At the close of this course, participants will understand the steps involved in setting up an anti-stigma program, how to anticipate and resolve some of the most common difficulties, as well how to incorporate evaluation tools as a way of monitoring program progress and outcomes.

Using a series of case presentations, course participants will work through the steps required to set up programs designed to reduce stigma and discrimination resulting from stigma. Course materials will be drawn from the World Psychiatric Association's Global Program to Fight Stigma and Discrimination Becuase of Schizophrenia. The format of the course will be highly interactive with a heavy emphasis on audience participation designed to identify, then resolve the many practical aspects of program start-up, implementation, and operation. Faculty from the course will be drawn from the WPA Global Anti-Stigma Program and will help participants work through 2-3 real-life scenarios.

References:

Sartorius N, Schulze H. (2005) Reducing the Stigma of Mental Illness. Cambridge: Cambridge University Press.

Stuart HL. (ed.) (2005) World Psychiatric Association Training Manual. How to Set Up an Anti-Stigma Program.

World Psychiatric Association, Geneva: World Psychiatric Association Global Programme to Fight Stigma and Discrimination Because of Schizophrenia.

Among schizophrenic patients, prevalence of non-compliance is 25-40%, and it is the most important factor for relapse and bad outcome. MEMS provides of a more precise tool for compliance monitoring than other systems.

1. To evaluate compliance in schizophrenic outpatients and its relationship with clinical and psychopathological variables. 2. To evaluate the degree of agreement between compliance estimated by psychiatrist, family and patients with ‘real’ compliance. 3. To evaluate psychopathological differences between patients treated with oral antipsychotics (APs) and long-acting injectable (LAI) or depot APs.

Data concerning clinical variables, psychopathology (insight, psychotic, negative and general psychopathology symptoms), and compliance with treatment (information reported by psychiatrist, caregiver and patient) are recorded. In patients treated with LAI/depot APs, reasons for instauration is also recorded. Compliance of oral APs is evaluated through MEMS, with a follow-up period of three months. Statistical analysis will be performed with the appropriate tests (Pearson's correlation coefficient, T-Student tests and ANOVA test).

To date, 106 patients have been recruited. 77 patients are treated with oral APs (with or without LAI/depot APs) and 29 are receiving only LAI/depot APs. The reasons of instauration of treatment with LAI/depot APs was confirmed non-compliance (24 pat.), suspected non-compliance (3 pat.) and ‘posological comfort’ (2 pat.).

To date, few studies have investigated compliance in schizophrenic patients through MEMS. Identification of variables related to non-compliance seems very relevant in order to establish preventive strategies.

This study assessed the factors associated to persistence of negative symptoms in patients treated with antipsychotics.

A retrospective, cross-sectional, multicenter study was carried out by 117 Spanish Psychiatrists (The CLAMORS Collaborative Group). Consecutive outpatients meeting DSM-IV criteria for Schizophrenia, Schizophreniform or Schizoaffective Disorder, under antipsychotic treatment for at least 12 weeks, were recruited. Negative symptoms were assessed using the PANSS scale (1-blunted affect; 2-emotional withdrawal; 3-poor rapport; 4-social withdrawal; 5-abstract thinking; 6-verbal fluency; 7-stereotyped thinking). Persistence of a negative symptom was defined by severity score >3. Multivariate logistic regression models were applied including gender, age, civil status, work situation, BMI, time on antipsychotic treatment and dose, CGI and Total and Positive PANSS scores, cardiovascular risk by SCORE (10-year death) and Framingham (10-year all CV events) equations and Metabolic Syndrome.

1452 evaluable patients (863 men, 60.9%), 40.7+12.2 years (mean+SD) were included. Negative symptoms (one or more) were presented in 60.3% of patients. All negative symptoms were associated to worst clinical severity (higher CGI and Total PANSS scores). Negative symptoms were also associated to gender (symptoms 4), age (symptoms 1,2,4,5), civil status (symptoms 2,4), work situation (symptoms 3,4,5), time on antipsychotic treatment (symptoms 1,2,3,6,7), and dose (symptom 2).

