G. Buchkremer

Psychoeducational psychotherapy for schizophrenic patients and their key relatives or care-givers: results of a 2-year follow-up

Psychoeducational medication management training (PMT), cognitive psychotherapy (CP) and key‐person counselling (KC) were carried out in various combinations in this randomized, controlled intervention study of schizophrenic out‐patients (according to DSM‐III‐R). Special design characteristics of the study were a control group consisting of non‐specifically treated patients and a 2‐year follow‐up after completion of treatment in order to evaluate medium‐term effects. A total of 132 patients underwent a follow‐up examination 2 years after completion of treatment and were evaluated with an intention‐to‐treat approach. In the second follow‐up year, all treatment groups had lower but not significantly different relapse rates compared to the control group. The most intensive treatment (PMT+CP+KC) produces a clinically relevant reduction in rehospitalization rate (a 26% reduction compared to the control group). In comparison with the non‐specifically treated control group, whose original effect decreased, at least a medium‐term therapeutic effect was recorded in the treatment groups.

Defining and predicting functional outcome in schizophrenia and schizophrenia spectrum disorders

BACKGROUND To assess criteria and to identify predictive factors for functional outcome. The criteria should cover all domains proposed by the Remission in Schizophrenia Working Group. METHOD PANSS ratings were used to evaluate the symptomatic treatment outcome of 262 inpatients with schizophrenia spectrum disorders within a naturalistic multicenter trial. Functional remission was defined as a GAF score >61 (Global Assessment of Functioning Scale), SOFAS score >61 (Social and Occupational Functioning Scale) and a SF-36 mental health subscore >40 (Medical Outcomes Study-Short Form Health Survey). Multivariate logistic regression and CART analyses were used to determine valid clinical and sociodemographic predictors. RESULTS In total, 52 patients (20%) fulfilled the criteria for functional remission, 125 patients (48%) achieved symptomatic resolution and when criteria for functional remission and symptomatic resolution were combined 33 patients (13%) achieved complete remission. Younger age, employment, a shorter duration of illness, a shorter length of current episode, less suicidality, and a lower PANSS negative and global subscore at admission were predictive of functional remission. The regression model showed a predictive value of more than 80%. CONCLUSIONS A significant association was found between functional remission and symptomatic resolution, indicating reasonable validity of the proposed definition for functional outcome. The revealed predictors for functional treatment outcome emphasize the need for psychosocial and vocational rehabilitation in schizophrenic patients.

Pharmacological long-term treatment strategies in first episode schizophrenia: Study design and preliminary results of an ongoing RCT within the German Research Network on Schizophrenia

Abstract.In first-episode schizophrenia the advantage of new atypical neuroleptics compared to low-dose haloperidol as well as the indicated duration of neuroleptic maintenance treatment has still to be based on empirical evidence.Accordingly, a multi-center study on the optimization of acute and long-term treatment in first-episode schizophrenia is currently being carried out as part of the German Research Network on Schizophrenia. This paper reports on the design, methods and preliminary results of the two-year randomized double-blind study comparing risperidone and low-dose haloperidol within the framework of psychological interventions. In the second treatment year, relapse rates under continued neuroleptic treatment are compared with those under stepwise drug withdrawal substituting instead prodrome-based early intervention (intermittent treatment).As to the results, by November 2003 142 first episode patients (ICD-10 F20) have been included in the long-term study. One-year relapse rates were very low (3.8 %). On average, symptoms as well as drug side-effects decreased steadily under maintenance treatment. Although compliance on average was high, about 60% of the patients dropped out during the first study year. More pronounced psychopathology, (neurological) side-effects, lower compliance at study entry and absence of psychological treatment seemed to enhance the risk for drop-out.In conclusion, treatment in first episode schizophrenia is effective under both (further on blinded) neuroleptics; however these patients are at high risk for treatment drop-out. This emphasizes the need for a special support program.

Early improvement as a predictor of remission and response in schizophrenia: Results from a naturalistic study

OBJECTIVE To examine the predictive validity of early improvement in a naturalistic sample of inpatients and to identify the criterion that best defines early improvement. METHODS Two hundred and forty-seven inpatients who fulfilled ICD-10 criteria for schizophrenia were assessed with the Positive And Negative Syndrome Scale (PANSS) at admission and at biweekly intervals until discharge from hospital. Remission was defined according to the recently proposed consensus criteria, response as a reduction of at least 40% in the PANNS total score from admission to discharge. RESULTS Receiver operating characteristic (ROC) analyses showed that early improvement (reduction of the PANSS total score within the first 2 weeks of treatment) predicts remission (AUC=0.659) and response (AUC=0.737) at discharge. A 20% reduction in the PANSS total score within the first 2 weeks was the most accurate cut-off for the prediction of remission (total accuracy: 65%; sensitivity: 53%; specificity: 76%), and a 30% reduction the most accurate cut-off for the prediction of response (total accuracy: 76%; sensitivity: 47%; specificity: 90%). CONCLUSION The findings of clinical drug trials that early improvement is a predictor of subsequent treatment response were replicated in a naturalistic sample. Further studies should examine whether patients without early improvement benefit from an early change of antipsychotic medication.

