C.W. Law

Specific executive dysfunction in patients with first-episode medication-naïve schizophrenia

Many studies have shown that schizophrenia is associated with a wide range of cognitive impairments. Empirical findings suggest that patients with schizophrenia suffer from a dysexecutive syndrome. However, the extent to which a general decline in neuropsychological function accounts for symptoms of executive dysfunction in schizophrenia is not clear. In this study, we examined further the nature and pattern of executive function in a sample of medication-naïve patients experiencing a first-episode of schizophrenia with a set of tests capturing the specific components of executive function. We also compared the performance of this clinical group with healthy controls. A total of 78 medication-naïve patients with first episode schizophrenia were recruited from the Early Assessment Service for Young People with Psychosis (EASY). Another 60 healthy controls were recruited for comparison. All subjects participated in a comprehensive set of executive function tests assessing initiation, sustained attention, online updating, switching, attention allocation, inhibition, and non-executive function. The executive function of patients with first-episode schizophrenia was found to be compromised relative to healthy controls. However, unlike patients with established schizophrenia, first episode patients exhibited only a limited deficit in sustained attention. Moreover, the majority of executive function deficits did not correlate with intellectual functioning and memory impairment in a sub-group of first episode patients without intellectual impairment. These findings suggest that first-episode patients exhibit a specific pattern of executive dysfunction compared to healthy controls and patients with an established illness. This differential breakdown of executive function components is unlikely to be an artefact of general intellectual decline or memory impairment in schizophrenia.

Maintenance treatment with quetiapine versus discontinuation after one year of treatment in patients with remitted first episode psychosis: randomised controlled trial

Objective To study rates of relapse in remitted patients with first episode psychosis who either continued or discontinued antipsychotic drugs after at least one year of maintenance treatment. Design 12 month randomised, double blind, placebo controlled trial. Setting Early psychosis outpatient clinics in Hong Kong. Participants 178 patients with first episode psychosis who had received at least one year of antipsychotic drug treatment between September 2003 and July 2006 and had no positive symptoms of psychosis. Interventions Patients received either maintenance treatment with quetiapine (400 mg/day) or placebo and were followed up for the next 12 months or until a relapse occurred. Main outcome measure Relapse assessed monthly and defined as re-emergence of psychotic symptoms (delusions, conceptual disorganisation, hallucinations, suspiciousness, and unusual thought content) according to predefined thresholds. Results 178 patients were randomised (89 to quetiapine and 89 to placebo). The Kaplan-Meier estimate of the risk of relapse at 12 months was 41% (95% confidence interval 29% to 53%) for the quetiapine group and 79% (68% to 90%) for the placebo group (P<0.001). Although quetiapine was generally well tolerated, the rate of discontinuation due to adverse or serious adverse events was greater in the quetiapine group (18%; 16/89) than in the placebo group (8%; 7/89) (relative risk 2.29, 95% confidence interval 0.99 to 5.28; χ2=3.20, df=1; P=0.07). Conclusion In a group of asymptomatic patients with first episode psychosis and at least one year of previous antipsychotic drug treatment, maintenance treatment with quetiapine compared with placebo resulted in a substantially lower rate of relapse during the following year. Trial registration Clinical trials NCT00334035.

What Does Recovery From Schizophrenia Mean? Perceptions of Long-Term Patients

Background: The study investigated the meaning of recovery to eight people with chronic schizophrenia. Method: A qualitative methodology was used based on a 3-hour focus group. The material was transcribed and analysed into 18 subcategories and 4 categories; namely recovery as a multi-dimensional construct, the relationship of medication to recovery, a sense of hopelessness and helplessness about recovery, factors that promoted recovery. Discussion: Respondents believed that full recovery could not be said to have been achieved until they stopped medication and had a steady job. The support and care of family and friends were also vital, although sometimes problematic. Independent living has a different meaning in Chinese culture. Conclusions: Further research directions are suggested as well as ways to change attitudes to the inclusion of medication in recovery.

