Ian R. H. Falloon

A brief method for assessing expressed emotion in relatives of psychiatric patients

A measure of the attitudes and feelings that a relative expresses about a mentally ill family member, termed expressed emotion (EE), is derived from an extensive, semistructured interview, the Camberwell Family Interview (CFI). The present article describes a method for the assessment of EE attitudes that uses a variation of the 5-minute speech sample, originally developed by Gottschalk and Gleser (1969). The measure is derived from responses made by a patients key relative when prompted to give thoughts and feelings about the patient for a 5-minute period. A coding system was developed to score behaviors analogous to those rated on the CFI, such as criticism and emotional overinvolvement. The relationship between blind EE ratings derived from the 5-minute speech samples and those from the CFI was investigated with two separate samples of relatives of schizophrenics. The relationship between the sets of ratings was very close and supports the value of the 5-minute speech sample as a brief EE screening procedure.

Family management in the prevention of exacerbations of schizophrenia: a controlled study.

Environmental stress has been implicated as an important factor in the relapse of schizophrenic patients receiving optimal drug therapy. In a randomized controlled study, we compared at-home family therapy with clinic-based individual supportive care in the community management of schizophrenia in 36 patients taking neuroleptic maintenance medications. The family-treatment approach sought to enhance the stress-reducing capacity of the patient and his or her family through improved understanding of the illness and training in behavioral methods of problem solving. The results at the end of nine months revealed the superiority of this approach in preventing major symptomatic exacerbations. Only one family-treated patient (6 per cent of all patients) was judged to have had a clinical relapse, as compared with eight patients (44 per cent) treated individually. Family-treated patients averaged 0.83 days in the hospital, as compared with 8.39 days for the comparison group. Significantly lower levels of schizophrenic symptomatology on blind rating-scale assessments supported these clinical observations of the superiority of family management.

The Prevalence and Correlates of Nonaffective Psychosis in the National Comorbidity Survey Replication (NCS-R)

BACKGROUND To estimate the prevalence and correlates of clinician-diagnosed DSM-IV nonaffective psychosis (NAP) in a national household survey. METHODS Data came from the United States National Comorbidity Survey Replication (NCS-R). A screen for NAP was followed by blinded sub-sample clinical reappraisal interviews. Logistic regression was used to impute clinical diagnoses to respondents who were not re-interviewed. The method of Multiple Imputation (MI) was used to estimate prevalence and correlates. RESULTS Clinician-diagnosed NAP was well predicted by the screen (area under the curve [AUC] = .80). The MI prevalence estimate of NAP (standard error in parentheses) is 5.0 (2.6) per 1000 population lifetime and 3.0 (2.2) per 1000 past 12 months. The vast majority (79.4%) of lifetime and 12-month (63.7%) cases met criteria for other DSM-IV hierarchy-free disorders. Fifty-eight percent of 12-month cases were in treatment, most in the mental health specialty sector. CONCLUSIONS The screen for NAP in the NCS-R greatly improved on previous epidemiological surveys in reducing false positives, but coding of open-ended screening scale responses was still needed to achieve accurate prediction. The lower prevalence estimate than in total-population incidence studies raises concerns that systematic nonresponse bias causes downward bias in survey prevalence estimates of NAP.

Persistent auditory hallucinations: coping mechanisms and implications for management

The strategies used by 40 chronic schizophrenic out-patients with persistent auditory hallucinations to cope with the intrusive phenomena were explored. Frequent coping mechanisms included changes in activity, interpersonal contact, manipulations of physiological arousal, and attentional control. A high risk of suicide was noted. Coping behaviour appeared somewhat independent of clinical and sociodemographic variables. Successful coping appeared to result from systematic application of widely used coping strategies. The implications for the clinical management of patients with persistent auditory hallucinations are discussed.

Is Theory of Mind in Schizophrenia More Strongly Associated with Clinical and Social Functioning than with Neurocognitive Deficits

This paper examines the correlations between ‘Theory of Mind’ (ToM) and neurocognitive performance, together with clinical and social functioning, in out-patients with schizophrenic disorders. It was hypothesised that, since the ability to make inferences about the environment and about other peoples’ mental states is a key ingredient of social competence, the assessment of ToM would correlate more strongly with current social functioning than with more traditional neurocognitive measures. ‘Independent raters’ assessed Theory of Mind, neurocognitive and clinical variables as well as community functioning in 44 subjects with schizophrenia. The neuropsychological measures were more closely associated with community functioning than with psychiatric symptoms. These associations remained evident when the effects of intelligence were controlled. Patients with a higher level of competence in making social inferences had better overall community functioning than those who showed less ability in this aspect of social cognition. In a regression model, the capacity to comprehend other people’s mental states (ToM-2) was among the best predictors of global social functioning, together with recent onset of illness, good verbal fluency and low levels of negative and positive symptoms. These results are consistent with other recent findings. ToM measures of social cognition may be a useful addition to neuropsychological assessment when developing programmes for reducing clinical impairments and improving the community functioning of subjects with schizophrenic disorders. Further studies are needed to verify the value of these measures as predictors of the successful application of specific psychosocial rehabilitation strategies.

