April Collins

Insight, neurocognitive function and symptom clusters in chronic schizophrenia.

Only recently has there been interest in the systematic study of insight in schizophrenia. The present investigation was designed to evaluate the specific relationship between psychopathological symptoms, neurocognitive deficits and awareness of illness in chronic schizophrenia. Fifty-eight outpatients with the DSM-III-R diagnosis of schizophrenia were rated on Davids Schedule for Assessing Insight, the Positive and Negative Syndrome Scale (PANSS), the Calgary Depression Scale and the Wisconsin Card Sorting Test (WCST). Results indicate that there is a significant association among these variables and that approximately 44% of the variance in the dependent variable could be explained by this combination of independent variables. Notably, however, negative symptoms were only moderately inversely correlated with awareness of illness, and they were not associated with scores on the WCST. Moreover, neither negative symptoms nor per cent perseverative errors contributed significantly to the prediction of insight in schizophrenia. These findings argue against the notion that unawareness of illness is the product of neuropsychological dysfunction in the frontal lobes. Instead, the most significant associations and predictors of insight were related to the positive symptoms of schizophrenia.

Depression in schizophrenia : a comparison of three measures

Depression, as a feature of schizophrenia, is well established. However, clarifying the exact nature of this relationship has been problematic. The clinical measures routinely utilized to evaluate depression have not been specifically designed for use in schizophrenia, and it is well recognized that a variety of depressive symptoms overlap with other features common to this illness, e.g. negative symptoms, neuroleptic induced side effects. The present study compared three commonly used measures of depression (Hamilton Depression Rating Scale (Ham-D), Calgary Depression Scale (CDS) and the depression subscale of the Positive and Negative Syndrome scale (PANSS-D) in a group of outpatients with schizophrenia, evaluating the degree of association between the scales. Additionally, the relationship between each of the depression measures, negative symptoms and extrapyramidal symptoms (EPS) was calculated. Results revealed that all three measures of depression were significantly correlated, although the CDS was unique in its ability to distinguish between depression, negative symptoms and EPS. It is concluded that the CDS, when compared with the HAM-D and the PANSS-D, is the most suitable measure of depression in schizophrenia.

The use of electronic monitoring (MEMS®) to evaluate antipsychotic compliance in outpatients with schizophrenia

Compliance with antipsychotic treatment is a well-recognized concern in the ongoing management of individuals with schizophrenia. The present investigation incorporated the Medication Event Monitoring System (MEMS) to evaluate compliance in a group of outpatients (N=52) with schizophrenia or schizoaffective disorder. Evaluating compliance as a dichotomous variable and using a threshold of 80%, the rate of noncompliance as measured by MEMS was 52%, considerably higher than self-report (3%), clinician rating (24%) and pill count (25%). The ability of treating clinicians to predict compliance/noncompliance was limited: 13 of 31 (42%) subjects they rated as compliant were noncompliant while 4 of 9 (44%) rated as noncompliant were actually compliant according to MEMS. Factors most consistently associated with noncompliance were higher total symptom scores and dosing complexity i.e., greater than once daily. Based on MEMS data, the overall mean level of compliance was 66%; however, it remains unclear as to what threshold is associated with a compromise in clinical response. More sophisticated measurement tools such as MEMS may assist us in better understanding how level and pattern of antipsychotic noncompliance, factors that at present remain poorly understood, impact on symptom exacerbation.

The role of family work in early psychosis

In keeping with the current clinical and research focus on early intervention and the rapid increase worldwide of programs for those experiencing a first episode of psychosis, the development of services for families has to be an integral part of any comprehensive program. Families can and do play a major role in the recovery from a first episode of psychosis. However, without support from and an alliance with professionals, they may find it difficult to see their way through the maze of emotions and challenges that inevitably accompany the first episode. This paper will briefly review the literature describing the impact of a first episode of psychosis on families. Secondly, to support the need for family work, we report on 2-year effectiveness study data that demonstrates that over time families show improvement in their psychological well-being and their experience of caregiving. To design an optimal family program within a first episode service we need to be sensitive to the phase and stage of the illness and have outcomes measured against the goals articulated for first episode family programs. Thus, thirdly we will describe a recovery model that has its origins in the Calgary First Episode Program and has since been expanded for use in the First Episode Psychosis Program in Toronto, Canada.

The Social Construction of Disability in Schizophrenia

Chronicity and disability can accompany a diagnosis of schizophrenia, but long-term follow-up studies are demonstrating that these outcomes are not inevitable. There is growing awareness that characteristics of long-term illness previously understood to be part of the disorder can be partially constructed through a convergence of physical, psychological, and social processes. In this study, the potential for social construction of disability was explored through secondary analysis of qualitative data. Findings suggest that family, consumers, professionals, and society each have a role in shaping a person with schizophrenia’s perceptions of his or her worth, competence, and place in society but that the individuals are not passive recipients of this input.

