Francisco J. Acosta

Medication adherence in schizophrenia

Non-adherence is a major problem in the treatment of schizophrenia. Its high prevalence, potentially severe consequences and associated costs make the study of this phenomenon a priority issue. In this article, basic non-adherence concepts of prevalence, consequences, evaluation methods, methodological restrictions of available studies, risk factors and intervention strategies, are reviewed. Studying non-adherence risk factors is a necessary step toward designing adequately oriented intervention strategies. An operative definition of adherence and good knowledge of its evaluation methods are essential to study this phenomenon. Unfortunately, most available studies contain methodological restrictions, especially concerning the evaluation methods, and an agreed operative definition of adherence has only very recently been reached. Knowing non-adherence risk factors, intervention strategies and available evidence on their effectiveness is essential in making treatment decisions in daily clinical practice.

Hopelessness and suicidal risk in bipolar disorder. A study in clinically nonsyndromal patients.

OBJECTIVE Attempted suicide and death due to suicide are not uncommon among patients with bipolar disorder. Although some risk factors for suicidality in bipolar patients have been identified, little is known about hopelessness and other possible trait or diathesis-related factors. Consequently, the objective of this study was to investigate variables associated with suicidal risk in clinically nonsyndromal bipolar patients. METHODS A sample of 102 outpatients with a diagnosis of bipolar disorder according to International Classification of Diseases, 10th Revision criteria during nonsyndromal stage were evaluated. On the basis of suicidal history, patients were divided into suicide attempt, suicidal ideation, and nonsuicidal groups. Sociodemographic, clinical, and psychopathological variables were assessed. RESULTS As compared with the nonsuicidal group, female sex, combined psychopharmacologic treatment, and hopelessness were independently associated with suicide attempt. Hopelessness and insight into having a mental disorder were independently associated with history of suicidal ideation. CONCLUSIONS Patients with bipolar disorder and suicidal history are characterized by the presence of hopelessness, which probably confers greater vulnerability for suicidal behavior in the presence of stress factors. This identification of the risk profile for suicidal behavior in nonsyndromal bipolar patients adds complementary information to risk factors established for suicidality during acute phases of the disease, allows for differentiated preventive and treatment approaches of patients at risk, and suggests psychotherapy as an advisable intervention in this group of patients.

Are there subtypes of suicidal schizophrenia? A prospective study

BACKGROUND Tragically, suicide is not uncommon in schizophrenia. The principal objective of this study was to examine possible subtypes of suicidal schizophrenic patients and identify their clinical and psychopathological profiles at long-term follow-up. METHOD The study involved 62 patients diagnosed with schizophrenia according to ICD-10 criteria, who were consecutively admitted following a suicide attempt. Of these subjects, 47 (75.8%) could be re-evaluated after 1 year. Sociodemographic, general clinical, and psychopathological variables were evaluated. RESULTS Two predominant subgroups were identified according to suicidal motivation: psychotic motivation and depressive motivation. At re-evaluation after 1 year, the depressive motivation subgroup showed higher depression and hopelessness scores. This subgroup also had greater educational level, age, and duration of illness, and more frequent existence of previous suicide attempts compared to the psychotic motivation subgroup. Of note in the psychotic motivation subgroup was the presence of hopelessness. The variables of educational level, duration of illness, and previous suicide attempts were the ones that best distinguished these subgroups. CONCLUSION These findings reinforce the notion that meaningful subgroups occur among suicidal schizophrenic patients. The different psychopathological profiles of the two prominent subgroups suggest the need for a different management approach in each case. The identification of these profiles in both subtypes at long-term follow-up may facilitate their detection by clinicians and, therefore, foster the adoption of appropriate preventive measures against subsequent suicidal behavior.

A psychopathological study of a group of schizophrenic patients after attempting suicide. Are there two different clinical subtypes

Fifty-six schizophrenic patients at the moment of their suicidal attempt were compared to a control group of 60 patients. Schizophrenic suicidal attempters showed an identifiable clinical profile at the acute phase. Two main groups could be differentiated in regard to their reasons (depressive or psychotic) for attempting suicide.