Depression in schizophrenia: recognition and management in the USA

The recognition of depression as a distinct syndrome within schizophrenia is a relatively recent development. The International Survey of Depression in Schizophrenia was designed to evaluate current clinical practice and prescribing trends in the management of the depressive component of schizophrenia. A 48-item questionnaire, comprising fixed-response questions and questions stimulated by case scenarios, was distributed to 37513 psychiatrists in the USA. A total of 43484 psychiatrists in Canada, Australia and 21 European countries also received the questionnaire. A total of 1128 US psychiatrists responded. Analysis of the data revealed that US psychiatrists identify symptoms of depression in approximately one-third of patients with schizophrenia, and largely appreciate the magnitude of the resultant burden on patients and their families. Responses to questions regarding treatment approaches and case scenarios demonstrated that the level of adjunctive prescribing of antidepressants in the USA is often higher than in other regions. Levels of awareness of depression in patients with schizophrenia and recognition of the need for effective management appear to be high among US psychiatrists. However, more than a quarter of these specialists rarely or never prescribe adjunctive antidepressant medications. Disparities in treatment approaches varying from the existing scientific evidence base underscore the need for further investigation into ways of optimizing the management of this serious coexisting condition.

Family management in the prevention of morbidity of schizophrenia: social outcome of a two-year longitudinal study

Effective community treatment of schizophrenia involves not merely the removal of florid symptoms, but restoration of effective social role functioning. The efficacy of a family management approach is compared with an individual approach of similar intensity in terms of its impact on the patients social adjustment after a florid episode of schizophrenia. Clinical reports, patient self-reports, and interviews with the family members of 36 patients, who were randomly assigned to family or individual management, demonstrated a consistent superiority for family management. The advantages for the family approach were sustained over a two-year period. The potential mechanisms through which the family approach may have achieved its greater efficacy are discussed from a multi-determined perspective.

Reliability of an Italian standardized and expanded Brief Psychiatric Rating Scale (BPRS 4.0) in raters with high vs. low clinical experience.

Roncone R, Ventura J, Impallomeni M, Falloon IRH, Morosini PL, Chiaravalle E, Casacchia M. Reliability of an Italian standardized and expanded Brief Psychiatric Rating Scale (BPRS 4.0) in raters with high vs. low clinical experience. Acta Psychiatr Scand 1999: 100: 229–236.

Optimal Treatment Strategies to Enhance Recovery from Schizophrenia

Objective: The aim of this paper is to examine the base for integrating biomedical, psychological and social strategies in the management of schizophrenia. Method: A review of the literature on schizophrenia with particular emphasis in management considerations. Results: Effective treatment components include psychoeducation, medication strategies, carer-based stress management training, community-based intensive treatment, living skills training, and specific drug and cognitive-behavioural strategies for residual symptoms. Conclusions: Treatment for schizophrenia is best provided by integrating the various and specific psychosocial intervention strategies in addition to the optimal use of medication. Methods for implementing these strategies in outpatient settings include the use of a comprehensive assessment and treatment plan, the training of mental health professionals, and periodic review with assessment packages.

Caregivers' Stresses When Living Together or Apart from Patients with Chronic Schizophrenia

Ratings of stress and burden and mental symptoms which were screened by the General Health Questionnaire (GHQ) caseness were collected from two types of primary caregivers either living with (n = 37) or separately from (n = 48) a patient with a chronic schizophrenic disorder. The stress levels and burden of caregivers living apart were similar to those who were living together with patients and around 25 percent of both groups met GHQ criterion for having a mental disorder. Multiple regression analyses of all subjects identified stress with the patients disorder and strain in their own marital relationships as most predictive of their subjective global stress ratings. These results suggest that mental health services should aim to assist key caregivers of people with chronic schizophrenic disorders to manage stress whether or not the patient lives in the same household as the caregiver.