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Processing speed and executive functioning are among the more impaired cognitive domains in schizophrenia, do not improve despite antipsychotic medication, and are associated with poor long-term functioning and quality of life. Cognitive remediation therapy for psychosis (REHACOP) try to improve cognitive deficits by teaching information processing strategies through guided mental exercises. The objective of this study is to evaluate the effectiveness of cognitive remediation therapy (REHACOP), compared to other treatments, on processing speed and executive functioning difficulties.
Material and methods
Fifty-seven patients with DSM-IV schizophrenia and 29 with first-episode psychosis were randomly allocated into one of two groups: Cognitive rehabilitation group (REHACOP) or occupational therapy group. The REHACOP group received 3 months structured group rehabilitation sessions (3 per week) focused on tasks requiring attention, language, memory, speed, executive functioning and activities of daily living. All subjects underwent a neuropsychological assessment pre- and post treatment, which included tests for processing speed (Trail-Making Test-A, Digit Symbol, and Stroop-Color) and executive functioning (Stroop Word-Color part and interference)
Repeated measures of MANOVA showed that the interaction term groupXtime was significant for the executive functioning (F = 9.88, p < 0.01) and processing speed (F = 5.92, p < 0.05) measures, suggesting that the REHACOP experimental group improved significantly when compared to the control group's performance on both domains.
Results suggest that REHACOP is effective to improve executive dysfunction and processing speed deficits in first-episode psychosis and schizophrenia compared to occupational therapy.
Course and outcome in schizophrenia are heterogeneous. Numerous studies have shown an association between the presence of negative symptoms and psychosocial and occupational functioning of patients.
To analyse the prevalence of negative symptoms in the course of illness in first episode psychosis and chronic schizophrenia and to establish its relation with the functional outcome.
43 patients with a first-episode psychosis (FEP) from our area were compared with 43 chronic schizophrenic patients and 43 normal controls from a parallel area. They were matched one on one for age, gender and years of education. All subjects were compared regarding psychopathology and functional outcome terms. Patients were examined with Positive and Negative Syndrome Scale (PANSS) for clinical symptom. Longitudinal functionality was prospectively assessed with the Clinical Global Impression (CGI) and Global Assessment of Functioning (GAF) rating scales.
We found significant differences between FEP and chronic patients in negative symptom severity (t = -4.97, p< 0.001) and global assessment of functioning (t = 7.58, p< 0.001). There was no statistically significant difference between the two groups in PANSS positive and general components or Clinical Global Impression. Negative symptom severity was associated with poorer GAF ratings in first episode psychosis and chronic schizophrenia.
Negative symptoms appear to be persistent. In our study negative symptom severity was associated with social and functional impairment, defined as Global Assessment of Functioning Scale score of less than or equal to 60.
Verbal fluency deficits have been pointed out as a possible endophenotype in schizophrenia (Szöke et al., 2008). However, whether these deficits are specific or linked to semantic-verbal inability remains unclear. Additionally, this cognitive domain is already affected in early psychosis and do not improve despite early clinical interventions.
Authors tested the efficiency of a cognitive intervention specifically developed for improving fluency in psychosis.
Material and methods
Ninety patients with first-episode psychosis were randomly assigned to one of two groups: Cognitive rehabilitation group (REHACOP) or occupational therapy. Patients at the REHACOP group received one month structured group rehabilitation sessions (3 per week) to improve fluency. Repeated assessments of semantic fluency and phonological fluency were conducted before and after the treatment.
Compared to occupational therapy, the experimental group produced significant additional improvements in phonological fluency (F = 6.87, p < 0.01), but not in semantic fluency (F = 0.61, n.s). The composite verbal fluency score was also significant (F = 4.65, p < 0.05). The improvement remained 3 months after the treatment end.
The cognitive treatment using REHACOP has proven to be effective in treating phonological fluency deficits in first-episode psychosis, whereas socialization or communication in group therapy by itself do not. The differential pattern showed by semantic fluency is consistent with the proposal of Szöke et al 2008, who suggest that semantic fluency is a putative endophenotype for schizophrenia with links to genetic basis compared to phonological fluency.