Persistence of negative symptoms plays an important role in patients treated with antipsychotics, being all of them associated to clinical severity but also to other sociodemographic and time and dose with current antipsychotic treatment.

On behalf of the CLAMORS Collaborative Group.

A sample of 60 patients receiving care in community mental health services (day hospital) has been evaluated using the DMF-T index (number of carius, missing and restored teeth) and the CPITN (Community Periodontal Index of Treatment Needs). The sample has been compared with a control group selected to mach the study group by age and gender.

Oral and dental health status of people with chronic and severe mental disorders seems to be significative worse than that of the general population. This can have clinical and social implications in their general health, stigma and social acceptation. Mental health services must be aware and make efforts to detect this problem and to facilitate treatment and preventive strategies.

Schizoaffective disorders have a long history and are clinically relevant, but their concept is still uncertain. Cognitive and neuropsychological functioning is impaired in acute illness, but deficits are obvious even during remission. The aim of this study was to evaluate the cognitive status of remitted schizoaffective patients.

32 remitted patients diagnosed to have schizoaffective disorder underwent neuropsychological testing: MWT-B, TMT, VLMT, WMS-R, D2 and proactive interference. The results were compared with a sample of 38 bipolar patients.

The scores of schizoaffective patients were under the average in all of the applied instruments. The patients had lower results compared to the group of bipolar patients.

Even in remission patients with schizoaffective disorder have neurocognitive deficits. Compared to healthy probands or bipolar patients cognitive flexibility, concentration and memory is worse.

The primary objective of this FDA-requested study was to examine the tolerability/safety and pharmacokinetics (PK) of 20 mg, 25 mg, and 30 mg per day of aripiprazole in children and adolescents, ages 10-17. Effectiveness of aripiprazole was also assessed in this patient population, and is described as the focus of this poster.

This was an open-label, 26-day, multi-center, sequential cohort, dose-escalation trial. Twenty-one (21) children and adolescents, aged 10 to 17 years old, were enrolled. Preferential enrollment was given to patients with schizophrenia or bipolar illness; however, other psychiatric diagnoses were also permitted. Fifty-seven percent (57%) of patients were diagnosed with bipolar disorder; 24%, Tourette's disorder; and 5%, schizophrenia, PDD, OCD, or conduct disorder. Patients started on a dose of aripiprazole 2 mg/day. Three cohorts reached final doses of 20, 25, or 30 mg/day over a maximum of 12 days and maintained that dose for an additional 14 days. Effectiveness was assessed using the CGI-Severity and CGI-Improvement scales.

Eighty-five percent (17/20) of the patients were “much improved” or “very much improved” at study endpoint (CGI-I).

Conclusions:

1. • Effectiveness of aripiprazole at doses of 20-30 mg/day is demonstrated in this child and adolescent patient population

2. • Observation of clinically meaningful improvement of global symptoms supports systematic evaluation in pediatric/adolescent disorders

Three years of group work for outpatients with psychosis was evaluated.

A small group of 6 to 8 medicated patients is run in co-therapy. A modified, non-structured, psychoanalytic group technique which includes psychoeducation, cognitive techniques, nonstructured conversation and clarifications is used.

Better control and differentiation of the psychotic symptoms, emotions and improved social functioning were observed. Group cohesiveness has developed very slowly. With its progression, we observed more honest and open conversation about symptoms and real life problems. Several therapeutic group factors are important for diminishing stigma. The members, who entered the group by their parent's request dropped-out more frequently. Group members were able to manage transient worsening of their psychosis in an outpatient care. The most frequent topics discussed were: psychotic symptoms and medication, interpersonal relations, stigma.

Long term group work has important short and long term effects on quality of life, compliance with treatment, social functioning and stigma reduction. Patients should be intrinsically motivated and well prepared for group work.

Psychosis is a highly stigmatised condition. Our clinical experience with long term groups of patients with psyhosis have shown that long term group therapy has an important destigmatising role.

A small group of 6 to 8 medicated patients is run in co-therapy. A modified, non-structured, psychoanalytic group technique which includes psychoeducation, cognitive techniques, nonstructured conversation and clarifications is used.

