Showing papers in "Schizophrenia Bulletin in 1997"

Determinants of Medication Compliance in Schizophrenia: Empirical and Clinical Findings

Abstract: Advances in psychopharmacology have produced medications with substantial efficacy in the treatment of positive and negative symptoms of schizophrenia and the prevention of relapse or symptom exacerbation after an acute episode. In the clinical setting, the individual patient's acceptance or rejection of prescribed pharmacological regimens is often the single greatest determinant of these treatments' effectiveness. For this reason, an understanding of factors that impede and promote patient collaboration with prescribed acute and maintenance treatment should inform both pharmacological and psychosocial treatment planning. We review the substantive literature on medication adherence in schizophrenia and describe a modified health belief model within which empirical findings can be understood. In addition to factors intrinsic to schizophrenia psychopathology, medication-related factors, available social support, substance abuse comorbidity, and the quality of the therapeutic alliance each affect adherence and offer potential points of intervention to improve the likelihood of collaboration. Because noncompliance as a clinical problem is multidetermined, an individualized approach to assessment and treatment, which is often best developed in the context of an ongoing physician-patient relationship, is optimal. The differential diagnosis of noncompliance should lead to interventions that target specific causal factors thought to be operative in the individual patient.

Functional and Anatomical Aspects of Prefrontal Pathology in Schizophrenia

Abstract: Clinical and experimental research have provided anatomical, pharmacological, and behavioral evidence for a prominent prefrontal dysfunction in schizophrenia. Negative symptoms and behavioral disorganization in the disorder can be understood as a failure in the working memory functions of the prefrontal cortex by which information is updated on a moment-to-moment basis or retrieved from long-term stores, held in mind, and used to guide behavior by ideas, concepts, and stored knowledge. This article recounts efforts to dissect the cellular and circuit basis of working memory with the goal of extending the insights gained from the study of normal brain organization in animal models to an understanding of the clinical disorder; it includes recent neuropathological findings that indicate that neural dystrophy rather than cell loss predominates in schizophrenia. Evidence from a variety of studies is accumulating to indicate that dopamine has a major role in regulating the excitability of the cortical neurons upon which the working memory function of the prefrontal cortex depends. Interactions between monoamines and a compromised cortical circuitry may hold the key to the salience of frontal lobe symptoms in schizophrenia, in spite of widespread pathological changes. We outline several direct and indirect intercellular mechanisms for modulating working memory function in the prefrontal cortex based on the localization of dopamine receptors on the distal dendrites and spines of glutamatergic pyramidal cells and on gamma-aminobutyric acid (GABA) ergic interneurons in the prefrontal cortex. Understanding the interactions between the major cellular constituents of cortical circuits-pyramidal and nonpyramidal cells-is a necessary step in unraveling the receptor mechanisms, which could lead to an effective pharmacological treatment of negative and cognitive symptoms, as well as improved insight into the pathophysiological basis of the disorder.

Physical and Sexual Assault History in Women With Serious Mental Illness: Prevalence, Correlates, Treatment, and Future Research Directions

Abstract: An emerging body of research on the physical and sexual abuse of seriously mentally ill (SMI) women documents a high incidence and prevalence of victimization within this population. While causal links are not well understood, there is convergent evidence that victimization of SMI women is associated with increased symptom levels, HIV-related risk behaviors, and such comorbid conditions as homelessness and substance abuse. These abuse correlates may influence chronicity, service utilization patterns, and treatment alliance. This article reviews the research literature on the prevalence, symptomatic and behavioral correlates, and treatment of abuse among SMI women, particularly women with schizophrenia. Within each topic, we discuss relevant research findings, limitations of available studies, and key questions that remain unanswered. We also discuss mechanisms that may underlie the relationship between trauma and schizophrenia-spectrum disorders. We conclude by outlining directions for future research in this area.

The Basal Ganglia and Cognitive Pattern Generators

Abstract: This article introduces the notion of cognitive pattern generators and suggests, by analogy with the central pattern generators of the motor system, that these pattern generators operate to organize neural activity underlying aspects of action-oriented cognition. It is further proposed that the basal ganglia are involved in the control of cognitive as well as motor pattern generators. Disorders of the basal ganglia may thereby contribute to neural circuit dysfunctions that are expressed as positive and negative symptoms of schizophrenia.