The high prevalence of those called “revolving-door patients” continue supposing a high sanitary cost. The aim of this study was to identify factors associated with multiple admissions in a psychiatric unit.
The sample included all patients hospitalized in a psychiatric unit at the hospital “Virgen de las Nieves” in the city of Granada (southern Spain), during the time period between 1998 and 2006 (n=1873). There is no consensus in the literature with regard to the definition of the “revolving-door phenomenon”. Basing on prior studies (Woogh, 1990; Thornicroft et al., 1992), we defined "revolving-door patients” as those who had been hospitalized eight or more times in an eight-year period (an average of at least an admission per year).
The prevalence of revolving-door patients was 10% (186/1873). The condition of revolving-door patients was associated with male sex (OR=1.5; IC 95%: 1.1-2.1), with a marital status different from the married one (OR=1.8; IC 95%: 1.3-2.6), and with the diagnoses of schizophrenia (OR=3.3; IC 95%: 2.4-4.6), schizoaffective disorder (OR=3.8; IC 95%: 2.3-6.5), bipolar disorder (OR=2.1; IC 95%: 1.4-3.2) and personality disorder (OR=2.2; IC 95%: 1.3-3.5).
Male sex, marital status different from the married one and the diagnoses of schizoaffective disorder or schizophrenia may be a risk factor of readmission in a psychiatric unit. A better comprehension about the characteristics of these patients may help to establish more effective strategies to board the psychiatric community.
We set up a study to analyze quality of life and social adaptation in a group of women suffering from fibromyalgia.
Patient inclusion from 1st March to 30th June 2010. An especially designed questionnaire was used for the study, together with Short-Form-36 Health Survey (SF36), Family Apgar questionnaire, Duke-UNC Functional Social Support (Duke-UNC 11) questionnaire, and Social Adaptation Self-evaluation Scale (SASS). SPSS was used for statistical analysis.
Following explanation of purpose of our study and confidentiality agreement, 35 women voluntarily joined our study. Mean age was 52.2 years standard deviation (SD) 7.17. 82,9% had children (mean 2.03 and SD 0.94); 85.7% of patients acknowledged coping with fibromyalgia “badly” or “very badly”; 60% acknowledged that their illness affected their families “severely” or “critically”; 94.3% acknowledged their quality of life affected “much” or “very much”; and 85.7% of patients had their social relationships “much” or “very much” affected. 82.9% of our group of patients was under psychiatric treatment. SF36 scored an average of 27.85 on the physical functioning subscale (SD 19.93); physical role 6.42 (SD 18.53); pain 16.64 (SD 13.7); social functioning 32.14 (SD 21.92); mental health 33.14 (SD 19.0); emotional role 15.23 (SD 30.61); vitality 16.28 (SD 18.60) and general health perception 16.71 (SD 14.54). Family Apgar scored 7.34 (SD 2.53). Duke-UNC 11 scored 35.17 (SD 11.34). Finally, SASS scored 31.32 (SD 7.59).
In view of the results, women suffering from fibromyalgia showed severe changes in all parameters analyzed, social adaptation being very much impaired.
Chronic Fatigue Syndrome (CFS) is characterized by severe fatigue associated with pain, sleep disturbance, attentional impairment and headaches. Evidence points towards a prominent role for Central Nervous System in its pathogenesis, and alterations in serotoninergic and dopaminergic neurotransmission have been described.
Attention-deficit Hyperactivity Disorder (ADHD) courses with inattention, impulsivity, and hyperactivity. It affects children and persists into adulthood in 50% of patients. Dopamine transporter abnormalities lead to impaired neurotransmission of catecholaminergic frontal-subcortical-cerebellar circuits.
To describe the prevalence of ADHD in a sample of CFS patients, and the clinical implications of the association.
To study the relationship between CFS and ADHD.
The initial sample consisted of 142 patients, of whom 9 were excluded because of severe psychopathology or incomplete evaluation. All the patients (age 49 ± 87; 94,7 women) received CFS diagnoses according to Fukuda criteria. ADHD was assessed with a diagnostic interview (CAADID), ADHD Rating Scale and the scale WURS, for childhood diagnose. The scales FIS-40, HAD, STAI and Pluthik Risk of Suicide (RS) were administrated.
