Purpose: Twenty principal component analyses of the PANSS revealed that a five-factor solution representing positive, negative, disorganization, depression/anxiety and excitability/hostility symptoms better explained the scale structure than the original three-subscale solution. Our goal was to identify to which of these five factors each of the PANSS items could be attributed based on the consistency of published factor analyses. Methodology: For each study reporting a five-factor solution, the items were assigned to any of the five factors according to the factor on which it had the strongest factor loading. Items were then rated as reaching or not our between-study stability criteria of 70% of agreement. Results: Ten items did not meet our stability criteria: Grandiosity, Stereotyped thinking, Somatic concern, Tension, Mannerism/posturing, Disorientation, Lack of judgment/insight, Disturbance of volition, Preoccupation, and Active social avoidance. Conclusions: A broad and a narrow definition o...

The Epidemiology and Descriptive and Predictive Validity of DSM-IV Delusional Disorder and Subtypes of Schizophrenia

Abstract: Objective: We studied the clinical and epidemiological features of DSM-IV delusional disorder and schizophrenia subtypes in a general population-based sample and investigated the descriptive and predictive validity of these diagnoses. Method: The study was based on a nationally representative survey of 8,028 persons aged thirty years or over from Finland. DSM-IV psychotic disorders were diagnosed using the SCID-I interview and/or case note data. Lifetime severity of symptoms and course and outcome of the disorder were assessed using the Major Symptoms of Schizophrenia Scale. Based on information from the interview, case notes, and health care registers, we assessed current and lifetime treatment contacts, hospitalizations, and antipsychotic medication use. Results: The prevalences were 0.18% (95% CI 0.11-0.30) for delusional disorder; 0.24% (95% CI 0.15-0.37) for paranoid, 0.42% (95% CI 0.30-0.59) for undifferentiated and 0.16% (95% CI 0.09-0.27) for disorganized schizophrenia. Both delusional disorder an...

Involving Families in the Care of Persons with Schizophrenia and Other Serious Mental Illnesses: History, Evidence, and Recommendations

Abstract: Families of individuals with schizophrenia and other serious mental illnesses often provide considerable support to their ill relatives, yet many remain unaware of or unable to access resources and information to help them effectively manage their caregiver role. Consequently, family members may experience burden and subsequent distress. There is substantial evidence to suggest that participation in family services and family involvement in a consumer's clinical care can minimize family burden, leading to better outcomes for the consumer and the family. Unfortunately, few families have contact with their relatives' treatment teams, and even less participate in formal support or educational programs. There are a number of consumer-, family-, provider-, and service-related barriers, which may inhibit family involvement. However, many of these barriers can be overcome when a more individualized, tailored approach to working with families is used. The current paper provides an overview of the impact of mental...

Motivating Persons with Schizophrenia Spectrum Disorders to Exercise: Rationale and Design

Abstract: Persons with schizophrenia spectrum disorders (SSDs) are not only at risk because of disabling disease symptoms but because necessary medications create health risks associated with high rates of obesity. Despite the well-known benefits of exercise, persons with SSDs rarely adhere to such regimens; few interventions to motivate exercise behavior have been tested in this group. The purpose of this study is to examine effects of the Walk, Address sensations, Learn about exercise, Cue exercise behavior for persons with SSDs (WALC-S) motivational intervention upon exercise behavior. We will recruit a total of eighty outpatients 18–68 years, meeting these criteria: 1) chart diagnosis of schizophrenia, any subtype, schizoaffective disorder or schizophreniform disorder, according to the criteria described in the Diagnostic and Statistical Manual for Mental Disorders, 2) English speaking, 3) Stable medication regimen (defined as no medication changes within the last month), and 4) medical clearance for moderate exercise in writing from primary care provider. Participants will be randomly assigned to the experimental (4-week WALC-S motivational intervention), or the control group (4-week time and attention control). After the first 4 weeks, all participants will attend a 16-week walking group.

Assessment of Substance Use and Substance- Use Disorders in Schizophrenia

Abstract: Assessment of substance use and substance-use disorders in schizophrenia presents unique challenges, but remains an important area for professionals working to understand and treat people with dual disorders. This paper reviews assessment of substance use, substance-use disorders, and related domains in people with schizophrenia. The first section includes a review of issues that make assessment of substance use and substance-use disorders particularly challenging in people with schizophrenia. This is followed by a review of measures that can be used to assess substance use and substance-use disorders in schizophrenia, including the strengths and weaknesses of different measures and information on the reliability and validity of each when available. The review concludes with a discussion of assessment considerations and uses of assessment in clinical practice.

