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The use of product-service systems business models is increasing in today's economy. Because the products that provide the service to the customers incur cost during their lifetime, the method of lifecycle costing finds wide-spread use. However, this paper shows the current methods have some inaccuracies when determining lifecycle costs. The methods do not consider the required number of products necessary to provide the offered service to the customers. This paper describes a new framework for lifecycle costing that includes these cost components.
Aim was to evaluate influencing factors of response and symptomatic remission in first-episode schizophrenia patients treated with risperidone or haloperidol.
229 first-episode schizophrenic patients were examined within a double blind controlled trial of the German Study Group on first-episode schizophrenia with biweekly PANSS ratings. Response was defined according to the definition by Lieberman et al. (2003) and symptomatic remission as the severity component of the consensus remission criteria by the Remission in Schizophrenia Working Group. Sociodemographic, psychopathological and functional variables as well as the treatment applied were evaluated regarding their potential predictive validity for treatment outcome. Univariate tests, logistic regression and CART-analyses were consulted as statistical methods.
126 patients (55%) achieved response and 118 patients (52%) symptomatic remission at discharge with no significant differences between the risperidone (51%) and haloperidol (49%) treated patients. Better baseline functioning, early treatment response, less depressive symptoms and a shorter duration of untreated psychosis were revealed significant predictors of response. Patients with symptomatic remission also had a significantly shorter duration of untreated psychosis and significantly less depressive symptoms at baseline. Logistic regression and CART-analyses revealed low general psychopathology, early treatment response and a high score in the Strauss-Carpenter-Prognostic-Scale at admission to be significantly positive predictive for symptomatic resolution.
Early treatment response, depressive symptoms and the level of psychosocial functioning were revealed to significantly predict outcome, with no significant differences between risperidone and haloperidol. The importance of an early adequate symptom control and the implementation of early intervention programs is highlighted.
Attempts to reduce high utilisation of psychiatric inpatient care by targeting the critical time of hospital discharge have been rare. In Germany, until now no such intervention has been implemented, let alone subjected to a clinical trial.
“Effectiveness and Cost-Effectiveness of Needs-Oriented Discharge Planning and Monitoring for High Utilisers of Psychiatric Services” (NODPAM) is a multicentre RCT conducted in five psychiatric hospitals in Germany (Günzburg, Düsseldorf, Regensburg, Greifswald, and Ravensburg). Subjects asked to provide informed consent to participate have to be of adult age with a primary diagnosis of schizophrenia or affective disorder, and a defined high utilisation of psychiatric care during two years prior to the current admission. Subjects are asked to provide detailed outcome data at four measurement points during a period of 18 months. Recruitment (which started in April 06) is still ongoing. Thus, baseline data of about 350 participants will be presented.
Recruitment has been quite successful and the study has been generally well accepted by participating patients and their clinicians in in- and outpatient treatment settings. Subjects showed substantial initial impairment on outcome measures (e.g. needs, psychopathology, quality of life, and level of functioning) and high utilisation of mental health care. Further results on conduct and feasibility of the trial will be presented.
The first phase of this mulicentre trial was promising. The potential of this study to strengthen the integration of mental health care provision in Germany will be discussed.
Cognitive impairment substantially contributes to functional disability in schizophrenia. Methods to improve functioning in long-term hospitalized patients are lacking. Cognitive Adaptation Training (CAT) improves functional outcomes in schizophrenia outpatients living in the US.
To investigate the efficacy of CAT in long-term hospitalized schizophrenia patients living in the Netherlands.
Twenty schizophrenia inpatients participated in this study. Ten patients received treatment as usual (TAU), the other 10 patients received TAU plus CAT. CAT uses environmental supports (e.g. calendars, alarm clocks) in order to compensate the impact of cognitive impairment. CAT was provided for 8 months. Assessments of the Multnomah Community Ability Scale (MCAS) and SOFAS were conducted at baseline, halfway, and after 8 months. In addition, participation in work-related activities (e.g. woodworking, graphic center) was recorded every month for a duration of 12 months. Anayses of mixed models were conducted, using the baseline score as a covariate.
