Ann M. Mortimer

Elder abuse and dementia--a pilot study.

An anonymous postal questionnaire was distributed to 200 members of a voluntary organisation providing information and support for the carers of dementia sufferers. Carers were asked about the possible occurrence of verbal, physical abuse and neglect. Those carers who admitted to any form of abuse were compared with those who did not and risk factors in both carers and patients were analysed to determine risk factors for abuse. Fifty-five per cent of carers admitted to some form of abuse with verbal abuse being the most common form. Verbal abuse was associated with a poor premorbid relationship and social isolation of the carer and was found to be a risk factor for physical abuse. Those carers who had high GHQ scores and who had been caring for longer were more likely to physically abuse the person they cared for. This study supports the hypothesis that various categories of abuse have different correlates.

Stability of set-shifting and planning abilities in patients with schizophrenia

Patients with schizophrenia have deficits in executive function that involve attentional set-shifting and planning ability. It is unclear, however, whether such deficits are stable during the course of the illness or if they fluctuate in response to medication effects or symptom changes. Patients with a DSM-IV diagnosis of schizophrenia (n=28) and healthy control subjects (n=17) were tested on computerised measures of attentional set-shifting and planning at baseline and 9-month follow-up. The measures used were the Intra/Extradimensional Shift test (ID/ED) and the Stockings of Cambridge test (SoC) from the Cambridge Automated Neuropsychological Testing Battery (CANTAB). On both tests, the patients were poorer than controls at baseline; however, there was no evidence of change over the 9-month follow-up. Additionally, there was little evidence of a relationship between executive test performance and medication or length of illness. This study accords with the presence of executive processing deficits in schizophrenia that are stable across time.

Somatic treatment of psychotic depression: review and recommendations for practice.

The diagnosis, classification, and course of psychotic major depression (PMD) is considered with regard to its status as a distinct syndrome. Several factors, especially biological markers, suggest, although as yet do not confirm, that PMD is distinct from nonpsychotic major depression (NPMD), particularly for the purposes of treatment. This article provides a critical review of somatic treatments for PMD, with attention to problems of inadequate treatment, as well as underused and more recently introduced treatments. The somatic treatment options reviewed include (1) combined antidepressant (AD) and antipsychotic (AP) therapy with tricyclic antidepressants (TCAs) and typical APs; (2) electroconvulsive therapy (ECT); (3) amoxapine; (4) selective serotonin reuptake inhibitors (SSRIs), alone and in combination; (5) several atypical APs, alone and in combination; (6) mood stabilizers and anticonvulsants; and (7) some experimental treatments and surgery. A comprehensive treatment algorithm (heuristic) is presented, which draws on some previous guidelines and the critical review. This heuristic is conservative in its aims, but forward-looking in its recommendations. The status of the TCA plus typical AP regime is challenged as the default first-line treatment, and preferable alternatives are discussed. ECT has been shown to be at least as effective in short-term treatment and should be considered more frequently, especially in severe presentations and as a maintenance treatment. Some single compounds should be considered as first-line monotherapies in less severe cases. For cases in which combined AD+AP regimes are instituted, SSRIs and atypical APs should be used before older classes of drugs are considered. These recommendations aim to minimize the number of treatments used and unwanted effects experienced.

Can Antipsychotics Improve Social Cognition in Patients with Schizophrenia

Social cognition is described as the higher mental processes that are engaged while people store, process, and use social information to make sense of themselves and others. Aspects of social cognition include emotion perception, social cue interpretation, attribution style, and theory of mind, all of which appear disordered in schizophrenia. Such social cognitive deficits are believed to be important predictors of functional outcome in schizophrenia, therefore they may represent a crucial treatment target. Few studies have evaluated the influence of antipsychotic treatment on these deficits. The purpose of this review is to examine the relationship between antipsychotic treatment and social cognition, whether antipsychotics improve social cognitive function, and if so to explore differential medication effects. Comprehensive searches of PsycINFO and MEDLINE/PUBMED were conducted to identify relevant published manuscripts. Fifteen relevant papers published in English were found, describing original studies. On the basis of this review, we have drawn the following conclusions: first, the results do not engender optimism for the possibility that antipsychotic drugs can specifically facilitate social recovery. Second, the actions of antipsychotics on social cognition are inconclusive, due to lack of standardization across research groups, leading to inconsistencies between study designs, methods used, and medication dosages. Third, large-scale longitudinal investigations are needed to explore the unclear relationships between social cognition, symptoms, and functional outcome. Other non-pharmacological treatments focusing on training patients in the social cognitive areas may hold more promise.

ARE THE COGNITIVE EFFECTS OF ATYPICAL ANTIPSYCHOTICS INFLUENCED BY THEIR AFFINITY TO 5HT-2A RECEPTORS?

It is well documented that atypical antipsychotics have an influence on cognitive function in patients with schizophrenia, although the neurochemical basis for this effect is not well understood. One suggestion is that the effects are exerted through action on 5HT-2A receptors, which leads to changes in the level of dopamine in the prefrontal cortex. The following study explored this hypothesis by comparing the cognitive effects of the atypical antipsychotics which have a high affinity for 5HT-2A receptors, with those that have little or no affinity to these receptors. Forty-four patients with a DSM-IV diagnosis of schizophrenia were recruited within 6 weeks of starting one of the atypical antipsychotics: clozapine, olanzapine, risperidone, quetiapine, or amisulpride. The patients were divided into two groups according to the 5HT-2A affinity of the individual medications (high 5HT-2A affinity--clozapine, olanzapine, risperidone vs. low 5HT-2A affinity--quetiapine, amisulpride). Patients were tested on a broad range of neuropsychological measures after 9 months and 18 months of treatment. The high 5HT-2A affinity group showed a decrement in performance on tests of visual recognition memory and planning ability. In contrast, the low-5HT-2A affinity group showed improvements on these measures in addition to others. The 5HT-2A affinity of the atypical antipsychotics is an important determinant of their cognitive effects.