A Cognitive Neuroscience View of Schizophrenic Thought Disorder

Abstract: The experimental association psychology approach to mental associations has been the conceptual background for the concept of schizophrenia. Cognitive neuroscience methods and concepts can be used to study various forms of schizophrenic thought disorder. In particular, the concepts of semantic associative and working memory can be applied fruitfully to schizophrenia research. Semantic associative networks can be simulated with self-organizing feature maps. Dysfunctional lexical access can be modeled in terms of low signal-to-noise ratio in intra- or between-network information processing. Evidence for the crucial role of dopamine in this function is presented, and a general neurocomputational model of schizophrenic thought disorder is developed. This model capitalizes on basic aspects of neural information processing (i.e., neuromodulation and neuroplasticity) and allows a parsimonious explanation of a number of otherwise inexplicable or unrelated clinical phenomena and experimental results.

Schizophrenia and Nicotine Use: Report of a Pilot Smoking Cessation Program and Review of Neurobiological and Clinical Issues

Abstract: Nicotine use is a major public health problem that increases medical morbidity and mortality Nicotine's action and the pathobiology of schizophrenic disorders have common neurobiological substrates Tobacco smoking alters medication blood levels and effectiveness, modifies psychiatric symptoms, and is a clue for other substance abuse This article presents an evaluation of a smoking cessation program for 24 smokers with schizophrenia Fifty percent completed the program, 40 percent decreased use by 50 percent, and 13 percent remained abstinent (carbon monoxide verified) for 6 months Nicotine replacement, motivational enhancement therapy, and relapse prevention behavioral therapy were important components of treatment Pharmacotherapy strategies of a higher-dose nicotine patch, combining nicotine gum and a patch, and augmentation medication to nicotine replacement should be evaluated in future studies in this population

Evaluation of Treatment-Resistant Schizophrenia

Abstract: A systematic approach to the evaluation and characterization of treatment resistance in schizophrenia has become increasingly important since the introduction of clozapine, risperidone, and olanzapine. The need for accurate evaluation will increase with the introduction of the next generation of antipsychotic medications. People with schizophrenia may manifest a poor response to therapy secondary to intolerance of medication, poor compliance, or inappropriate dosing, as well as true resistance of their illness to antipsychotic drug therapy. Clinicians facing the decision of when to change from one antipsychotic to another must clearly understand the appropriate length of a trial and what target symptoms respond to antipsychotics in order to maximize the response in patients with treatment-resistant schizophrenia.

Cortical Development and Thalamic Pathology in Schizophrenia

Abstract: In this article, morphological data suggesting that brain development may be altered in schizophrenia are reviewed in relation to the major events in neural development. In the absence of severe defects in brain structure in individuals with schizophrenia, developmental processes governing the establishment, refinement, and maintenance of connections are potential sites of pathological involvement. Alterations in connectional patterns are likely to result in activity-dependent changes in gene expression for molecules involved in the neurotransmission process, with functional consequences. Loss of cells in the thalamus may be primary or secondary to cortical or other subcortical pathology. Loss of thalamic cells and/or of corticothalamic inputs could lead to disintegration of thought processes by a failure in functional brain states dependent on collective oscillation of large ensembles of cortical and thalamic neurons.

Anomalous Cerebral Asymmetry and Language Processing in Schizophrenia

Abstract: Reversal or reduction of normal structural cerebral asymmetries may be related to the pathogenesis of schizophrenia, but this relationship remains controversial. We review the literature and describe a further study designed to detect whether anomalous asymmetries are present early in the illness (at the first episode), whether they predict deficits in language processing, and whether they may be related to a genetic predisposition for schizophrenia. Asymmetries of brain widths and segments of the sylvian fissure were assessed in a magnetic resonance imaging study of 87 patients with a first episode of schizophrenia and 52 normal controls. These asymmetries were correlated with specific measures of language processing, memory, and hand skill. An independent group of 14 pairs of siblings with schizophrenia were also evaluated for evidence of heritability to cerebral asymmetries. Width asymmetries were reduced in patients compared with controls in the posterior (p = 0.02) and occipital (p = 0.05) regions. Brain horizontal length, on the other hand, was significantly more asymmetrical in patients (left > right; p = 0.04). For sylvian fissure measurements, asymmetries in controls (left > right) were greatest for the horizontal component; this asymmetry tended to detect differences in patients by comparison with controls (p < 0.06). In a range of tests of language and memory, few significant correlations between performance and cerebral asymmetries were detected either in patients or controls, although patients consistently scored poorer than controls in the majority of tests. In 14 pairs of psychotic siblings, within-pair correlations for the horizontal sylvian fissure asymmetry were significantly greater than between-pair correlations. These findings are consistent with the early presence (possibly genetic) of anomalous cerebral asymmetry. However, the functional correlates of reduced asymmetry remain obscure.