An Archival, Follow-Forward Exploration of the Metabolic Syndrome in Randomly Selected, Clozapine-Treated Patients

Abstract: Objectives: Cross-sectional studies indicate that clozapine is associated with unusually high rates of the metabolic syndrome (MetS) in schizophrenia. These studies cannot address the extent to which schizophrenia or other factors are major risks for the MetS, independent of clozapine exposure. The objectives of this study were to longitudinally examine metabolic risk factors before and after clozapine initiation: 1) to determine MetS prevalence rates during firstgeneration antipsychotic (FGA) and clozapine treatment; 2) to identify metabolic changes contributing to the MetS; and, 3) to evaluate the extent to which prior treatment and subject variables contributed to increased MetS prevalence rates. Methods: Using an archival, follow-forward design, metabolic risk factors were sampled on a quarterly basis from medical records of twenty-five randomly selected inpatients. The sampling period was six years (three years of FGA and three years of clozapine). All subjects had been treated only with FGAs prior to clozapine exposure. Results: During clozapine treatment 16 of 25 (64%) subjects met MetS criteria; however, half (8 of 16) of the subjects already met MetS criteria during FGA treatment. Increased MetS prevalence with clozapine resulted from increases in fasting glucose and triglyceride levels and increased systolic BP. BMI was stable over time. Gender, age of clozapine initiation, and clozapine dose and duration may have contributed to long-term MetS risk. Conclusions: Clozapine-treated patients are at increased risk for the MetS. When observed longitudinally, however, it is clear that a significant proportion of the metabolic risk involves factors other than clozapine exposure alone.

Promoting Therapeutic Alliance in Clozapine Users: An Exploratory Randomized Controlled Trial

Abstract: Objective: To pilot a brief cognitive behavioral therapy-based intervention designed to enhance client empowerment and the therapeutic alliance with the aim of reducing clozapine discontinuation. Design: Randomized controlled trial with two conditions: therapy (Alliance Enhancement Therapy [AET]) and control (psychoeducation alone). Assess ments took place at: baseline, twelve weeks and twenty-four weeks (follow-up). The primary outcomes were levels of empowerment, alliance with the clinical team and clozapine discontinuation. Secondary outcomes included insight and other clinical measures. Methods: Treatment-resistant patients who had a diagnosis of schizophrenia, had been registered for clozapine in the previous month and who consented, were independently randomized to active versus control therapy. Results: Thirty-nine patients entered the study. Both groups improved on the main measures with no differential effects of AET intervention. However, patients who attended for more than five sessions showed a differen tial enhancement of working alliance. Conclusions: Although the active therapy showed no general improvement, it did provide some added value over psychoeducation alone when patients attended several sessions. Effective methods of reducing clozapine discontinuation and engaging patients in psychosocial interventions are needed.

Augmentation of Olanzapine by Fluphenazine Decanoate in Poorly Responsive Schizophrenia

Abstract: Introduction: Evidence suggests that atypical antipsychotics affect a broader range of schizophrenic psychopathology and are generally better tolerated than conventional antipsychotics. Therefore, they have become the most commonly used class of antipsychotic drugs in clinical practice. But poor compliance and resistance is noteworthy even among those receiving atypical drugs. The objective of this study was to examine whether there could be any encouraging outcome if fluphenazine decanoate was added, as an adjuvant, to olanzapine in poorly responsive cases of schizophre nia. Method: Twenty-eight female inpatients with a diagnosis of schizophrenia, according to the Structured Clinical Interview for DSM Disorders’ diagnostic criteria, who had shown poor response to olanzapine, were entered into a twelve-week, parallel group, double-blind study for random assignment to either fluphenazine decanoate or placebo in a 1:1 ratio. Primary outcome measures of the study were changes in the mean total scores of the Scale for Assessment of Positive Symptoms (SAPS) and the Scale for Assessment of Negative Symptoms (SANS). The secondary measures were the Schedule for Assessment of Insight (SAI), the Clinical Global Impressions-Severity of Illness (CGI-S) and the Simpson-Angus Scale (SAS). Treatment efficacy was analyzed by t-test, split-plot (mixed) and repeated measures analysis of variance (ANOVA) comparing both groups over twelve weeks. All secondary measures (SAS, SAI, and CGIS) were analyzed by t-test. Results: According to the findings, the mean total scores of SAPS (P<0.01), SAI (P<0.0001) and CGI-S (P<0.03) in the “fluphenazine plus olanzapine” group were decreased significantly in comparison with the “placebo plus olanzapine group.” In spite of an increase in mean total score of SANS in the target group, there was no significant difference in this regard at the study’s conclusion (P<0.09). The mean total score of SAS was also increased significantly in the augmented group (P<0.0001). Effect size (ES) analyses for changes in SAPS, SAI and CGI-S at the end of treatment indicated a large improvement with the fluphenazine augmentation. Conclusions: Adding fluphen azine decanoate to olanzapine may improve some cases of poorly responsive schizophrenia. However, it is essential that consideration be given to the emergence of extrapyramidal side effects and the strengthening of negative symptoms due to fluphenazine, and the probable pharmacokinetic interaction between the two drugs.