38 patients (28,8%) were diagnosed of childhood ADHD (4 combined, 22 hyperactive-impulsive, 12 inattentive) and persisted into adulthood in 28 (21,1%; 5 combined, 4 hyperactive-impulsive, 19 inattentive). There were no differences in Fukuda criteria profile and FIS-40 between groups. ADHD patients scored higher in HAD-Anxiety (9,88 ± 4,82 vs. 12,57 ± 3,49; p = 0,007), HAD-Depression (9,69 ± 4,84 vs. 12,04 ± 4,53; p = 0,023), STAI-E (30,55 ± 14,53 vs. 38,41 ± 11,35; p = 0,012), and RS (6,13 ± 3,48 vs. 8,49 ± 3,07; p = 0,002).
ADHD is frequent in CFS patients and it is associated with more severe clinical profile.
It is well stablished that therapeutic compliance is a fundamental predictive factor in the outcome of first-episode psychosis. Risperidone long-acting injection has demonstrated high remission rates and improvements in treatment adherence.
1- To analyse the efficacy of risperidone long-acting injection vs oral atypical antipsychotics in first-episode psychosis.
2- To describe in both groups the evolution of clinical and cognitive symptoms, functional outcome, quality of life, insight and treatment adherence.
18 patients with a first-episode psychosis treated with long-acting risperidone were compared with 21 first-episode psychosis treated with oral atypical antipsychotic medication. They were matched one on one for age, gender and years of education. All subjects were compared regarding psychopathology and functional outcome terms. Patients were examined with Positive and Negative Syndrome Scale (PANSS) for clinical symptoms. Longitudinal functionality was prospectively assessed with the Clinical Global Impression (CGI) and Global Assessment of Functioning (GAF) rating scales.
We found significant differences between both groups in negative symptom severity and global assessment of functioning. There was no statistically significant difference between the two groups in PANSS positive and general components. Negative symptom severity was associated with poorer GAF ratings.
Our data suggest that risperidone long-acting injection assures treatment compliance and therefore could improve clinical and functional outcome.
We present the construction of an expert system (ES) for the diagnosis of Obsessive-Compulsive Disorders (OCD). It concerns an artificial intelligence tool, in Lisp language compatible with any personal computer (PC) with a hard disk. The ES asks the user 50 questions in natural language, on the patient or on a clinical history. It is provided with 115 rules of reasoning. Using single or multivaluate variables, the ES reaches the diagnosis of the Obsessive-Compulsive Disorders or the recommendations of differential diagnosis with related patterns or involucred with obsessive pathology: phobic, affective, schizophrenic and Gilles de la Tourette disorders. Finally, the perspectives for the utilisation of the ES in psychopathology are disscussed, in conjunction with the 2 serious problems created, design difficulty and user acceptance.
Fibromyalgia seems to be associated with various forms of psychopathology, particularly major affective disorders.
To evaluate associated psychopathology in a series of women with diagnosis of fibromyalgia.
Patient inclusion from 1st March to 30th June 2010. Symptom Checklist (SCL-90-R) was used for evaluation. SPSS was used for statistical analysis of data and results.
A total of 34 women voluntarily joined our study. Mean age was 52.2 years (standard deviation (SD) 7.17). 11.4% were singled, 74.3% married or unmarried couples, 8.6% were divorced, and 5.7% were widowers. 74.3% of women lived with their couple and/or children whereas 8.6% lived by their own, and 8.6% with their parents. Results obtained with SCL-90-R showed:
Our patients with fibromyalgia scored higher in somatization, obsession-compulsion, depression, and anxiety. In view of the results, there is an important association between fibromyalgia and various forms of psychopathology.
To determinate the prevalence of several mental disorders and its relationship with sex among patients admitted in a Psychiatric Unit.
The sample included all patients hospitalized in a Psychiatric Unit at the Hospital “Virgen de las Nieves” in the city of Granada (southern Spain), during the time period between 1998 and 2006 (n=1873). The tenth version of international classification diseases (ICD-10) was used to classify the mental disorders.