What does recovery from psychosis mean? Perceptions of young first-episode patients

Background: This study explored the experience of first-episode psychosis from the patients’ perspective and the meanings they attach to the illness and their recovery. Method: A qualitative methodology was used based on a focus group. Audio tapes were transcribed verbatim and three researchers participated in a content analysis that identified four major themes: the meaning of psychosis and psychotic experience; the meaning of recovery; stigma; and having an optimistic view of recovery. Discussion: Participants’ view of recovery was broader than that often held by psychiatrists, extending beyond symptom control and medication compliance, and they identified positive features that the experience of illness had brought. Their concerns included the side effects of medication and the fear of their illness being disclosed (to employers, university authorities, acquaintances, etc.) in the face of societal stigma. Conclusion: Ideas about what constitutes recovery need to take account of patients’ views and experience in order to emphasize therapeutic optimism rather than pessimism, and to inform treatment contexts and the views of medical staff.

Detection of non-adherent behaviour in early psychosis

OBJECTIVEnAdherence to antipsychotic treatment is an important aspect of the long-term management of schizophrenia. The evaluation of adherence is often difficult in the clinical setting. This study compared patient self-reporting and clinician judgment of adherence behaviour in patients with early and chronic schizophrenia.nnnMETHODnClinician-rated questionnaires and parallel patient self-rated questionnaires were administered to 229 patients with early schizophrenia (illness duration < 5 years) and 255 patients with chronic schizophrenia. Items in the questionnaires addressed two forms of adherence behaviour (forgetting to take medication and deciding to stop medication) as well as attitudes toward medication.nnnRESULTSnSignificant non-adherent behaviour was reported by patients, particularly in the early schizophrenia group. Non-adherent behaviour was related to feelings of embarrassment about taking medication. Both non-adherence and embarrassment were under-recognized by clinicians. Starting from a prior probability of 0.24, knowledge of the patients attitudes increased the posterior probability to 0.33, whereas clinicians detection of non-adherence (deciding to stop medication) improved the posterior probability to 0.65. When both clinicians evaluations and patients attitudes were known, the posterior probability improved to 0.68.nnnCONCLUSIONnNon-adherence is a widespread phenomenon in early schizophrenia. Increasing clinicians sensitivity to patients feelings of embarrassment may be an important factor in the detection of non-adherence. When taking a base rate of non-adherence into consideration, clinicians evaluations appeared to be more effective in detecting non-adherence than simple information obtained from patients on their attitudes toward medication. Pragmatic real-life estimation of non-adherence has important implications for the possibility of intervention.

What does recovery from schizophrenia mean? Perceptions of medical students and trainee psychiatrists.

Background: The attitudes of medical professionals towards recovery from schizophrenia are key in defining the therapeutic encounter and may change as they move through their medical career. Method: A qualitative methodology was used based on three focus groups of medical students and trainee psychiatrists in Hong Kong. Both held pessimistic attitudes towards recovery in schizophrenia. Four major categories and one central theme emerged, with little difference between students and doctors. The four categories were: (1) recovery is defined by the cessation of medication and the resumption of normal psychosocial functioning; (2) formal recovery requires medical confirmation plus the patient’s admission of illness; (3) recovery should be discussed, but largely in terms of the contribution of drug compliance; and (4) participants recognized that stigma was an impediment to recovery while holding attitudes that were as unaccepting towards people with schizophrenia as lay people’s. Conclusions: Traditional medical education over-emphasizes symptomatic recovery and ignores the need for a more flexible construction of the concept. Professional knowledge must incorporate both quantitative and qualitative data and inculcate humanitarian concern through active contact with users, and acceptance of the legitimacy of their expert experience. Medical education should seek effective ways to change entrenched negative attitudes in students about schizophrenia and the possibility of recovery. Further large-scale research should be carried out to establish attitudes of medical professionals towards recovery from schizophrenia and how this changes during typical career trajectories. This information could then be used to devise effective means within medical education to combat stigma and change attitudes.