Recovery, Spirituality and Religiousness in Schizophrenia

Abstract: Recovery is an important element in the care of patients with severe mental disorders such as schizophrenia. Being a process rather than a goal, recovery involves taking into account patients' preferences in terms of values and life goals. Data showing that religion and spirituality can be an important part of recovery have begun to appear in the literature. Indeed, religious coping appears to be important for patients with schizophrenia, not only as a way of coping with their disorder and other life issues, but also in terms of one's identity and setting important life goals. By contrast, the deleterious influence of religion on positive symptoms may have been overestimated, as there is no evidence supporting this hypothesis. Even if a minority of patients experiences delusions with religious content, this does not appear to constitute, a fortiori, a negative issue, as qualitative research shows that this does not hinder patients from gaining some help from religion or spirituality. Psychiatrists should ...

Antipsychotic Adherence Intervention for Veterans over Forty with Schizophrenia: Results of a Pilot Study.

Abstract: This pilot study tested the feasibility, acceptability, and effect sizes of a multimodal, individual intervention designed to optimize antipsychotic medication use in patients ≥40 years of age with schizophrenia or schizoaffective disorder. Methods: We randomized forty patients into two groups: usual care (UC) versus a nine-session, manualized antipsychotic adherence intervention (AAI). The AAI attempted to improve adherence by combining three psychosocial techniques: 1) education; 2) skills training; and, 3) alliance building. Sessions employed a semistructured format to facilitate open communication. The primary outcome was antipsychotic adherence at study end. We obtained qualitative data regarding patient preferences for the duration and modality for receiving the adherence intervention. Results: Compared to the UC group, a greater proportion of the AAI group was adherent post intervention based on medication possession ratio, a commonly used measure of medication adherence (85% vs. 66.6%; OR=2.64), a difference that was statistically not significant. The entire AAI group reported that they intended to take medications, and 75% were satisfied with the intervention. Conclusions: The AAI was feasible and acceptable. Preliminary data on its effectiveness warrant a larger study. Qualitative data show that patients prefer brief adherence interventions and accept telephone strategies.

Depressive Symptomatology and Attributional Style in Patients with Schizophrenia

Abstract: Objectives: The aim of the study was to evaluate the attributional styles and self-serving bias (SSB) in schizophrenic patients with depressive symptoms (schizophrenia and depressive symptoms [SD]) and without depressive symptoms (schizophrenia nondepressed [SND]), and control subjects (C). Methods: Forty-four outpatients with schizophrenia (twenty-two SD and twenty-two SND) and fifty gender- and age-matched C subjects completed the Attributional Style Questionnaire (ASQ). Attributional styles for positive and negative events were calculated by separately summing the responses for positive and negative items on the ASQ subscales (internality, stability, and globality). Results: For negative events, we found that patients with schizophrenia, independently of levels of depressive symptoms, made more internal, stable, and global attributions than C subjects. For positive events, both C subjects and SND patients made more internal, stable, and global attributions than SD patients. Moreover, C subjects and SND...