The principal diagnoses were psychotic disorders (36%), affective disorders (30%), substance-related disorder (8%) and personality disorder (7%). The prevalence of men was 57% and the prevalence of women was 43%. Male sex was significantly associated with substance-related disorder (OR=3.2; IC 95 %: 2.1-4.9), schizophrenia (OR=3.7; IC 95 %: 2.7-4.9) and mental retardation (OR=1.2; IC 95 %: 2.4-4.0). Female sex was significantly associated with bipolar disorder (OR=1.7; IC 95 %: 1.3-2.3), dysthymia and other depressive disorders (OR=2.4; IC 95 %: 1.9-3.1) and neurotic disorders (OR=2.3; IC 95 %: 1.4-3.7).
According with literature (Vogel et al, 1997) the principal diagnoses among patients hospitalized were psychotic disorders, followed by affective disorders. Previous epidemiological studies have shown similar prevalence of bipolar disorder among both sexes (Kessler et al, 1997; Kawa et al, 2005). Nevertheless, among patients with bipolar disorder who need hospitalization may be more women.
Antipsychotic treatment is known to be associated with secondary sexual dysfunction (SD). Recognition and treatment of this adverse effect has received growing attention. Until now, all antipsychotic agents were thought to potentially cause SD mediated by increased prolactin. Our aim was to observe whether aripiprazole modifies SD in patients with schizophrenia after 3 months of treatment.
Material and Methods:
Multicenter, observational, open-label, prospective, three-month study with single group of aripiprazole treated patients. Sexual activity was assessed using CGI-S and CGI-I for SD; SALSEX scale, validated for Spanish, 3 times after initiating study drug. Patient's clinical status was evaluated by CGI-S and CGI-I for psychotic disorders, and by BPRS Scale.
Result: 42 patients (70% men), 38 completed the study. Incidence of SD at 3 months was null for all patients studied. As period of treatment advanced, the Salsex score decreased, showing a mean overall reduction of –5 points (SD 3.6). Largest reduction was observed in subgroup of patients with SD in baseline visit, who exhibited a mean reduction of –6 points (SD 3.1).
Men with SD in baseline evaluation showed more marked improvement than women at 40 days of treatment (p=0.0447). However, recovery was similar for both groups at 90 days of treatment.
In schizophrenia, SD secondary studies to antipsychotics are important in establishing effectiveness of these agents in chronic treatment. After 3 months of aripiprazole treatment, no SD was observed in patients. Patients who presented SD at study initiation improved over course of 3 months treatment with aripiprazole.
Depression is associated with high rates of comorbidity with other psychiatric disorders. Adherence to antidepressant medication regimens has been associated to different factors. Few studies have analyzed the influence of comorbid psychiatric disorders and adjunctive pharmacological treatments on antidepressant adherence.
The study evaluates the association of comorbid psychiatric disorder and pharmacological treatments with adherence rates to antidepressants in a large sample of depressive outpatients.
3606 depressive patients were included in a cross-sectional epidemiological study, involving a stratified sample of 750 psychiatrists selected to participate. Patients were included if they met DSM-IV criteria for current single or recurrent non-psychotic major depressive disorder. Simplified Medication Adherence Questionnaire (SMAQ) and Hamilton Depression Rating Scale (HDRS) were used to assess adherence and depression severity.
Adherence rates are lower in depressive patients with psychiatric comorbidity (62.8%) than in patients without comorbidity (69.1%) (Chi-square = 15.9, p < 0.001, OR = 1.6, 1.2–1.8). There are no significant differences in adherence rates between those patients taking or not benzodiacepines.
Psychiatric comorbidity plays a negative role in adherence to antidepressant treatment. Benzodiazepine use has no influence on adherence rates. Special attention should be paid to the symptom overlapping between anxiety and depression and to the benzodiazepine prescription in comorbid depressive patients.
Schizophrenia is a psychiatric disorder which involves chronic or recurrent psychosis and it is commonly associated with impairment in social and occupational functioning. Antipsychotic medications are a first-line treatment, however, most patients experience disabling impairment even after benefiting from antipsychotics, including positive and negative symptoms, cognitive deficits, poor social functioning and episodes of acute symptomatic relapse.
Systematic literature review in UpToDate and Pubmed.
To identify the most relevant intervention areas of systematic rehabilitation in schizophrenia.
