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The move towards the use of second-generation antipsychotics for the treatment of schizophrenia has provoked much discussion over how to differentiate between the various second-generation agents available on the market. The aim of this review is to provide information that may help clinicians in the decision-making process. The results of comparative studies on general efficacy measures (such as the Positive and Negative Syndrome Scale [PANSS] and the Brief Psychiatric Rating Scale [BPRS]) and comparative studies on cognition do not clearly favour one second-generation agent over another. However, some differences between second-generation agents have become apparent from studies which have examined specific symptoms such as hostility, suicidal ideation and depression/anxiety. There are also differences between second-generation agents with regard to specific aspects of tolerability. For example, in a number of studies olanzapine is associated with fewer extrapyramidal symptoms (EPS) than risperidone, but treatment with risperidone or amisulpride is associated with less weight gain and somnolence. Some studies have investigated the results of switching patients from one antipsychotic agent to another. They have generally reported a successful switch to a second-generation agent.
Overall, there is not enough scientific evidence available to clearly favour one second-generation antipsychotic agent over another in terms of general efficacy or tolerability. Therefore, clinicians must make an individualised treatment decision, and select the most appropriate antipsychotic agent for each patient.
Cognitive dysfunction is increasingly considered to be the strongest clinical predictor of poor long-term outcome in schizophrenia. Associations have been found between the severity of cognitive deficits and social dysfunction, impairments in independent living, occupational limitations, and disturbances in quality of life (QOL).
In this cross-sectional study, the relationships of cognitive deficits and treatment outcomes in terms of QOL, needs, and psychosocial functioning were examined in 60 outpatients with schizophrenia who had a duration of illness over 2 years and had been treated with either clozapine or olanzapine for at least 6 months.
The present study suggests that cognitive functioning might be a predictor of work functioning/independent living outcome in stabilized patients with schizophrenia: deficits of visual memory and working memory were negatively associated with occupational functioning, and older patients lived independently and/or in a stable partnership more often. The patients' assessments of QOL and needs for care did not show any significant associations with cognitive functioning.
These findings suggest that cognitive functioning is a key determinant of work functioning/independent living for stable outpatients with schizophrenia.
The present cross-sectional study examined the relationships of psychopathology, side effects, and sociodemographic factors with treatment outcomes in terms of patients' quality of life (QOL), functioning, and needs for care.
Sixty outpatients with chronic schizophrenia who had been treated with either clozapine or olanzapine for at least 6 months were investigated.
Most psychopathological symptoms as well as psychic side effects, weight gain, and female sex were associated with lower QOL, while cognitive symptoms correlated with better QOL. Female sex, cognitive symptoms, and parkinsonism negatively influenced occupational functioning, and negative symptoms determined a lesser likelihood of living independently. Age, education, depression/anxiety, negative symptoms, and psychic side effects were predictors of patients' needs for care.
Our results highlight the complex nature of patient outcomes in schizophrenia. They reemphasize the need of targeting effectiveness, i.e. both symptomatic improvement as well as drug safety, in such patients.
Outcome in schizophrenia is multidimensional and consists of clinical and psychosocial domains. Difficulties in affect recognition are a hallmark of schizophrenia, but there is little research investigating the consequences of this deficit on patients’ psychosocial status. This cross-sectional study examined the relationship of facial affect recognition and treatment outcomes in terms of psychopathology, quality of life (QOL), and psychosocial functioning.
We investigated 40 regular attendees of a specialized schizophrenia outpatient clinic who had been stable both from a symptomatic and a medication perspective for a minimum of 6 months and 40 healthy volunteers who were chosen to match patients in age, sex, and education. Affect recognition was positively associated with patients’ level of education and negatively with increasing age. Deficits in this area corresponded to the severity of negative and affective symptoms as well as to poor work and global functioning. These findings suggest that affect recognition is an important aspect of psychosocial functioning in stable outpatients with schizophrenia.
Health-related quality of life (HRQOL) is significantly affected in individuals with schizophrenia or bipolar I disorder (BD-I). The current study investigated whether symptomatic remission and resilience might differently impact HRQOL in these patients.
Fifty-two patients with schizophrenia and 60 patients suffering from BD-I from outpatient mental health services as well as 77 healthy control subjects from the general community were included into a cross-sectional study. HRQOL and resilience were assessed using the WHOQOL-BREF and the Resilience Scale. In patients, psychopathology was quantified by the Positive and Negative Syndrome Scale or the Montgomery Asberg Depression Rating Scale and the Young Mania Rating Scale, respectively.