A Review of Diffusion Tensor Imaging in Schizophrenia

Abstract: Functional and structural neural pathway disconnection may play a prominent role in the pathophysiology of schizophrenia. Diffusion tensor imaging (DTI) is a noninvasive magnetic resonance imaging technique ideally suited to investigate neuroanatomical connectivity in schizophrenia. DTI provides information about the integrity and physiology of white matter fiber tracts. This review describes basic DTI methods and studies of schizophrenia. The aims are to provide a basic understanding of the DTI imaging technique, describe general DTI study findings in schizophrenia and genetically vulnerable populations, and the pathological mechanisms that may account for white matter disturbances in schizophrenia.

The Importance of Screening for Osteoporosis in Mental Health Settings

Abstract: treated with numerous psychotropic medications, including anticonvulsants, the overall risk of fracture was found to be moderate (13). Some studies in the epilepsy literature do address the problem of bone health and the findings appear to be appropriate for consideration by mental health clinicians as well. The purpose of this paper is to summarize previous studies that indicate that bone health is compromised in the presence of anticonvulsant medications and to underscore the need to evaluate bone mass in patients being treated with anticonvulsant medications in the mental health setting. Anticonvulsant medications may be categorized as those that induce the hepatic cytochrome P-450 system and those that do not. Some of those that do induce the hepatic cytochrome P-450 system include phenytoin, phenobarbital, carbamazepine, primidone, and oxcarbazepine. Some of those that do not induce the hepatic cytochrome P-450 system include valproic acid, lamotrigine, gabapentin, azetazolomide, clonazepam, and topiramate. The differ entiation between enzyme-inducing and nonenzymeinducing anticonvulsants is important because a differen tiation is often made in studies to determine whether either class is associated with greater bone loss.

Schizophrenia: 1979-2009

Abstract: Background: As more becomes known about the complex causation of schizophrenia, the variability of treatment response, and the effectiveness of preventive measures, treatments are likely to change. Methods: A standard regimen from a review article written in 1979 is examined and compared to currently recommended practice, thirty years later. Results: Over this period, there have been many small changes and some very significant improvements: attitudes toward families of patients have altered; patient autonomy has increased; early intervention, assertive community treatment teams, psychoeducation, and cognitive behavioral therapy have all been introduced in the last thirty years. Recovery (defined variously, but with a focus on counteracting disability and enhancing self-determination in the face of stigma), rather than symptom reduction, has become the main aim of treatment. Conclusions: Despite many changes, the overall health of patients with schizophrenia is poor and mortality rates are excessive. Impr...

The Role of Gender in Early and Very Early Onset of Psychotic Disorders

Abstract: This study examines the impact of gender and very early onset on the prognosis of a psychotic disorder. Methods: Eighty-seven youths under 18 years of age, 36 (41%) female and 51 (59%) male, hospitalized with first-episode psychosis were investigated in a multi-site, longitudinal, retrospective follow-up cohort design. An exploratory examination of the subjects was undertaken to assess the impact of very early transition to psychosis on prognosis. Data at Time 1 (time of discharge) were retrospectively collected using a standardized questionnaire from patients' hospital records, and follow-up data at Time 2 (a minimum interval of two years post discharge) were obtained using a mailout questionnaire. Subjects were followed for at least two years (3.9±1.3 years). Results: Females with very early onset (<13 years) were more likely to have a poorer prognostic course and experience relapse resulting in hospital readmission than older females (13-18 years). Conversely, older males were more likely than younger ...

The Effects of Olanzapine and Risperidone on Learning and Retaining Entry-Level Work Skills

Abstract: Objective: This study compared the effects of olanzapine and risperidone, in combination with work skills training or occupational therapy, on the ability of patients with schizophrenia to learn three different entry-level job tasks. Methods: One hundred and twenty stable outpatients with schizophrenia or schizoaffective disorder were randomly assigned to open-label risperidone or olanzapine. After four weeks of treatment, subjects were randomly assigned to receive either work skills training or occupational therapy. Work skills training consisted of six sixty-minute sessions designed to train subjects on three entry-level job tasks. Occupational therapy sessions were matched for time and therapist attention. Subjects were assessed on psychiatric symptoms, level of functioning, side effects, and acquisition and retention of work skills at baseline, after four weeks on study medication, and at twelve and twenty-four weeks after study entry. Results: Subjects assigned to work skills training learned all three work tasks and retained two of the tasks significantly better than subjects assigned to occupational therapy. There were minimal differences between subjects assigned to risperidone and olanzapine. Conclusions: Patients with schizophrenia and schizoaffective disorder were able to learn and retain entry-level job skills while taking either antipsychotic medication. The highly structured skillstraining protocol used to teach entry-level job skills was prepotent over the pharmacological effects of antipsychotic medication. Future research is needed on the interaction between medications and skills training on key psychosocial outcomes such as the work functioning of patients with schizophrenia.