45 years old schizophrenic male who admitted in a Medium Stay Psychiatry Unit with severe behavioural impairment and psychotic symptoms. At least 10 hospitalizations and pronounced disability in basic life skills despite optimal treatment. Poor insight and compliance, frequent relapses, co-morbid substance abuse and difficult family support. Clozapine was added to his treatment with improvement in psychotic symptoms. A multidisciplinary intervention was also done and he was discharged home with important improvement in social skills, better insight and familiar functioning
Despite following an adequate antipsychotic treatment, including Clozapine as the main medication in resistant schizophrenia, it is often partially effective with severe impairments in social and occupational functioning. Family-based interventions, cognitive behavioural therapy and social skills training, added to this medication seem to be essential in the systematic treatment of schizoprenia. It includes a multidisciplinary team and a specific length of time but it is based on the patient's status. Despite evidence of their efectiveness, the availability of these interventions varies widely, as does the availability of clinicians to provide them.
Recently, a renaissance of interest in ‘negative symptoms’ as emotional withdrawal or blunted affect, has occurred. Some investigators believe that these symptoms are important indicators of outcome, of response to treatment and of a distinct underlying pathologic process.
Research on the negative-symptom syndrome in schizophrenia has been handicapped until recently.
This research aims at studying whether acute phase proteins, precisely, Alpha1-glycoprotein, can be considered as a marker of negativesymptom in Schizophrenia.
29 chronic schizophrenics were assessed by the Positive and Negative Syndrome Scale (PANSS). A routine blood test including Alpha1-glycoprotein levels was carried out.
Alpha1-glycoprotein shows a positive correlation, according to Pearson correlation coefficient, with the Negative Scale at an almost significant level (p=.05), and at a significant level in the following items, Blunted affect (p=.03), Passive/apathetic Social Withdrawal (p=.01) of the Negative spectrum and Poor Attention (p=.02) of the General Psychopathology Scale.
There is a significant correlation with two Negative variables and an almost significant one, spite of the small sample, with the Negative Scale. Further studies with bigger samples are needed in order to consider alpha1-glycoprotein as a schizophrenia negative psychopathology marker.
The objective of the present study was to examine the predictive value of clinical and cognitive -including the cognitive reserve (CR) - variables on the severity of the patient's illness at one year of follow-up.
A study was held with 45 patients with first episode psychosis (FEP) from 3 main hospitals in the Basque Country (Spain). All patients underwent cognitive, clinical, and functional assessments at baseline and at 6 months follow-up. The cognitive measures included were: the Stroop test, Vocabulary sub-test from WAIS-III, the WCST, and Trail Making Test. The clinical and functional measures included were: Positive and Negative Syndrome Scale (PANSS), Young Mania Scale, Montgomery-Asberg Depression scale, and CGI (Clinical Global Impression).
Six-months follow-up data were available for 29 patients. Regression analysis was performed with the 6-month follow-up CGI measure as a dependent variable. Results showed that after controlling for CGI at baseline, -PANSS Negative Symptoms Scale (B = 0.47, p ≤ .05) and the CR measure -Vocabulary from WAIS-III- (B = 0.36, p ≤ .05) were the only two which significantly predicted severity of illness after 6 months (R2 = 0.44) and remained significant when CGI at base line was controlled in the regression analysis. The rest variables did not reach statistical significance.
These findings emphasize that CR have a role on outcome in first episode psychosis, and enhance that exist a relation between cognition and clinical measures in psychosis.
Basque Government, Health Department (2008111010); EITB-Maratoia (BIO 09/EM/015).
The Eiffel study is a longitudinal, naturalistic study of patients with first episode psychosis (FEP) designed to evaluate the predictive value of defective insight on treatment adherence and global functioning.
Five hundred seventy-seven patients with FEP were assessed at baseline and at a 1-year follow-up. They were compared in terms of sociodemographic factors, psychopathology, insight, treatment adherence and functional outcome. Longitudinal functionality was prospectively assessed with the clinical global impression (CGI) and global assessment of functioning (GAF) rating scales.
At baseline, up to 50% of our sample presented with a lack of insight. Most clinical symptoms, including insight, improved over the follow-up period. Insight, education and social withdrawal significantly predicted CGI and GAF at follow-up. Insight and level of education were predictive of treatment adherence.