After 6 months, CAT patients spent significantly more partial days at activity centers, compared to TAU patients. Differences remained significant after 12 months. With regard to the other measures, CAT patients showed improvement on the SOFAS and the MCAS after 8 months (trend) with a large effect size (0.8).
These findings suggest that inpatients with schizophrenia may benefit from CAT. In particular, the method may be effective to increase productivity in this chronic population. These results are promising, research with a larger sample size is needed to further investigate the effect of CAT in long-term hospitalized psychiatric patients.
The self or identity is often seriously challenged by the emergence of psychotic symptoms. A first reason for that is most likely due to the traumatic experience caused by the sudden emergence of hallucinations or persecutory ideas that challenge both the representation of oneself and that of the world and others. A second reason is linked to the social consequences of having a mental illness and of being assigned with the label of “mentally ill or disabled person”. A third relates to the patients’ cognitive impairment that alters their ability to take distance from these self-challenging events, to give a meaning to these experiences and to build coherent narratives of their life that integrate a great variety of personal experiences such as turning points or unpleasant events. For these reasons, recovering from a severe mental illness is a process through which the self evolves by integrating the lessons of past personal events, building new representations of oneself and looking to new directions for future projects. Excerpts of patients’ narratives collected in experimental setting will be presented in order to illustrate how indexes of recovery can be measured in self-narratives and how they help identifying the steps of self-recovery that have been identified in qualitative research on patients with schizophrenia .
The speed of onset of depressive episodes is a clinical aspect of affective disorders that has not been sufficiently investigated. Thus, we aimed to explore whether patients with fast onset of the full-blown depressive symptomatology (≤ 7 days) differ from those with slow onset (> 7 days) with regard to demographic and clinical aspects.
Subjects and methods:
Data were obtained within an observational study conducted in outpatients with major depression who were treated with duloxetine (30–120 mg/day). Onset of depression (without any preceding critical life event) was fast in 416 (less than one week) and slower in 2220 patients.
Compared to patients with slow onset, those with fast onset of depression had more suicide attempts in the previous 12 months (2.7% versus 1.3%, P = 0.046) and less somatic comorbidity (61.7% versus 74.1%, P < 0.0001). In addition, they were slightly younger at onset of depression (mean ± SD 40.2 ± 14.6 versus 42.8 ± 14.2 years, P < 0.001) and used analgesics at baseline significantly less frequently (22.8% versus 33.4%, P < 0.0001).
Discussion and conclusion:
The speed of onset of depression has to be regarded as a relevant clinical characteristic in patients with unipolar depression.
The use of clozapine (CLZ) for treatment-resistant schizophrenia is well established in adults. However, it is seldom used in youth with early onset schizophrenia (EOS) largely because of lack of clarity about its risk benefit ratio. This review synthesises and evaluates available evidence regarding the efficacy and tolerability of CLZ in EOS with the aim to assist clinical decision-making.
We conducted a systematic review of the primary literature on the clinical efficacy and adverse drug reactions (ADRs) observed during CLZ treatment in EOS. We also identified relevant practice guidelines and summarised current guidance.
CLZ showed superior efficacy than other antipsychotics in treating refractory EOS patients; short-term clinical trials suggest an average improvement of 69% on the Brief Psychiatric Rating Scale that was sustained during long-term follow-up (up to 9 years). No fatalities linked to CLZ treatment were reported. Sedation and hypersalivation were the most common complaints, reported by over 90% of patients. Other common ADRs (reported in 10-60% of patients) were enuresis, constipation, weight gain, and non-specific EEG changes. Less common ADRs (reported in 10-30% of patients) were akathisia, tachycardia and changes in blood pressure. Neutropenia was reported in 6–15% of cases but was usually transient while agranulocytosis was rare (< 0.1%). Seizures were also uncommon (< 3%). Metabolic changes were relatively common (8–22%) but emergent diabetes was not frequently observed (< 6%). Overall the rate of discontinuation was low (3–6%). Current guidelines recommend the use of CLZ in EOS patients who have failed to respond to two adequate trials with different antipsychotics and provide detailed schedules of assessments to evaluate and assess potential ADRs both prior to initiation and throughout CLZ treatment.