Notably, both patient groups showed lower HRQOL and resilience compared to control subjects, non-remitted patients indicated lower HRQOL than remitted ones. The effect of remission on HRQOL was significantly larger in patients with BD-I than in those with schizophrenia but did not explain the difference in HRQOL between groups. Resilience predicted HRQOL in all three groups. When accounting for the effect of resilience among remitted patients, only the difference in HRQOL between schizophrenia patients and control subjects was significant.
These findings demonstrate the impact of symptomatic remission and resilience on HRQOL of both patients suffering from schizophrenia and BD-I and indicate that these factors are especially relevant for HRQOL of patients with BD-I.
The Antipsychotic Long-acTing injection in schizOphrenia (ALTO) study was a non-interventional study across several European countries examining prescription of long-acting injectable (LAI) antipsychotics to identify sociodemographic and clinical characteristics of patients receiving and physicians prescribing LAIs. ALTO was also the first large-scale study in Europe to report on the use of both first- or second-generation antipsychotic (FGA- or SGA-) LAIs.
Patients with schizophrenia receiving a FGA- or SGA-LAI were enrolled between June 2013 and July 2014 and categorized as incident or prevalent users. Assessments included measures of disease severity, functioning, insight, well-being, attitudes towards antipsychotics, and quality of life.
For the 572 patients, disease severity was generally mild-to-moderate and the majority were unemployed and/or socially withdrawn. 331/572 were prevalent LAI antipsychotic users; of whom 209 were prescribed FGA-LAI. Paliperidone was the most commonly prescribed SGA-LAI (56% of incident users, 21% of prevalent users). 337/572 (58.9%) were considered at risk of non-adherence. Prevalent LAI users had a tendency towards better insight levels (PANSS G12 item). Incident FGA-LAI users had more severe disease, poorer global functioning, lower quality of life, higher rates of non-adherence, and were more likely to have physician-reported lack of insight.
These results indicate a lower pattern of FGA-LAI usage, reserved by prescribers for seemingly more difficult-to-treat patients and those least likely to adhere to oral medication.
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) was published by the American Psychiatric Association (APA) in 2013, and the Work Group on the Classification of Psychotic disorders (WGPD), installed by the World Health Organization (WHO), is expected to publish the new chapter about schizophrenia and other primary psychotic disorders in 2017. We reviewed the available literature to summarize the major changes, innovations, and developments of both manuals. If available and possible, we outline the theoretical background behind these changes. Due to the fact that the development of ICD-11 has not yet been completed, the details about ICD-11 are still proposals under ongoing revision. In this ongoing process, they may be revised and therefore have to be seen as proposals. DSM-5 has eliminated schizophrenia subtypes and replaced them with a dimensional approach based on symptom assessments. ICD-11 will most likely go in a similar direction, as both manuals are planned to be more harmonized, although some differences will remain in details and the conceptual orientation. Next to these modifications, ICD-11 will provide a transsectional diagnostic criterion for schizoaffective disorders and a reorganization of acute and transient psychotic and delusional disorders. In this manuscript, we will compare the 2 classification systems.
Long-acting injectable formulations of antipsychotics are treatment alternatives to oral agents.
To assess the efficacy of aripiprazole once-monthly compared with oral aripiprazole for maintenance treatment of schizophrenia.
A 38-week, double-blind, active-controlled, non-inferiority study; randomisation (2:2:1) to aripiprazole once-monthly 400 mg, oral aripiprazole (10–30 mg/day) or aripiprazole once-monthly 50mg (a dose below the therapeutic threshold for assay sensitivity). (Trial registration: clinicaltrials.gov, NCT00706654.)
A total of 1118 patients were screened, and 662 responders to oral aripiprazole were randomised. Kaplan–Meier estimated impending relapse rates at week 26 were 7.12% for aripiprazole once-monthly 400mg and 7.76% for oral aripiprazole. This difference (−0.64%, 95% CI −5.26 to 3.99) excluded the predefined non-inferiority margin of 11.5%. Treatments were superior to aripiprazole once-monthly 50mg (21.80%, P⩽0.001).
Aripiprazole once-monthly 400mg was non-inferior to oral aripiprazole, and the reduction in Kaplan–Meier estimated impending relapse rate at week 26 was statistically significant v. aripiprazole once-monthly 50 mg.