In the early phases of group work stigma was manifested as drop-out of at least two members. With the development of group cohesiveness the group started talking about stigma. A feeling of universality in group work is often a fundamental destigmatising step.

Patients fear that their symptoms could be unique. Talking about the psychotic symptoms and feelings helps to differentiate them. Improved control over the problems and their life has an important destigmatising power. Group therapy has a destigmatising role through several group therapeutic factors, especially feelings of universality, altruism and group cohesiveness. Subsequentely, patients with psychosis start using their healthier parts and experience less stigma.

Group psychotherapy for patients with psychosis is a task which evokes considerable anxiety and poses significant difficulties for the psychotherapist. I have started to work in a co-therapeutic pair in outpatients long term group for medicated patients with psychosis as a psychiatric resident.

A modified, non-structured, psychoanalytic group technique which includes psychoeducation, cognitive techniques, nonstructured conversation and clarifications is used.

From the beginning I felt insecure, stigmatised, anxious and under the impression, that psychotherapy does not work for patients with psychosis. During last three years, I have developed more empathy, interest and understanding and less anxiety for patients with psychosis.

Working in group has been important, both, as a personal and professional experience. Listening to patients and trying to understand them has improved my understanding of psychosis in a broader sense. Now, I strongly believe that patients with psychosis can benefit from modified psychotherapeutic work in a long term. Personally, with the help of the group, I have became more honest and open and less manipulative person and less stigmatised of being the psychiatrist.

The trend toward normalization of RMT and ICI with antipsychotic treatment seems to be independent of the magnitude of therapeutic effect.

It was suspected that the delusional disorders of bewitchement and devil persecution of two female patients (41 and 40 years old) could be the consequence of an erroneous interpretation of the sensations induced by panic attacks, as several authors have previously suggested. Both patients had schizophrenia spectrum antecedents (Patient A was suffering from a schizo-affective disorder, Patient B had a schizotypic disorder and an antecedent of brief hallucinatory episode). Thus these individuals had some tendency toward psychotic thinking. The interest of this case report stems from the manner in which we tested our clinical hypothesis.

The patients agreed to the use of a lactate provocation test in double-blind, placebo-controlled conditions during four randomized sessions on consecutive days (two with lactate and two with placebo). The active lactate test used a 0.5 molar racemic lactate sodium 10 ml/kg solution, infused in 20 minutes.

Neither patient displayed panic symptoms during the placebo sessions whereas patient A developed two full-blown panic attacks during the active lactate sessions and patient B developed one subthreshold and one moderate panic attack during the active lactate sessions. The results of these investigations led to a specific cognitive therapeutic treatment of the delusional convictions in patient A.

The results of this investigation, at least in patient A, strongly support our clinical hypothesis about a possible relationship between panic disorder and delusional disorder in some cases.

Therapeutic adherence is a key issue in patients suffering from schizophrenia. The possibility of psychotic relapse is increased by the omission of medication. Relapses decrease the chance of favourable prognosis of the disorder, and this leads to further hospitalization, which entails increased social expenses. Unfortunately, medication omission, or non-compliance, is very frequent in patients with schizophrenia. Good compliance develops as a result of an interaction among multiple factors affecting the physician, the patient and his/her relatives. The objective was to define principal factors which affect compliance in persons with schizophrenia.

A survey was conducted using a self-rated questionnaire to assess compliance in patients, their relatives and their physicians. Subjects participated from various geographical areas of the country in order to make a sample representative.

909 schizophrenic patients, 73 physicians and 423 relatives participated in this study. Forty-one percent of patients indicated non-compliance by their own decision. The analogous estimate from physicians was 57%. Almost half of the patients (42%) forgot to take the medication or miss it due to other cognitive dysfunctions. This problem affects more patients according to physicians' (49%) and the relatives' (55%) opinion.

Based on our estimates improvement of therapeutic adherence in patients with schizophrenia has high clinical importance, since lack of adherence is directly related to therapeutic failure, and results in an elevated risk for patients' deterioration and life-functioning.

Sertindole is an antipsychotic agent that shows affinity for D2, 5-HT2A, 5-HT2C, and a1-adrenoceptors. Preclinical research suggests that sertindole has a preferential effect on the activity of limbic and cortical dopaminergic neurons, and clinical trials have confirmed that sertindole is efficacious at a low D2 receptor occupancy, comparable to that produced by clozapine, which may confer a lower risk of EPS.

