Falko Biedermann

Facial emotion recognition and its relationship to subjective and functional outcomes in remitted patients with bipolar I disorder

Hoertnagl CM, Muehlbacher M, Biedermann F, Yalcin N, Baumgartner S, Schwitzer G, Deisenhammer EA, Hausmann A, Kemmler G, Benecke C, Hofer A. Facial emotion recognition and its relationship to subjective and functional outcomes in remitted patients with bipolar I disorder. Bipolar Disord 2011: 13: 537–544.

Theory of mind and its relevance in schizophrenia.

Purpose of review Social cognitive impairments are considered to be core features of schizophrenia and have been hypothesized to play a mediator role between basic neurocognition and patients’ outcomes. In this context, theory of mind (ToM) abilities are of special relevance, and deficits in this area may represent trait markers of schizophrenia. Recent findings In this review, studies published since September 2010 have been summarized with a particular focus on the relationships between ToM and psychopathology, neurocognition, and psychosocial outcomes in patients with schizophrenia, as well as on ToM abilities in high-risk individuals. In addition, recent neuroimaging data as well as treatment interventions have been described. Summary The reviewed literature strengthens the hypothesis that ToM deficits have the potential to be valid markers for schizophrenia.

Emerging drugs for schizophrenia

Introduction: Since the development of clozapine, scores of antipsychotics have been introduced. These are, with one exception (aripiprazole), based on the pharmacological principle of 5-HT2/dopamine antagonism. Research on other treatment targets, which, in part, influence dopaminergic pathways directly or indirectly, is mounting. Managing psychotic symptoms is only one facet of successful treatment of schizophrenia. Effective remedies against negative symptoms and cognitive deficits are still an unmet clinical need. Areas covered: With the focus on the topics mentioned above, the authors briefly review the latest clinical research organized on the basis of receptor systems and other drug targets, which are discussed to be involved in the pathophysiology of schizophrenia. Expert opinion: In conclusion, although clinicians will have to have considerable patience before truly novel anti-schizophrenia treatments become obtainable, a number of interesting leads with considerable theoretical potential are being explored. As yet, it is difficult to predict which of these mechanisms will effectively augment the currently available treatments.

Antipsychotics in the early stage of development.

Purpose of review In this article, we will summarize some of the most recent pharmacological approaches by briefly reviewing the latest research results related to different neurotransmitter receptor systems but also alternative approaches that do not affect central nervous system receptors directly. Recent findings Although the field still struggles with the lack of major breakthroughs, some novel pharmacological leads have provided encouraging findings in proof of concept or early phase II clinical trials. Although some of these approaches are based on the modified dopamine/glutamate hypothesis of schizophrenia, others appear to have been driven by more serendipitous observations. Apart from this, more traditional routes such as compounds targeting D2/HT2 receptors are also still being pursued. Attempts to advance treatment response of negative symptoms and cognitive impairment, two areas of considerable unmet need have been an overriding theme in many studies. Summary Clinical psychopharmacologists increasingly realize that it is highly unlikely that we have a magic bullet to treat adequately all aspects of this complex disorder in the foreseeable future. Rational polypharmacy may be the trend for the next decade.

Combined clozapine and electroconvulsive therapy in clozapine-resistant schizophrenia: clinical and cognitive outcomes.

Abstract For treatment-refractory schizophrenia, electroconvulsive therapy (ECT) remains controversial because of its cognitive adverse effects. We report here on clinical and cognitive outcomes of a treatment-resistant schizophrenia patient treated with clozapine and right unilateral ECT. The patient was administered 300 mg of clozapine and 12 right unilateral ECT sessions. Psychopathology was rated by means of the Positive and Negative Syndrome Scale. The neurocognitive test battery included the Wisconsin Card Sorting Test, the Münchner Gedächtnis Test, an attentional performance test, the Trail Making Test, and the Hamburger-Wechsler Intelligence Test. The Positive and Negative Syndrome Scale total score decreased, and all cognitive measures improved. Electroconvulsive therapy would seem to be a safe treatment option for treatment-refractory schizophrenia patients.

MEASURING ADHERENCE TO MEDICATION IN SCHIZOPHRENIA: THE RELATIONSHIP BETWEEN ATTITUDES TOWARD DRUG THERAPY AND PLASMA LEVELS OF NEW-GENERATION ANTIPSYCHOTICS

Background: Nonadherence to medication is still a major problem in the treatment of schizophrenia. The current longitudinal study investigated whether the patients’ attitudes toward treatment correlated with the ratio of observed vs expected plasma levels of antipsychotic drugs as an objective measurement of adherence. Methods: Data of patients starting monotherapy with a new-generation antipsychotic were collected 2, 4, and 12 weeks after the initiation of treatment. Next to the assessment of patients’ attitudes toward medication by means of the Drug Attitude Inventory, the ratio of the observed vs expected plasma level was calculated. Antipsychotic-induced side effects were evaluated by means of the Udvalg for Kliniske Undersogelser Side Effect Rating Scale. Results: A total of 93 patients were eligible for statistical analysis. About one-half of the ratios of observed vs expected plasma levels ranged from 0.5 to 2 and were considered normal, whereas the other ratios were considered either too low (<0.5) or too high (>2). No consistent correlation between patients’ attitude toward drug therapy and the individual ratios of observed vs expected plasma levels of medication was detected. This finding was not affected by side effects. Conclusions: Our results highlight the importance of recognizing the complex nature of adherence to medication in schizophrenia patients. Importantly, we found no consistent correlation between subjective and objective measures of medication adherence. Therefore, monitoring adherence to medication remains a challenge in clinical practice.