Insight significantly predicted the general clinical course, treatment adherence and functional outcome in our FEP sample after 1 year. Only education additionally accounted for the longitudinal course. Since our results suggest that better insight improves treatment adherence and consequently clinical course and functional outcome, insight could be a specific target of treatment in early intervention programs.
Comorbidity between alcoholism and depression has long been acknowledged, and the possibility that similar brain mechanisms, involving both serotonergic (5-HT) and noradrenergic systems (NE), underlie both pathologies has been suggested. Thus, inhibitors of NE and 5HT uptake have been proposed for the treatment of alcoholism, as they have shown to reduce alcohol intake in various animal models. However, most of the studies mentioned were carried out acutely and there is a lack of knowledge of the possible long-term effects. Clinical studies report an overall low efficacy of antidepressant treatment on alcohol consumption, or even a worsened prognosis. In addition, several cases of alcohol dependence following antidepressant treatment have been reported in the literature.
We aimed at comparing the acute and chronic effects of the treatment with the antidepressant drug reboxetine on alcohol consumption.
We used a rat model of alcohol self-administration, and two different schedules of reboxetine administration (acute and chronic).
Our results confirm the acute suppressant effects of reboxetine on alcohol consumption but indicate that, when this drug is administered chronically in a period of abstinence from alcohol, it can significantly increase the rate of alcohol self-administration.
These results are important for the understanding of the clinical reports describing cases of increased alcohol consumption after antidepressant treatment, and suggest that much more research is needed to fully understand the long term effects of antidepressants, which remain the most widely prescribed class of drugs.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Several trials have shown the efficacy of long acting injectable (LAI) second-generation anti-psychotics compared with other anti-psychotics. LAI aripiprazole is a novel therapeutic tool in the management of patients with schizophrenia.
The present study aimed to evaluate the clinical outcomes of patients who initiated treatment with LAI aripiprazole, by comparing their clinical outcomes prior and after initiating treatment with LAI aripiprazole.
This observational, retrospective, mirror study assessed a series of socio-demographic and clinical variables during the 12 months prior to commencing LAI aripiprazole, while on another anti-psychotic medication, and the first 12 months of LAI aripiprazole. The sample included a series of consecutive patients receiving LAI aripiprazole at the Doctor Peset university hospital health area, in Valencia (Spain). The variables analyzed in the study included: emergency room visits, number and average length of hospitalizations, relapse, rate of abandonment of treatment and number of anti-psychotics needed as maintenance treatment.
The preliminary analysis showed a reduction in the rate of emergency room visits and the number of relapse and total hospitalizations while on LAI aripiprazole; however, there is no a reduction of the average length of hospitalizations. A reduction in the number of anti-psychotics as maintenance treatment was not appreciated, however, there was an improvement in treatment adherence.
The preliminary results showed that LAI aripiprazole is an useful option that could suppose a benefit concerning treatment adherence, a decreased in number of relapses and hospitalizations and use of health resources.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
The death rate due to suicide in elderly people is particularly high. As part of suicide selective prevention measures for at-risk populations, the WHO recommends training “gatekeepers”.
In order to assess the impact of gatekeeper training for members of staff, we carried out a controlled quasi-experimental study over the course of one year, comparing 12 nursing homes where at least 30% of the staff had undergone gatekeeper training with 12 nursing homes without trained staff. We collected data about the residents considered to be suicidal, their management further to being identified, as well as measures taken at nursing home level to prevent suicide.
The two nursing home groups did not present significantly different characteristics. In the nursing homes with trained staff, the staff were deemed to be better prepared to approach suicidal individuals. The detection of suicidal residents relied more on the whole staff and less on the psychologist alone when compared to nursing homes without trained staff. A significantly larger number of measures were taken to manage suicidal residents in the trained nursing homes. Suicidal residents were more frequently referred to the psychologist. Trained nursing homes put in place significantly more suicide prevention measures at an institutional level.
Having trained gatekeepers has an impact not only for the trained individuals but also for the whole institution where they work, both in terms of managing suicidal residents and routine suicide prevention measures.