The Temporolimbic System Theory of Positive Schizophrenic Symptoms

Abstract: This article proposes that subtle structural and functional disturbance of limbic key structures in the medial temporal lobe-especially of the left hippocampal formation and parahippocampal gyrus-can explain the so-called positive symptoms of schizophrenia After presenting pathophysiological considerations linking limbic dysfunction to schizophrenia, the article reviews evidence from structural, biochemical, and functional studies supporting the theory Also discussed here are neurodevelopmental and laterality aspects, as well as predictions, questions, and future tasks derived from the theory

Substance Use Disorder and the Early Course of Illness in Schizophrenia and Affective Psychosis

Abstract: The relationship between a history of substance use disorder and the early course of psychotic illness was examined in 96 subjects with schizophrenia and 106 subjects with affective psychosis followed in the Suffolk County Mental Health Project, a longitudinal study of first-admission psychosis. Subjects received a structured diagnostic interview and clinical ratings at baseline assessment and again 6 months later. The 6-month assessment included information about treatment received during the interval. A lifetime history of substance use disorder was associated with worse clinical functioning at 6 months for schizophrenia subjects, but not for those with affective psychosis. There were no significant associations of substance use disorder with type of treatment during the interval or with self-reported compliance with medication. Schizophrenia subjects were more likely than subjects with affective psychosis to report cannabis use during the interval and to meet criteria for cannabis use disorder.

Functional and Anatomical Aspects of Prefrontal Pathology in Schizophrenia

Abstract: Neuropathology is a field that correlates autopsy findings to clinical symptomatology. Since the brain has an inordinate number of parceled regions, each having a different function, it makes more sense to work in an inverse fashion and use clinical findings to establish pathological correlations. In this regard, a lesion in the prefrontal lobes can explain some of the salient findings in schizophrenia, for example, scrambled language, disordered thinking, and abnormal behavior. Recent quantitative cytoarchitectural observations by Goldman-Rakic and Selemon sustain such a correlation. By using a computerized image analysis system, these authors have described an abnormally high neuronal density and reduced cortical thickness in many of their patients with schizophrenia. The importance of these findings is discussed in terms of the recent schizophrenia literature.

Neuropsychological and Psychophysiological Correlates of Psychosocial Functioning in Schizophrenia

Abstract: This study tested hypothesized relationships between neuropsychological and psychophysiological variables and concurrent levels of clinical and psychosocial functioning in schizophrenia. The sample consisted of 40 subjects diagnosed with a chronic schizophrenia spectrum disorder and living in community-based settings. The psychophysiological variables were tonic skin conductance (SC) level, SC reactivity to stressors, and SC response to orienting stimuli. The neuropsychological measures were the Stroop, the Controlled Word Association Test, and four subtests of the Wechsler Adult Intelligence Scale-Revised (block design, digit symbol, digit span, and arithmetic). The psychosocial variables were measures of symptomatology, independent living, work, and social functioning. The results suggested that higher symptoms were associated with higher resting arousal, lower stress reactivity, status as an electrodermal responder, and deficits in verbal fluency and visuo-motor functioning. The pattern for better social functioning was higher resting arousal, lower stress reactivity, and more responses to orienting stimuli. Higher levels of independent living were associated with better visuo-motor and verbal processing. Increased work functioning was associated with better complex visuo-spatial processing. These findings are discussed in terms of (1) the specificity of associations between psychosocial, psychophysiological, and neuropsychological variables and (2) a holistic perspective toward understanding these relationships and their relevance to rehabilitation in schizophrenia.

Neuropathology of Schizophrenia: Cortex, Thalamus, Basal Ganglia, and Neurotransmitter-specific Projection Systems

Abstract: This article reviews neuropathological studies in the search for an anatomical correlate of schizophrenia. Replication of many results has proven to be difficult. A consistent finding is the lack of significant gliosis in the neocortex. Intriguing findings that need further corroboration include decreased volume and cell number of the mediodorsal thalamic nucleus, cytoarchitectural alterations of the prefrontal cortex and upper layers of the anterior cingulate gyrus, and superior temporal gyrus abnormalities. Most neuropathological studies investigate regional brain volume and cell density. Highly variable shrinkage of brain tissue postmortem makes these estimates prone to bias and often not comparable across studies. So far, no strong clinicopathological correlations and no pathological criteria to diagnose schizophrenia have been established.