Long-Term Maintenance Electroconvulsive Therapy in the Treatment of Schizophrenia and Schizoaffective Disorder—A Case Series

Abstract: Submitted: September 19, 2008; Revised: October 8, 2008; Accepted: October 30, 2008 Introduction Since the first days of electroconvulsive therapy (ECT) over seventy years ago when Cerletti first treated a schizophrenic patient, it has been established that ECT is an effective treatment for psychotic disorders (1). Electroconvulsive therapy was once the mainstay of biological treatments for psychotic disorders, but with the advent of neuroleptics, most schizophrenic and schizoaffective disorder patients were treated primarily with medications. For treatmentrefractory patients, however, or for those with acute exacerbations of psychoses, the addition of ECT to neuroleptics is effective in reducing psychotic and affective symptoms (2-4). Both acute and short-term maintenance ECT (mECT) have been utilized and are effective in this patient population (57). Chanpattana and colleagues have reported on the use of combined acute course neuroleptics in treatment-resistant schizophrenia, with fifty-five percent of patients showing clinical improvement in positive symptoms (8). Additionally, they reported sustained improvement in quality of life, psychopathology, and social functioning in the majority of treatment-refractory schizophrenia patients treated with mECT for one year (9). Schizophrenia and schizoaffective disorder are lifelong illnesses, typically beginning in the early decades of life, and Bruce Sutor , Keith G. Rasmussen 1

An Exploratory Study of the Potential Prognostic Usefulness of the Routinely Conducted Computed Tomography Scan in Patients Hospitalized for a First Episode of Psychosis

Abstract: Rationale: The clinical utility of routinely conducted computed tomography (CT) brain imaging during the evaluation of first-episode psychosis is often very limited, results typically relegated to ruling out gross intracranial pathology. Little is known about whether more commonplace findings and variants, often unreported in the radiological summary, could provide prognostic information. This study, focused on a low-income, predominantly African-American sample of public-sector, first-episode patients, addressed the understudied question of whether or not findings on routine clinical CT scans are associated with variables that may have prognostic importance. Methods: The sample included seventy-five consecutively admitted patients, aged 18-40 years, who were hospitalized for a first episode of psychosis. Sociodemographic and clinical data were obtained by a psychiatrist through a structured retrospective chart review based on dictated discharge summaries. Radiological variables were recorded by a neurora...

Highlights from The Twelfth Biennial International Congress on Schizophrenia Research, San Diego, CA March 28-April 1, 2009

Abstract: The Twelfth Biennial International Congress on Schizophrenia Research (ICOSR) was held in San Diego, California from March 28 to April 1, 2009. This was the largest Congress meeting to date, with 289 presentations, 825 posters, and 11 workshops that covered all aspects of schizophrenia research. This biennial meeting included approximately 1,140 attendees from approximately 29 countries. This article provides a selected account of the Congress proceedings with a focus on genetics, treatment, cognition, and prevention. Presentations included in the current manuscript were selected based on their apparent relevance and anticipated interest to clinical practitioners. The next ICOSR meeting, occurring in 2011, will be held in Colorado Springs, Colorado.

Preventive Interventions for Schizophrenia: A Case Report

Abstract: Prodromal phase of psychosis refers to the period from the first noticeable symptoms or unusual experiences to the first prominent psychotic symptoms. Early recognition and treatment of schizophrenia is one of the most important therapeutic goals. However, symptoms presented during the prodromal phase of psychosis are often nonspecific and difficult to recognize. Therefore, the Scale of Prodromal Symptoms (SOPS) and the Structured Interview for Prodromal Syndromes (SIPS) are designed to help clinicians identify prodromal symptoms. In addition, the Comprehensive Assessment of At-Risk Mental States Scale (CAARMS) is designed to help recognize individuals at high risk. Furthermore, preventive interventions have been suggested for such at-risk patients to delay or prevent progression to psychosis. These interventions include psychosocial support, close monitoring of worsening of the symptoms, psychotherapeutic approaches, and early judicious use of antipsychotics, if warranted.