Available data although limited in terms of number of studies are consistent in demonstrating that CLZ is effective and generally safe in the treatment of refractory EOS provided patients are regularly monitored
The use of clozapine (CLZ) for treatment-resistant schizophrenia is well established in adults. However, it is seldom used in children and adolescents with early onset schizophrenia (EOS) largely because of lack of clarity about its risk benefit ratio. This review synthesises and evaluates available evidence regarding the efficacy and tolerability of CLZ in EOS with the aim to assist clinical decision-making.
We conducted a systematic review of the primary the literature on the clinical efficacy and adverse drug reactions (ADRs) observed during CLZ treatment in EOS. We also identified relevant practice guidelines and summarised current guidance.
CLZ showed superior efficacy than other antipsychotics in treating refractory EOS patients; short-term clinical trials suggest an average improvement of 69% on the Brief Psychiatric Rating Scale that was sustained during long-term follow-up. No fatalities linked to CLZ treatment were reported. Sedation and hypersalivation were the most common complaints (90% of patients). Other common ADRs (10-60% of patients) were enuresis, constipation, weight gain, and non-specific EEG changes. Neutropenia was reported in 6-15% while agranulocytosis was rare. Seizures were also uncommon. Metabolic changes were relatively common (8-22%). Overall the rate of discontinuation was low (3-6%). Current guidelines recommend the use of CLZ in treatment-resistant EOS patients and provide detailed schedule of assessments to evaluate and assess potential ADRs both prior to initiation and throughout CLZ treatment.
Available data is consistent in demonstrating that CLZ is effective and generally safe in the treatment of refractory EOS provided patients are regularly monitored.
Increasing evidence suggests that clock genes may be implicated in a spectrum of psychiatric diseases, including sleep and mood related disorders as well as schizophrenia. The bHLH transcription factors SHARP1/DEC2/BHLHE41 and SHARP2/DEC1/BHLHE40 are modulators of the circadian system and SHARP1/DEC2/BHLHE40 has been shown to regulate homeostatic sleep drive in humans.
In this study, we characterized Sharp1 and Sharp2 double mutant mice (S1/2-/-) using online EEG recordings in living animals, behavioral assays, global gene expression profiling and bioinformatic modeling. Gene expression in human brains samples was performed with qRT-PCR.
EEG recordings revealed attenuated sleep/wake amplitudes and alterations of theta oscillations. Increased sleep in the dark phase is paralleled by reduced voluntary activity and cortical gene expression signatures reveal associations with psychiatric diseases. S1/2-/- mice display alterations in novelty induced activity, anxiety and curiosity. Moreover, mutant mice exhibit impaired working memory and deficits in prepulse inhibition resembling symptoms of psychiatric diseases. Network modeling indicates a connection between neural plasticity and clock genes, particularly for SHARP1 and PER1, which are also significantly downregulated in the frontal cortex of schizophrenic patients.
Our findings support the hypothesis that abnormal sleep and certain (endo)phenotypes of psychiatric diseases may be caused by common mechanisms involving components of the molecular clock including SHARP1 and SHARP2
This chapter contains discussion of two distinct skeptical ways around the Darwinian problem of evil. One way is neo-Cartesian theory, according to which we are in no epistemic position to know that animals suffer in a subjective manner comparable to the conscious suffering of human beings. The other is Skeptical Theism, according to which we are in no epistemic position to say with confidence that some apparently gratuitous evils really are gratuitous, i.e., not grounded in morally sufficient reasons that God has for allowing them. The author explains why he does not accept either of these skeptical means of escape from the Darwinian Problem. The prima facie appearance of animal suffering is too strong to be overridden by the reasons and evidence that advocates of the neo-Cartesian view give for such skepticism. Further, the author contends that the absence of God-justifying explanation, which advocates of Skeptical Theism see as expected on theism, is in fact incompatible with the parental goodness of God.