Family Work in Early Psychosis

Abstract Many individuals with schizophrenia have family members who are actively involved in their care. Often, these family members feel burdened and experience significant distress as a consequence of this increased responsibility. Family interventions have been shown to reduce relapse in individuals with psychosis, highlighting the importance of the family component in psychosis treatment programs. This paper describes how an optimal family intervention can be devised using a recovery framework, and used within an early psychosis treatment program. Three-year outcome data is presented demonstrating improvement in family well-being, and clinical implications are discussed.

Advancing the Recovery Orientation of Hospital Care Through Staff Engagement With Former Clients of Inpatient Units

OBJECTIVES This study was undertaken to assess the impact of consumer narratives on the recovery orientation and job satisfaction of service providers on inpatient wards that focus on the treatment of schizophrenia. It was developed to address the paucity of literature and service development tools that address advancing the recovery model of care in inpatient contexts. METHODS A mixed-methods design was used. Six inpatient units in a large urban psychiatric facility were paired on the basis of characteristic length of stay, and one unit from each pair was assigned to the intervention. The intervention was a series of talks (N=58) to inpatient staff by 12 former patients; the talks were provided approximately biweekly between May 2011 and May 2012. Self-report measures completed by staff before and after the intervention assessed knowledge and attitudes regarding the recovery model, the delivery of recovery-oriented care at a unit level, and job satisfaction. In addition, focus groups for unit staff and individual interviews with the speakers were conducted after the speaker series had ended. RESULTS The hypothesis that the speaker series would have an impact on the attitudes and knowledge of staff with respect to the recovery model was supported. This finding was evident from both quantitative and qualitative data. No impact was observed for recovery orientation of care at the unit level or for job satisfaction. CONCLUSIONS Although this engagement strategy demonstrated an impact, more substantial change in inpatient practices likely requires a broader set of strategies that address skill levels and accountability.

Integrated Care Pathways for Schizophrenia: A Scoping Review.

Abstract This paper summarizes the existing evidence for integrated care pathways (ICPs) for the treatment of schizophrenia. Scoping review methods following PRISMA guidelines were employed due to the variable nature of the evidence in this area. The review identified 13 papers. Of these papers, 7 focused on describing ICP content and process-related data and 6 examined clinical outcomes. Of the 6 studies providing outcome data, 2 reported improved outcomes associated with ICPs. Conceptually, ICPs hold great promise for improving the quality of schizophrenia care. However, in contrast with other specialty healthcare domains, the schizophrenia ICP evidence base is very limited and has not fulsomely begun to address ICPs for effectiveness.

Specialized home treatment versus hospital-based outpatient treatment for first-episode psychosis: a randomized clinical trial

Objective: This pilot study compared the effectiveness of specialized care that was home based versus hospital based for individuals experiencing their first psychotic episode.

Patient Characteristics, Length of Stay, and Functional Improvement for Schizophrenia Spectrum Disorders: A Population Study of Inpatient Care in Ontario 2005 to 2015

Objectives: Schizophrenia and associated illnesses account for a large proportion of mental illness burden and health care expenditures, with the majority of expense involving inpatient care. To date, the literature exploring factors associated with length of stay (LOS) and functional improvement during inpatient care is underdeveloped. In response, this study examined the association between patient characteristics, LOS, and functional improvement using Ontario Mental Health Reporting System (OMHRS) data from 2005 to 2015. Methods: The associations of patient characteristics (including key demographics, psychosocial variables, reasons for admission, and service use history) and 2 outcome measures (LOS and Global Assessment of Functioning [GAF]) were analysed with generalised linear mixed modelling (GLMM). From 2005 to 2015, a total of 48,498 episodes for distinct patients from 18 psychiatric hospitals and 57 general hospitals in Ontario were included. Results: For psychiatric and general hospitals, mean LOS was 96.6 and 20.5 days, and mean GAF improvement was 14.8 and 16.1, respectively. The majority of associations probed demonstrated a high degree of significance with similar patterns across general and tertiary facility contexts. Older age and more recent readmission following a psychiatric discharge were associated with longer LOS and less GAF improvement. Recent experience of adverse life events and substance misuse were associated with shorter LOS. Conclusions: While the findings of this exploratory cross-sectional analysis will require further inquiry with respect to validity and reliability, they suggest that a different service pathway is likely required for individuals with greater psychosocial challenge and extensive service use histories.