Antipsychotic treatment dosing profile in patients with schizophrenia evaluated with electronic monitoring (MEMS

BACKGROUND Although the Medication Event Monitoring System (MEMS®) device offers accurate information on treatment dosing profile, such profile has never been studied in patients with schizophrenia. Enhancing our knowledge on this issue would help in developing intervention strategies to improve adherence to antipsychotic treatment in these patients. METHODS 74 outpatients with schizophrenia were monitored with the MEMS device for a 3-month period, for evaluation of antipsychotic treatment dosing profile, possible influence of medication schedule-related variables, adherence to treatment--considering dose intake within prescribed timeframes--and possible Hawthornes effect of using the MEMS device. RESULTS Dose-omission gaps occurred in 18.7% of monitoring days, most frequently during weekends, almost significantly. Almost one-third of prescribed doses were taken out of prescribed time. Neither the prescribed number of daily doses nor the indicated time of the day for dose intake (breakfast, dinner), were associated with correct antipsychotic dosing. Excess-dose was rare in general, and more frequent out of prescribed dose timeframe. No Hawthornes effect was found for the MEMS device. Adherence reached only 35% according to a definition that included dose intake within prescribed timeframes. CONCLUSIONS Antipsychotic treatment dosing was considerably irregular among patients with schizophrenia. Strategies to reduce dose-omission gaps and increase dosing within prescribed timeframes seem to be necessary. Gaining knowledge on precise oral antipsychotic dosing profiles or the influence of schedule-related variables may be useful to design strategies towards enhancing adherence. There appears to be no Hawthornes effect associated with the use of MEMS devices in outpatients with schizophrenia.

Qualitative content of auditory hallucinations and suicidal behavior in schizophrenia

Whereas depressed mood, hopelessness, and previous suicide attempts have been well established as risk factors for suicidal behavior in schizophrenia (Siris, 2001), the role of psychotic symptoms and their quality has remainedmore controversial (Hawton et al., 2005; Hor and Taylor, 2010). Existing studies have focused on quantitative aspects of psychotic symptoms, to the exclusion of qualitative features. We question whether such a focus fosters premature conclusions regarding factors associated with suicidality in this patient group, and offer the distinction between pleasant versus unpleasant auditory hallucinations as a qualitative case in point.

Influence of antipsychotic treatment type and regimen on the functionality of patients with schizophrenia.

Abstract Background: Enhanced functionality is a major goal in the treatment of schizophrenia. However, possible differences in the effectiveness of first- vs. second-generation antipsychotics or between depot/long-acting injectable (D/LAI) vs. D/LAI plus oral antipsychotics are not clear. Aims: This study was designed to evaluate possible differences between the effects of different antipsychotic treatment types or regimens on the functionality of patients with schizophrenia. Methods: 85 outpatients with schizophrenia, who were being treated with D/LAI antipsychotics— co-administered or not with oral antipsychotics—and had been adherent to the treatment during the previous year were evaluated. Socio-demographic, clinical, treatment-related, global severity and functionality variables were evaluated. Patients were grouped according to the type of antipsychotic drug (first- vs. second-generation) or according to the co-administration (or not) of oral antipsychotics. Results: No differences were found between first- and second-generation antipsychotics in terms of global functionality. Patients treated with LAI risperidone showed better global functionality and better performance in their habitual social activities and personal–social relationships than patients treated with risperidone plus oral second-generation antipsychotics. Better functionality was also found to be associated with higher education level, paranoid subtype of schizophrenia, harmful use of nicotine, adherence to oral treatment and absence of concomitant oral anticholinergic or psychopharmacological treatment. Conclusions: Our results suggest that D/LAI antipsychotic treatments should be administered in monotherapy whenever possible and that the treatment schedule should be simple, in order to achieve better functionality.