An instrument to assess mental patients’ capacity to appraise and report subjective quality of life

Quality of life (QOL) is increasingly recognized as an important outcome measure in treatment studies and service evaluation. However, patients or service users may sometimes lack the capacity to either evaluate or express their subjective QOL, for example due to cognitive impairment, communication disorders, symptom distress or burden of completing the assessment itself. This paper describes the development of an instrument, the capacity to report subjective quality of life inventory (CapQOL), which evaluates the ability of patients to appraise their subjective QOL and to complete related measures. The CapQOL is a simple and brief screening tool, designed for use in people with a wide range of mental disabilities. It helps researchers to identify individuals who are unable to appraise or report their subjective quality of life. We administered the CapQOL to 442 patients with early psychosis. About 89% of the participants were assessed to be able to complete a subjective QOL measure. The CapQOL demonstrated satisfactory psychometric properties. Further validation studies in people with psychosis as well as other mental disabilities are indicated.

Predicting 1-year risk for relapse in patients who have discontinued or continued quetiapine after remission from first-episode psychosis.

OBJECTIVEnRelapse is common among patients with psychotic disorders. Identification of relapse predictors is important for decision regarding maintenance medication. Naturalistic studies often identify medication non-adherence as a dominant predictor. There are relatively few studies for predictors where adherence is already known. It is this situation i.e., discontinuation of medication that predictors will be most useful. We identify predictors for relapse in situations of (i) discontinuation and (ii) continuation of maintenance medication.nnnMETHODnAnalysis of relapse predictors is based on a randomized controlled study (n=178) comparing relapse rates between patients who discontinued or continued medication for at least 1 year following first-episode psychosis. Demographic, clinical and neurocognitive variables were assessed at baseline as predictors of relapse within 1 year.nnnRESULTSnRisk of relapse was 79% in the discontinuation group and 41% in the maintenance group. Predictors in the discontinuation group were diagnosis of schizophrenia, poorer semantic fluency performance, and higher blink rate. Predictors in the continuation group were disinhibition soft signs and more general psychopathology symptoms.nnnCONCLUSIONnDifferent predictors of relapse were identified for first episode psychosis patients who discontinued and continued maintenance medication. Neurocognitive dysfunctions are important predictors for both groups. While signs of frontal dysfunction and dopamine hyperactivity predict relapse in the discontinuation group, sign of cognitive disinhibition predicts relapse in the continuation group.

MRI Predicts Remission at 1 Year in First-Episode Schizophrenia in Females with Larger Striato-Thalamic Volumes

Background/Aims: The Remission in Schizophrenia Working Group has defined remission as ‘a low-mild symptom intensity level, maintained for a minimum of 6 months, where such symptoms do not affect an individuals behaviour [Andreasen et al.: Am J Psychiatry 2005;162:441-449]. Since brain morphology relates to symptomatology, treatment and illness progression, MRI may assist in predicting remission. Methods: Thirty-nine patients newly diagnosed with DSM-IV schizophrenia underwent MRI brain scan prior to antipsychotic exposure. The Global Assessment of Functioning (GAF) score was entered into a voxel-based analysis to evaluate its relationship with cerebral grey matter volume from the baseline MRI. We entered age, total intracranial volume and intake GAF score as co-variates. Males and females were analysed separately because gender is a potent determinant of outcome. Results: Males had lower GAF scores than females, both at intake and at 1 year. Males comprised only 40% (12 out of 39) of the early remission group. For females only, early remission was strongly and positively correlated with bilateral lentiform and striatal volumes. For males, there was no such relationship. Conclusion: Larger striato-thalamic volume correlated with early remission in females only. These baseline MRI findings were unlikely to be confounded by antipsychotic treatment and chronicity. These brain morphological markers show gender dimorphism and may assist in the prediction of early remission in newly diagnosed schizophrenia.

A comparison of psychological profiles between suicide ideators and non-ideators among psychiatric patients: a preliminary report

This journal suppl. entitled: Abstracts of the IXth International Congress on Schizophrenia Research