CADASIL: underdiagnosed in psychiatric patients?

Objective:  Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is exclusively related to symptoms of the central nervous system. Retrospectively in up to 15% the initial presentation is psychiatric disturbances. In these cases the diagnosis often is delayed or missed.

Prediction of symptom remission in schizophrenia during inpatient treatment

Objective: Standardized consensus criteria for remission in schizophrenia were recently proposed. The present study applied the symptom-severity component of these criteria to a sample of inpatients in order to determine the rates of remission during inpatient treatment and to explore predictors of remission. Method: A total of 288 inpatients from a multi-centre follow-up programme who fulfilled ICD-10 criteria for schizophrenia were included in the present analyses. PANSS ratings at admission and at discharge from hospitalization were used to examine remission status. Clinical and sociodemographic variables at admission were tested for their ability to predict remission at discharge. Results: In total, 55% of the sample achieved symptom remission during inpatient treatment; 84% percent showed remission with respect to ‘reality distortion’, 85% with respect to ‘disorganization’ and only 65% with respect to ‘negative symptoms’. Logistic regression analysis revealed that the global functioning (GAF) in the year before admission, the total score of the Strauss–Carpenter Prognostic Scale and the PANSS negative subscore at admission were predictive for symptom remission. The regression model showed a predictive value of about 70% and explained 36% of the observed variance. Conclusion: The results highlight the impact of negative symptoms for the course and treatment response of schizophrenic illness.

Standardized Remission Criteria in Schizophrenia: Descriptive Validity and Comparability with Previously Used Outcome Measures

INTRODUCTION Standardized consensus criteria for remission in schizophrenia were recently proposed. As yet, the validity of these criteria and their comparability with previously used outcome measures are unclear. METHODS The symptom-severity component of the proposed remission criteria was applied to 288 inpatients who fulfilled the ICD-10 criteria for schizophrenia. Global functioning and psychopathological symptoms were assessed using GAF, PANSS, SANS, HAM-D and CDSS. RESULTS When patients with symptom remission at discharge from hospitalization (n=158, 54.9%) were compared to those without symptom remission, significant differences were found with respect to the global functioning (GAF) and all observed psychopathological symptom dimensions. The percentage agreement with previously used outcome measures ranged between 52.6 and 80.0%, the kappa values between 0.120 and 0.594. A moderate accordance (kappa value: 0.495) was found with a Clinical Global Impression (CGI) severity score of three or less. DISCUSSION The results indicate a high descriptive validity of the symptom-severity component of the proposed remission definition. However, the new criteria differ partially from previously used outcome measures. This aspect should be considered in the interpretation of clinical trials.

Evaluation of a cognitive behaviourally oriented service for relapse prevention in schizophrenia

Klingberg S, Wittorf A, Fischer A, Jakob‐Deters K, Buchkremer G, Wiedemann G. Evaluation of a cognitive behaviourally oriented service for relapse prevention in schizophrenia.

The influence of familial loading on the course of schizophrenic symptoms and the success of psychoeducational therapy.

This prospective study examines the influence of familial loading on the course of schizophrenic illness and the extent to which this is modifiable by psychoeducational training as a form of psychotherapy. 182 schizophrenic patients enrolled in the study were allocated at random into four different treatment groups and one control group. 40% of the patients had mentally ill relatives, 20% with some form of schizophrenia. Patients attending the treatment group and those in the control group were examined before and immediately after psychoeducational training and at 2-year and 5-year follow-ups. Control group patients with mentally ill relatives displayed a significant increase in psychopathological symptoms and rehospitalization rate compared to those without. The psychoeducational training arrested or even improved the increase in psychopathological symptoms in patients with mentally ill relatives. Familial loading contributes substantially to a high rehospitalization rate and a poor outcome in schizophrenic patients. Psychoeducational interventions are an appropriate means of arresting this unfavorable development.

Electroconvulsive therapy : a review on indications, methods, risks and medication

This paper reviews and presents data of practical impact for those administering electroconvulsive therapy (ECT). In the first section, physical and physiological aspects of the stimulus as well as methods of stimulation are discussed. The second section deals with indications for ECT, efficacy and treatment modalities such as seizure duration, treatment frequency and total number of ECT applications. The last section is devoted to side effects, risks, comedication and comorbidity.