Austria covers an area of some 84 000 km2 and has a population of 8.1 million. According to World Bank criteria, Austria is a high-income country. The overall health budget represents 8% of gross domestic product (World Health Organization, 2005). The state of Austria is divided into nine federal provinces, which have significant legislative rights, including in healthcare provision.
Life expectancy at birth is 76.2 years for males and 82.3 years for females (in 2005). The proportion of the population under the age of 15 years is 15% and the proportion above 65 years is 17%. Austria is among the 19 countries worldwide which are projected to have at least 10% of their population aged 80 years or over by the year 2050. Since some mental disorders, such as dementia, increase with age, the number of psychiatric patients will probably rise dramatically.
Mental health policy and services
The number of psychiatric hospital beds has decreased substantially. In the year 2001 there were 4696 psychiatric beds in total (i.e. 59 per 100 000 population), down from nearly 12 000 beds in 1974 – a decrease of more than 60%.
The National Hospital Plan includes suggestions for the establishment of psychiatric units in general hospitals. Ten psychiatric units in general hospitals have been established, and several others are planned. Most traditional mental hospitals have been transformed to meet the needs of patients with acut mental illness. In addition, some of them have extended their services to people with physical diseases.
Each of the nine provinces has developed a mental health plan. Although there are regional differences between these, the key points of all plans are: a focus on community psychiatry, the decentralisation of psychiatric services and the social reintegration of persons suffering from mental disorders. The planning and provision of community psychiatric services are the responsibility of the provinces. Although some provinces now have a comprehensive network of community services, others are less advanced. The majority of these services (for vocational rehabilitation, supported housing, counselling, etc.) are provided by private organisations, but are predominantly funded by government agencies. The staff includes a variety of different professions (e.g. psychiatrists, social workers, nurses, psychotherapists, psychologists).
Second-generation antipsychotics (SGAs) represent an advance in the long-term management of schizophrenia.
To review the available evidence concerning SGA long-acting injections (LAIs).
A systematic review of the literature was conducted using PubMed.
Risperidone long-acting injection was the first licensed SGA–LAI compound and is effective in the long-term management of schizophrenia, with a safety profile similar to that of oral risperidone. Olanzapine pamoate has recently been approved in Europe. In terms of efficacy, at injection intervals of up to 4 weeks it appears comparable to oral olanzapine, although the potential for ‘post-injection syndrome’ (delirium) calls for additional safety considerations. Paliperidone palmitate is currently under review with the licensing authorities. It also affords the potential advantage of monthly dosing.
More long-term comparisons of SGA–LAIs with oral SGAs as well as with first-generation antipsychotic LAIs are needed. These studies should include cost-effectiveness data.
Austria covers an area of some 84000 km2 and has a population of 8.1 million. According to World Bank criteria, Austria is a high-income country. The overall health budget represents 8% of gross domestic product (World Health Organization, 2005). The state of Austria is divided into nine federal provinces, which have significant legislative rights, including in healthcare provision.
Background. Previous studies have suggested that men and women process emotional stimuli differently. In this study, we used event-related functional magnetic resonance imaging (fMRI) to investigate gender differences in regional cerebral activity during the perception of positive or negative emotions.
Method. The experiment comprised two emotional conditions (positively/negatively valenced words) during which fMRI data were acquired.
Results. Thirty-eight healthy volunteers (19 males, 19 females) were investigated. A direct comparison of brain activation between men and women revealed differential activation in the right putamen, the right superior temporal gyrus, and the left supramarginal gyrus during processing of positively valenced words versus non-words for women versus men. By contrast, during processing of negatively valenced words versus non-words, relatively greater activation was seen in the left perirhinal cortex and hippocampus for women versus men, and in the right supramarginal gyrus for men versus women.
Conclusions. Our findings suggest gender-related neural responses to emotional stimuli and could contribute to the understanding of mechanisms underlying the gender disparity of neuropsychiatric diseases such as mood disorders.
El presente estudio transversal examinó las relaciones de las manifestaciones psicopatológicas, los efectos secundarios y los factores sociodemográficos con el resultado del tratamiento desde el punto de vista de la calidad de vida (CdV), el funcionamiento y las necesidades de asistencia de los pacientes.
Se estudió a 60 pacientes ambulatorios con esquizofrenia crónica que habían tenido tratamiento con clozapina u olanzapina durante 6 meses al menos.