Sexuality, Reproduction, and Family Planning in Women With Schizophrenia

Abstract: This article reviews data about how schizophrenia affects sexuality, pregnancy, the puerperium, parenting, and family planning. Women with schizophrenia have high rates of coerced sex, sexual risk behavior, and unwanted pregnancies. High rates of obstetric complications and custody loss increase morbidity for women and their offspring. Since untreated psychosis increases these problems, the risks of withholding pharmacotherapy must be weighed against the risks of prescribing medications during pregnancy. The puerperium is a time when women are especially vulnerable to exacerbations of schizophrenia. Mothers with schizophrenia may have a reduced ability to read children's cues, and they often have weak social support networks. Their children may be more difficult to raise than other children. Parenting rehabilitation can address some of these problems. Often, women with schizophrenia who are sexually active and do not wish to become pregnant do not use contraception. Incorporating family planning measures into mental health care delivery systems may reduce unwanted pregnancies.

Perseveration in Schizophrenia

Abstract: Perseveration in schizophrenia may take a variety of forms, which can be conceptualized as varying manifestations of an underlying neurocognitive deficit. Comparative studies have demonstrated higher than normal levels of perseverative responding among schizophrenia patients on capacity-demanding tasks, including prompted discourse, reversal learning, and the generation of guessing sequences. There is little evidence that perseveration is associated with deficit signs of schizophrenia. However, perseveration appears to covary with both positive thought disorder and voluntary motor disturbance. Perseveration in schizophrenia thus appears to be a productive sign elicited by a failure to mobilize cognitive resources in situations requiring controlled information processing and the concomitant inhibition of activated but task-inappropriate responses. An information-processing model proposed by Shallice (1988) attributes perseveration to a failure of a higher level executive control system to modulate a lower level response selection system under a requirement for novel response generation. This model suggests that perseveration is the consequence of a failure of frontal specification of striatal outputs during controlled processing, resulting in the continued reselection of previously activated outputs.

Motivation to Quit Using Substances Among Individuals With Schizophrenia: Implications for a Motivation-based Treatment Model

Abstract: Although the motivation to quit using substances is an important prognostic and treatment-matching factor in substance abuse treatment, there is limited information on motivation to quit among individuals with schizophrenia. This study used the five-stages-of-change model to evaluate the motivational levels of 497 individuals with schizophrenia or schizoaffective disorder in an outpatient mental health clinic. Rates of substance abuse, motivation levels to quit each specific substance, and correlates to motivational levels were evaluated. At least one substance use disorder was diagnosed in 224 of the subjects (45%); however, there was significant variability among the caseloads of the outpatient division teams. The patients in the triage/acute services and community outreach teams had substance abuse rates of about 70 percent. Most subjects had low motivation to quit substances, and the rates varied according to substance (range of 41% for opiates to 60% for cocaine). Treatment-matching strategies are suggested in the motivation-based treatment model.

Treatment of Tardive Dyskinesia

Abstract: Although the new generation of atypical antipsychotic agents could some day eliminate concerns about tardive dyskinesia (TD), this disorder remains a significant clinical problem for both patients and physicians. Fortunately, many, if not most, cases of TD are mild. For patients with mild to moderate TD, therapeutic efforts are primarily directed at minimizing neuroleptic exposure or, when possible, changing to atypical agents. Most cases of TD do not seem to progress, suggesting that the risk of remaining on typical neuroleptics is probably small. Patients with moderate to severe forms of TD present greater challenges. These patients frequently require medication to suppress their dyskinesias. A variety of suppressive agents have been tried with limited success. No treatment strategy has emerged that is clearly superior or even successful in most patients. Increasing doses of typical neuroleptics may be useful for short-term suppression; however, the long-term efficacy and risk of this strategy have not been studied carefully. Data on atypical neuroleptics are scant. Clozapine's short-term suppressive effects seem, at best, weak, but patients may improve with long-term treatment. Medications with relatively few side effects that may have suppressive efficacy for some patients include calcium channel blockers, adrenergic antagonists, and vitamin E. Gamma-amino-butyric acid agonists agents and dopamine depleters are frequently useful, but have troubling side effects of their own. A variety of other medications have been employed, but are not well studied. For patients with tardive dystonia, anticholinergic agents or botulinum toxin has been particularly effective. Efforts to understand the neurobiology of TD may shed light on this persistent clinical conundrum.