Sibutramine in the treatment of antipsychotic-induced weight gain: a pilot study in patients with schizophrenia.

Weight gain represents a frequent side effect of antipsychotic drug treatment. The current trial investigated the effect of add-on treatment with sibutramine in schizophrenia outpatients who had gained more than 7% of weight during the course of treatment. This 24-week placebo-controlled study evaluated the effects of sibutramine added to ongoing antipsychotic treatment. Weight, waist–hip ratio, BMI, blood pressure/pulse and ECG were monitored regularly. In addition, several laboratory tests were performed. Psychopathological symptoms and side effects were assessed frequently. Fifteen patients were assigned randomly to add-on treatment with sibutramine 10 mg or placebo. The two groups did not differ in weight, sociodemographic, or clinical data. Eleven patients were considered for statistical analysis. Significant weight loss was observed in the sibutramine group (mean=−6.1 kg), whereas patients on placebo experienced a mean weight gain of 1.9 kg. A reduction in HbA1c was apparent in the sibutramine but not in the placebo group. No significant between-group differences were found in changes in psychopathology or drug safety. This pilot trial suggests that adjunctive treatment with sibutramine may be safe and effective in schizophrenic patients with antipsychotic-induced weight gain.

Affective prosody perception in symptomatically remitted patients with schizophrenia and bipolar disorder

Affect perception has frequently been shown to be impaired in patients suffering from schizophrenia or bipolar disorder (BD), but it remains unclear whether these impairments exist during symptomatic remission and whether the two disorders differ from each other in this regard. Most previous studies have investigated facial affect recognition, but not the ability to decode mental states from emotional tone of voice, i.e. affective prosody perception (APP). Accordingly, the present study directly compared APP in symptomatically remitted patients with schizophrenia or BD and healthy control subjects and investigated its relationship with residual symptomatology in patients. Patients with schizophrenia and BD showed comparable APP impairments despite being symptomatically remitted. In comparison to healthy control subjects, overall APP deficits were found in BD but not in schizophrenia patients. Both patient groups were particularly impaired in the identification of anger and confounded it with neutral prosody. In addition, schizophrenia patients frequently confused sadness with happiness, anger, or fright. There was an inverse association between the degree of residual positive symptoms and the ability to correctly recognize happiness in schizophrenia patients. Overall, these data indicate that impairments in APP represent an enduring deficit and a trait marker of both schizophrenia and BD and that the level of impairment is comparable between disorders.

Psychotic disorders in DSM-5 and ICD-11.

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.

Prescribing Practice in Inpatients Versus Outpatients With Schizophrenia Initiating Treatment With Second-Generation Antipsychotics: A Naturalistic Follow-Up Study.

Objective The primary objective of this study was to investigate whether the choice and dosage of antipsychotic medication differ between patients with schizophrenia starting treatment in an inpatient or outpatient unit. In addition, we investigated whether the reason for the introduction of new antipsychotic medication had an impact on the treatment setting and whether the use of benzodiazepines differed between inpatients and outpatients. Method From October 1997 to September 2010, patients with a schizophrenia spectrum disorder according to the International Classification of Diseases, Tenth Revision aged between 18 and 65 years were allocated to a naturalistic drug-monitoring program when starting treatment with a second-generation antipsychotic drug. Psychopathological symptoms were rated at baseline and after 1, 2, 4, and 8 weeks of treatment using the Positive and Negative Syndrome Scale. Inpatients and outpatients were compared with regard to the use of antipsychotics and benzodiazepines. To compare different drugs, chlorpromazine and diazepam equivalents were calculated. Results Lack of efficacy and side effects were the main reasons for initiating new antipsychotic medication. Combined evaluation of all antipsychotic compounds by meta-analysis resulted in a significant effect of the treatment setting, with inpatients receiving higher doses than outpatients. In addition, inpatients were prescribed benzodiazepines more often and in higher doses than outpatients. Conclusions Both antipsychotics and benzodiazepines were prescribed at higher doses in an inpatient setting. Moreover, benzodiazepines were prescribed more frequently to inpatients. Accordingly, the treatment setting needs to be taken into consideration in treatment recommendations for schizophrenia spectrum disorders.