PubMED was searched for all randomised controlled trials of sertindole where EPS ratings were performed and published in English language in peer-reviewed medical journals. All of these published studies were reviewed regarding the occurrence of EPS in patients.

Five clinical trials of sertindole fulfilled these criteria. Comparators were placebo, haloperidol and risperidone. Rating scales used were: Simpson –Angus Scale (SAS), Barnes Akathisia Scale (BAS), and Abnormal Involuntary Movement Scale (AIMS). Furthermore, the need for anti EPS medication, and the incidence of EPS-related events (presented as percentage of patients), if registered, was recorded. If significant differences were reported, NNT (number needed to treat) values were calculated and presented with point estimates and 95% CI. In three studies significant differences between sertindole and haloperidol were observed. In the two remaining studies, no significant differences were noted between sertindole vs placebo and risperidone, respectively.

In summary sertindole has been shown to have an exceptionally low propensity for EPS, and abnormal movement side effects.

This study assessed the persistence of negative symptoms in patients treated with antipsychotics.

A retrospective, cross-sectional, multicenter study was carried out by 117 Spanish Psychiatrists (The CLAMORS Collaborative Group). Consecutive outpatients meeting DSM-IV criteria for Schizophrenia, Schizophreniform or Schizoaffective Disorder, under antipsychotic treatment for at least 12 weeks, were recruited. Negative symptoms were assessed using the PANSS scale (1-blunted affect; 2-emotional withdrawal; 3-poor rapport; 4-social withdrawal; 5-abstract thinking; 6-verbal fluency; 7-stereotyped thinking). Persistence of a negative symptom was defined by severity score > 3. Persistence of primary negative symptoms was defined when: not present extrapyramidal symptom (EPS); not present items 2 (anxiety) or 6 (depression) of General Psychopathology PANSS scale (<=3); dose of haloperidol non higher than 15 mg/d; and not present antiparkinsonian treatment.

1452 evaluable patients (863 men, 60.9%), 40.7+12.2 years (mean+SD) were included. Negative symptoms (one or more) were presented in 60.3% of patients. The most frequent negative symptoms were social withdrawal (45.8%), emotional withdrawal (39.1%), poor rapport (35.8%) and blunted affect (33.1%). Primary negative symptoms (one or more) were present in 33.1% of patients. The most frequent primary negative symptoms were also social withdrawal (18.2%), emotional withdrawal (14.8%), poor rapport (14.8%) and blunted affect (12.8%).

Persistence of negative symptoms plays an important role in most patients treated with antipsychotics, being near half of them primary negative symptoms.

On behalf of the CLAMORS Collaborative Group.

Patients with schizophrenia have a reduced life expectancy of 20% in comparison to the general population. They have a relative risk of 1.6 for all cause mortality. Recent innovations in antipsychotic treatment have improved the social integration of patients thanks to a better control of symptoms, however undesirable effects of medication may affect physical health.

To develop a consensus document about the Evaluation of Physical Health of Patients with Schizophrenia along their life, and to propose recommendations for diagnostic and clinical interventions to manage modifiable risk factors which impact on quality of life and life expectancy.

A literature review was performed to identify diseases and/or risk factors potentially related to patient with schizophrenia.

A systematic review of the literature was performed to evaluate the morbid-morbidity of patients with schizophrenia in relation to the identified conditions. 25 psychiatrists and 8 experts from the different specialities participated in the consensus meeting to adapt the general population guidelines to the management of patients with schizophrenia.

The literature review revealed that increased mortality in patients with schizophrenia is associated to respiratory diseases, cardiovascular diseases and cancer. Increased morbidity is associated to diabetes and metabolic syndrome, respiratory diseases, hepatitis, HIV and dyskinesia.

The resulting recommendations were submitted to the Spanish psychiatry medical societies for their validation.

The physical health of patients with schizophrenia requires specific monitoring and follow-up to guarantee that their life expectancy, quality of life and social functioning is similar to the general population.