The Long-term Course of Childhood-onset Schizophrenia: A 42-year Followup

Abstract: This article presents results of a 42-year long-term followup of 44 patients (19 males, 25 females) with childhood-onset schizophrenia. Age at onset ranged from 6 to 14 years (mean =11.8 years). The patients and their first-degree relatives were interviewed in 1994, 27 years after the first followup, by the same investigator with the Present-State Examination (PSE) and the Disability Assessment Schedule. The clinical records were analyzed with the Instrument for the Retrospective Assessment of Onset of Schizophrenia and with sections of the PSE. The cases were rediagnosed according to DSM-III-R, based on longitudinal data obtained between onset and the first hospital admission. Although cumulative prevalence is earlier in females than in males, no gender differences exist in average age at onset. An acute onset was significantly more frequent after 12 years of age. An early age at onset was correlated with high social disability scores. Of the patients, 25 percent were completely, 25 percent partially, and 50 percent were poorly remitted at the second followup. None of the patients with chronic onset remitted completely. The results are discussed with respect to epidemiology, gender differences, and etiological hypotheses of childhood schizophrenia.

At issue: genes, experience, and chance in schizophrenia--positioning for the 21st century.

Abstract: Genetic factors make important contributions to the etiologies of schizophrenia. The mode of familial inheritance remains unknown, but it is highly likely that multiple genes and idiosyncratic environmental factors are involved. Rapidly evolving genetic technologies have been applied in the genetic analysis of schizophrenia, and several genomic regions have been posited as harboring susceptibility genes. Currently, the strongest evidence implicates chromosomes 6 and 8, but these linkages are not yet confirmed. In this article we discuss genetic risk factors, gene-environment interaction, the feasibility of genetic testing, psychiatric genetic counseling, and the dangers of genetic discrimination as they apply to schizophrenia. We also address and correct specific misconceptions about the genetics of schizophrenia held by many in the scientific community and in the media, and discuss a blueprint for future genetic research and informed dissemination of findings to the public and to lawmakers.

Course and Outcome for Schizophrenia Versus Other Psychotic Patients: A Longitudinal Study

Abstract: We studied 276 patients longitudinally, beginning at the acute phase and continuing at three successive followups over 7.5 years, comparing 74 schizophrenia patients with 74 other psychotic patients and 128 nonpsychotic patients on early course and outcome. Schizophrenia patients showed significantly poorer functioning than patients with other psychotic disorders at each of the three followups (p < 0.05). More schizophrenia patients than other psychotic patients showed consistent psychopathology and a course in which there was not complete remission at any of the three followups (p < 0.05). Most schizophrenia patients did not show severe decrements in social activity level. Poor outcome schizophrenia patients showed significantly slower recovery at each followup than did other psychotic patients with initial poor outcomes (p < 0.01). The results indicate that, during the early course, schizophrenia patients still show relatively poor outcomes, although a small number of schizophrenia patients enter into complete remission. Over time, many schizophrenia patients fluctuate between severe disability and moderate disability rather than always showing severe disability. Schizophrenia patients tend to recover more slowly then other psychotic patients. Differences between schizophrenia patients and other psychotic patients in clinical course over time may be larger than differences at any single followup.

Postmortem Studies of the Hippocampal Formation in Schizophrenia

Abstract: In recent years, dramatic abnormalities have been found in the hippocampal formation in schizophrenia. These include diminished levels of dendritic spines, reelin, and the 67 kd isoform of glutamic acid decarboxylase, and increased levels of brain derived neurotrophic factor. These findings are not limited to the hippocampal formation and are consistent with excessive synaptic pruning. So far, however, there is little to indicate when the process began.