The chapter includes a comprehensive account of the Darwinian problem of evil, centered on evolutionary animal suffering inscribed by natural selection into the conditions of existence. The author contends that the problem arises from the unveiling of a Darwinian World by modern scientists. They have unveiled four interconnected truths about the natural realm, as it has been in the past, and as it is now. The unveilings are (1) “deep evolutionary time,” (2) a “plurality of worlds” existing successively in the planetary past, (3) “aniti-cosmic micro-monsters” that cause widespread, brutal suffering for animals, and (4) “evil inscribed,” i.e., that animal suffering in nature is not accidental, but is systemic – inscribed by natural selection into the conditions of existence for animals. It seems that the source of evolutionary evils suffered by animals is not a Fall, as traditionally alleged by theists, but the design of nature itself.
In this chapter the author considers Aesthetic Theodicy, according to which selected forms of cosmic beauty are valuable enough to justify natural evils suffered by animals. He begins by defending the use of aesthetic values in theodicy on the ground that aesthetic goods often have moral value. He then examines the classical versions of Aesthetic Theodicy, in which one appeals to cosmic harmony, balance, and overall fittingness of all parts into a beautiful and morally valuable whole. This approach fails to account well enough for the extreme disharmony, imbalance, and dysteleology in the Darwinian World, as unveiled by science. Next, he examines post-classical versions, in which one appeals to “major beauty” (so Whitehead) created by cosmic conflict and disintegrative elements of nature. He examines the specific appeal to the tragic moral beauty of evolution, particularly in predation. He argues that these approaches identify morally valuable forms of beauty, but they do not contain scenarios in which God defeats tragic evils for the victims. Nor can the appeal to tragedy account for the existence of Darwinian horrors. He concludes that perhaps sacred canonical sources can help.
This chapter includes a defense of Rolston’s thesis that Darwinian evolution is “cruciform” or “kenotic” in character, i.e., that the self-sacrificial role of animals in nature is strongly analogous to the part played by Jesus Christ in redeeming the world. With Southgate, the author rejects Rolston’s conclusion, however, that the moral goodness of this “cruciformity” outweighs and justifies evolutionary suffering. The Darwinian kenōsis (the author’s phrase) has partial God-justifying force, but for full justification an eschatological sequel is required. The comparison strengthens the position of theism in the controversy on both the evidential and justificatory levels of the Darwinian problem of animal suffering. The author also argues that Paul’s famous digression on divine election in Romans 8-11 provides unexpected help on all these levels. It supports the aesthetic analogue of God as Artist, and the imagery helps to sharpen the thesis taken from Job: God is creating the messianic Cosmos by extraordinary artistic-moral means. In the emergence of the Church from the cross, we can already begin to “see” the truth of this proclamation.
In this chapter, the author explores the book of Job for a perspective on the modern Darwinian Problem of evil. He concurs with recent scholars who reject the commonplace reading of Job, i.e., that God refuses to answer Job’s question: how can his suffering be just? He concurs with Carol Newsom that in the divine speeches at the end, God answers Job indirectly in the form of carefully crafted symbolic poetics, the rhetorical structure and imagery of which radically reconstruct Deuteronomic tradition on God and suffering. The author proposes that the treatment of God and wild animals in Job makes the Darwinian configuration of animal suffering more plausible on canonical theism than commonly supposed. He further proposes that Job provides grounds for belief that the Jewish/Christian God will defeat evils for animals and include them in the messianic eschatological realm. Job offers a religiously framed aesthetic perspective on Darwinian evil that helps us to recover the “theistic sight” in nature that Darwinian discoveries have obscured.