Lexical knowledge degradation in schizophrenia

This study documents a severe picture naming impairment in a series of 22 chronically hospitalised schizophrenics. The pattern and level of naming impairment were comparable in degree and type to that seen neurological patients with left hemisphere lesions. This deficit was further examined to determine whether it conformed to a disorder affecting access to the lexical representations or some degradation of the stored representations themselves. Patient naming was examined twice (18months apart) for evidence of consistency and for word frequency effects. The pattern of individual patient performance on these criteria showed that the majority had storage disorders; access disorders alone occurred in only a small minority of patients. A subset of 11 of the same patients that were tested on three occasions (across 30months) showed the same pattern but further indicated that when access problems are present, they reflect difficulty with deliberate, rather than automatic, access to the lexicon.

A Longitudinal Analysis of Memory in Patients with Schizophrenia

Memory deficits are widely reported in patients with schizophrenia, but uncertainties remain about the extent and the longitudinal course of these deficits. Twenty-eight patients with a DSM-IV diagnosis of schizophrenia were tested on multiple aspects of memory at baseline, 9- and 18-month follow-up. Measures included: digit span, the Rivermead Behavioural Memory test (RBMT) battery, the Graded Naming Test (GNT) and several computerized memory tests from the Cambridge Automated Neuropsychological Testing Battery (CANTAB). A group of healthy controls (N=17) was tested on the CANTAB battery at baseline and 9-month follow up. The patients performed significantly poorer than controls on all CANTAB measures; however, there was no difference in change between groups over a 9-month period. Within-group patient comparisons revealed that symptoms reduced significantly over the study period, but had no association with memory. Significant improvements were observed for patients on two verbal memory tasks: the GNT and digit span, but not on any other measure. Interestingly, these were the only two tests on which patients were within normal limits at baseline. This study shows that patients with schizophrenia have deficits in multiple aspects of memory which remain stable over long periods of time. In addition, patients showed a tendency to improve on memory tasks which contained a verbal component.

How do we choose between atypical antipsychotics? The advantages of amisulpride

Clinician choice of an atypical antipsychotic may depend on a number of factors such as perceived efficacy, tolerability and cost. It is also important that the choice of treatment takes into consideration the previous response to treatment, experience of side-effects and personal clinical characteristics. The receptor-affinity profiles of the atypical antipsychotics differ; with the exception of amisulpride, a selective D2/D3 antagonist, all the atypical antipsychotics exhibit a greater affinity for the serotonin-2A receptors than dopamine receptors. However, there is no evidence that the variation in receptor affinities is relevant to efficacy. Indeed, the crucial factor may be fast dissociation from low affinity for the D2 receptor. Tolerability also varies between the atypical antipsychotics and the side-effect profile may be related to the receptor-affinity profile of the individual drugs. Extrapyramidal side-effects are generally less of a problem with most atypical drugs than with conventional drugs, but weight gain, loss of glycaemic control, sedation and hyperprolactinaemia remain problematic in some patients. Amisulpride is effective for the treatment of both positive and negative symptoms, and is well tolerated with regard to weight gain, glucose tolerance and sedation. In two clinical trials, the AMIRIS and SOLIANOL studies, amisulpride demonstrated clear advantages over some other atypical antipsychotics with respect to negative symptoms, depressive symptoms and weight gain.

Cognitive function and social abilities in patients with schizophrenia: Relationship with atypical antipsychotics

Abstract  Although atypical antipsychotics have been associated with improvements in cognitive function in schizophrenia, the neurochemical basis for such effects is not well understood. Candidate neurotransmitter systems primarily involve dopamine and serotonin. The current study explored this issue by examining the cognitive abilities, social function and quality of life in patients with schizophrenia who were medicated with atypical antipsychotics. Comparisons were done for matched schizophrenia patients who were on antipsychotics with (i) an affinity for multiple receptors (olanzapine, clozapine, quetiapine) versus those that have preferential affinity for dopamine receptors (risperidone, amisulpride); and patients on medication with (ii) a high affinity for serotonin (5HT‐2A) receptors (risperidone, olanzapine, clozapine) versus those with a low (or no) affinity for 5HT‐2A receptors (quetiapine, amisulpride). No differences emerged between groups on any cognitive or social variable when the groups were compared for the dopaminergic properties of antipsychotic medication. By contrast, differences did emerge when patients were compared on the 5HT‐2A affinity of their antipsychotic medications. Patients on low 5HT‐2A‐affinity antipsychotics exhibited a better performance on a measure of selective attention and adjustment to living. These findings accord with the notion that serotonergic mechanisms are important determinants of both the cognitive and the social effects of the atypical antipsychotics.

Symptom dimensions in old-age schizophrenics Relationship to neuropsychological and motor abnormalities

In most factor analytical studies of schizophrenic symptomatology, a three-factor solution was found. The aim of this study was to investigate symptomatological dimensions in old age and to clarify whether the dimensions correlate differently with neuropsychological and motor parameters. One hundred and thirty-one DSM-III-R chronic schizophrenics (mean age 68 years) were assessed using SANS, SAPS, a neuropsychological test battery and motor scales. Exploratory and confirmatory factor analyses yielded a model with three dimensions (negative, disorganized, paranoid), two of which (negative, disorganized) showed different correlations with neuropsychological and motor phenomena. Thus, three symptomatological dimensions could also be demonstrated in a chronic, old-age schizophrenic sample. The pathophysiological significance of the different correlations with neuropsychological and motor parameters should be clarified in neuroimaging and neuropathological studies.