Pharmacotherapy of Schizophrenia Patients With Comorbid Substance Abuse

Abstract: Substance abuse worsens the course of schizophrenia and significantly impairs the relationship between the patient and the health care team. Recent advances in laboratory studies of substance abuse and the pharmacology of schizophrenia open up new possibilities for pharmacotherapy of substance abuse in schizophrenia patients. D1 dopaminergic receptor agonists may directly block the drive for stimulant use. D2 dopaminergic receptor antagonists may indirectly block the drive for stimulant and nicotine use, while opioid antagonists appear to reduce the drive to use alcohol. New generations of neuroleptics with serotonin (5-HT2) receptor antagonism and/or 5-HT1A agonist activity may reduce substance abuse in schizophrenia patients who self-medicate negative symptoms or neuroleptic side effects. Pharmacotherapy efficacy may be enhanced by adding contingency management, social skills training, and other manualized programs. Tables are provided of potentially useful medications. Preliminary results are presented of cocaine-abusing schizophrenia patient treated with desipramine and traditional neuroleptics.

Patient Attributes and Expressed Emotion as Risk Factors for Psychotic Relapse

Abstract: In the context of a prospective, controlled treatment study, contrasting family interventions with individual treatment, the role of expressed emotion (EE) as a predictor of relapse was examined in patients with recent-onset schizophrenia and related disorders (n = 97). EE was compared with 13 predictor variables. The variables, taken from EE and family intervention studies, related to demography, premorbid functioning, present and past illness history, and comorbid substance abuse. Psychotic relapse was operationalized with a conservatively measured relapse criterion, composed of monthly ratings based on the Brief Psychiatric Rating Scale and on clinical judgment during the 12 months of outpatient treatment. Of the 14 predictor variables entered in stepwise survival analyses, 6 variables had probable predictive power on the conservative relapse criterion. These variables were entered in a Cox regression model. EE turned out to be the major predictor of relapse in the overall sample (hazard ratio [HR] 4.90; confidence interval [CI] 1.05-22.92). This finding remained when only patients with a first psychotic episode (p = 0.02) and patients in the individual treatment condition (p = 0.001) were examined. Cannabis abuse was the major predictor of relapse in patients with high-EE families (HR 4.27; CI 1.12-16.29).

Seizures and Schizophrenia

Abstract: Patients with epilepsy develop psychosis or schizophrenia at a rate exceeding that expected if the two disorders were independent. Similarly, patients with schizophrenia are more prone to seizures than the general population. This excess vulnerability may be conferred by the neuropathological substrate of schizophrenia itself or by the secondary effects of the illness, including exposure to psychotropic medications that lower the seizure threshold. Neuropathological investigations into the anatomic substrate of seizures in patients with psychosis or schizophrenia are consistent with the notion that there are neurodevelopmental abnormalities involving the mesial temporal lobe. Finally, clinical recommendations for the evaluation and pharmacological management of patients with schizophrenia who have one or more seizures are described.

Social-Adaptive Functioning Evaluation (SAFE): A Rating Scale for Geriatric Psychiatric Patients

Abstract: Geriatric chronic psychiatric inpatients often remain in a chronic psychiatric hospital because of serious deficits in adaptive life functions. Because the additional complications and adaptive changes associated with aging have not been considered in previous scales, the Social-Adaptive Functioning Evaluation (SAFE) was developed. The items in the scale measure social-interpersonal, instrumental, and life skills functioning and are designed to be rated by observation, caregiver contact, and interaction with the subject if possible. Interrater and test-retest reliability were examined (n = 60) and convergent and discriminant validity were rated against other relevant measures (n = 50) in separate studies, with all being found adequate. The factor structure of the scale was examined with exploratory factor analysis, revealing a three-factor structure. Finally, predictive validity was examined in a preliminary study of 140 patients, 45 of whom were discharged after the assessment. The results indicate that patients who remained hospitalized could be discriminated from those who were sent to nursing homes or community care on the basis of certain SAFE items and subscales. These results support the use of this instrument in later studies of geriatric psychiatric patients.

Coping With Negative Symptoms of Schizophrenia: Patient and Family Perspectives

Abstract: An exploratory study was conducted of the strategies that schizophrenia patients and their relatives employ to cope with negative symptoms. Coping strategies and their perceived efficacy were elicited in semistructured interviews conducted separately with patients and relatives. Coping responses were coded according to the following dimensions: behavioral-cognitive, social-nonsocial, and problem focused-emotion focused. Overall, the number of coping strategies was related to perceived coping efficacy for both patients and relatives, regardless of the type of strategy. Perceived coping efficacy tended to be highest for apathy; intermediate for alogia, anhedonia, and inattention; and lowest for blunting. Relatives with more knowledge about schizophrenia used more coping strategies and reported higher levels of coping efficacy. Patient rejection by relatives and distress (either patient or relative) tended to not be related to coping strategies. The findings suggest that patients and relatives use a wide variety of strategies to cope with negative symptoms of schizophrenia. Future clinical work and research need to evaluate whether families may benefit from psychoeducational approaches to teaching them how to better manage negative symptoms.