La mayoría de los síntomas psicopatológicos, igual que los efectos secundarios psíquicos, el aumento de peso y el sexo femenino se asociaban con una CdV más baja, mientras que los síntomas cognitivos correlacionaban con una CdV mejor. El sexo femenino, los síntomas cognitivos y el parkinsonismo influían negativamente en el funcionamiento ocupacional, y los síntomas negativos determinaban una menor probabilidad de vida independiente. La edad, el nivel educativo, la depresión/ansiedad, los síntomas negativos y los efectos secundarios psíquicos eran predictores de las necesidades de asistencia de los pacientes.
Nuestros resultados destacan la naturaleza compleja de la evolución del paciente en la esquizofrenia y ponen de nuevo el énfasis en la necesidad de centrarse en la eficacia, es decir, en la mejoría de los síntomas y además la seguridad farmacológica, en estos pacientes.
Se considera cada vez más que la disfunción cognitiva es el predictor clínico más fuerte de mala evolución a largo plazo en la esquizofrenia. Se han encontrado asociaciones entre la gravedad de los déficit cognitivos y la disfunción social, la afectación de la vida independiente, las limitaciones ocupacionales y las perturbaciones en la calidad de vida (CdV).
En este estudio transversal, se examinó las relaciones de los déficit cognitivos y el resultado del tratamiento desde el punto de vista de la CdV, las necesidades y el funcionamiento psicosocial en 60 pacientes ambulatorios con esquizofrenia que tenían una duración de la enfermedad de más de 2 años y habían recibido tratamiento con clozapina u olanzapina durante al menos 6 meses.
El presente estudio indica que el funcionamiento cognitivo podría ser un predictor de la evolución en el funcionamiento laboral/vida independiente en los pacientes estabilizados con esquizofrenia: los déficit de memoria visual y memoria operativa se asociaban negativamente con el funcionamiento ocupacional, y los pacientes mayores vivían independientemente, en pareja estable o ambas cosas más a menudo. Las evaluaciones de los pacientes de la CdV y las necesidades de asistencia no mostraron asociaciones significativas con el funcionamiento cognitivo.
Estos hallazgos indican que el funcionamiento cognitivo es un determinante clave del funcionamiento laboral/vida independiente para los pacientes ambulatorios estables con esquizofrenia.
The extent to which antipsychotics improve patients' well-being is uncertain.
To examine psychopathology and patient-rated functioning and well-being in patients treated with risperidone.
In a 1-year, open-label, international multicentre trial of long-acting risperidone in 615 stable adult patients with schizophrenia, self-rated functioning and well-being were measured every 3 months using the Short Form 36-item questionnaire (SF–36). Psychopathology was quantified using the Positive and Negative Syndrome Scale (PANSS).
Significant improvements were found on the SF–36 mental component summary score and vitality and social functioning scales. PANSS and mental component summary scores were moderately correlated.
Patient-reported functioning and well-being appear to differ from investigator-rated psychotic symptoms. Patient-rated well-being should be assessed with symptoms to help measure treatment outcomes.
Schizophrenia is one of the most severe and debilitating major psychiatric diseases, with a yearly prevalence of 0.4–0.8% in the general population (Dohrenwend, 1980; Flekkoy, 1987) and a lifetime risk of 1–1.5% (Regier et al, 1984; Robins et al, 1984). It is the prototype of a severe mental illness, with the capacity to disrupt routine daily functions in all areas of life, but especially work, social relationships, and self-care. Schizophrenia also increases the vulnerability of a patient to physical and other mental disturbances (Koran et al, 1989). Until recently, the clinical course of this disease has been far worse than that of most other psychiatric disorders, thus making it devastating for many individuals and costly to society (McGlashan, 1988). Schizophrenic patients occupy 20–25% of all the beds available for psychiatric in-patient care and account for 40% of all long-stay hospital days (Talbott et al, 1987; Meise et al, 1992). It is not so much the direct costs associated with treatment, but rather the indirect costs, such as those that arise from morbidity and mortality, that place a severe burden on the social economy (Gunderson & Mosher, 1975; Hall et al, 1985; Rice et al, 1992).
Two studies have been performed to evaluate the effect of activation tasks on neuroleptic-induced akathisia (NIA). In the first sample (30 patients) we found a consistent increase of symptoms during mental activation while motor activation led to a decrease. In a second study 34 patients with the same diagnosis were evaluated, using slightly different statistical procedures: while the effects of motor activation were corroborated, mental activation did not change NIA. Since mental and motor activation are usually considered to increase tardive dyskinesia and Parkinsonism, these measures might be helpful in differentiating NIA from other antipsychotic-induced movement disorders.
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