The Evaluation and Treatment of First-episode Psychosis

Abstract: A first episode of psychosis is a traumatic experience for patients and families. At the time of initial evaluation, the differential diagnosis should include a broad range of neurological, general medical, and psychiatric conditions. Methodological advances in operationally defining illness onset, "offset," and remission have allowed more careful studies of treatment response in first-episode patients. These studies strongly support the efficacy of antipsychotic medication as both acute and maintenance treatment for patients with a first episode of psychosis. The optimal duration of maintenance treatment, however, has not been determined, and patients at low risk for relapse following medication withdrawal cannot be identified with specificity. First-episode psychotic patients typically experience 12 to 24 months of psychosis before receiving treatment, and a long duration of untreated psychosis may be associated with a poorer treatment response. Early intervention may improve outcome in first-episode psychosis, and the use of novel antipsychotics with improved efficacy and fewer side effects may improve medication compliance and reduce morbidity associated with repeated relapses.

Cross-ethnic Symptom Differences in Schizophrenia: The Influence of Culture and Minority Status

Abstract: The two objectives of this tri-ethnic study were (1) to test competing hypotheses from the minority status and ethnic culture perspectives in examining cross-ethnic symptom differences in schizophrenia and (2) to test cultural mediators of the symptom differences. Analyses were done on samples of minority (African-American and Latino) and nonminority (white) groups. Hypothesized cross-ethnic symptom differences were tested, and indicators of sociocentricity were examined as cultural mediators of symptom differences. The sample consisted of 184 individuals (51.6% white, 32.6% African-American, 15.8% Latino, 75% male) diagnosed with schizophrenia in an outpatient, urban setting. Symptom variables were obtained from the Brief Psychiatric Rating Scale and the Quality of Life Scale. Two sociocentric indicators (empathy and social competence) were used to differentiate minority from nonminority groups. Multiple regression was used to test the mediational influence of the sociocentric indicators on the symptom differences. After controlling for social class, significant differences were found in eight symptom variables. These showed the nonminority group to be consistently more symptomatic than the ethnic minority groups, findings which supported the ethnic culture hypothesis. Sociocentric indicators were found to be significant mediators of the cross-ethnic symptom differences. This study supported the ethnic culture hypothesis, which predicted lower symptoms for the ethnic minority groups, and showed that sociocentric variables strongly mediated the more benign symptom profile for the ethnic minority groups. The study indicates that culture should be more fully integrated into current biopsychosocial models of schizophrenia.

Clinical Benefits of Paid Work Activity in Schizophrenia: 1-year Followup

Abstract: In a previous article in the Schizophrenia Bulletin (Vol. 22, No. 1, 1996), we presented findings of a study on the clinical and rehabilitative effects of work activity on 150 subjects diagnosed with schizophrenia or schizoaffective disorder. Subjects were randomly assigned to either a Pay ($3.40/hr) or No-Pay group and given 6-month work placements in a Department of Veterans Affairs medical center. At the 5-month followup, Pay subjects had worked more hours and earned more money (from any employment) than No-Pay subjects. Pay subjects also had significantly greater improvement in symptoms and lower rehospitalization rates. Clinical improvement was closely linked to amount of participation. We concluded that pay increased participation. The current study examined clinical and rehabilitative outcomes at 1-year followup, 6 months after the conclusion of the work program. Results indicated that the Pay subjects had a significant decrease in work activity once they had completed the work program. However, 75 percent of those who had fully participated in the program continued working during the subsequent 6 months, either as volunteers or for pay. Clinical outcomes for subjects in the Pay condition were attenuated at 1-year followup but still significantly better than for subjects in the No-Pay condition. More than 40 percent of participants continued to be "much improved" on total symptoms, and more than 50 percent were "much improved" on positive symptoms. Discussion focuses on the importance and limitations of work for pay as a clinical intervention and concludes that continuous work services are necessary and beneficial for many people with schizophrenia.