Lars Helldin

Standardized remission criteria in schizophrenia.

Objective:  Recent work has focussed on schizophrenia as a ‘deficit’ state but little attention has been paid to defining illness plasticity in terms of symptomatic remission.

Remission in prognosis of functional outcome: A new dimension in the treatment of patients with psychotic disorders ☆

INTRODUCTION The aim of the present study was to investigate whether or not the new concept of remission in the treatment of schizophrenia is of importance for functional outcome. The hypothesis was that patients having attained remission would function at a higher level and have a lower care requirement than those who had not attained remission. MATERIALS AND METHODS Remission is defined through the application of the Positive and Negative Syndrome Scale (PANSS) instrument whereby none of the eight chosen items, representing core symptoms, should be found to present a value exceeding 3 points. The utility of attaining the severity criteria for remission, or not, was examined with regard to activity of daily living (ADL) ability, establishment of social functioning and social network, and amount of health care and community support that the patient consumed. Two hundred and forty-three patients were examined, of whom 93 patients (38%) had attained remission and 150 patients (62%) had not. The present patient population, consisting of 50% of all available patients with schizophrenia spectrum disorder within a homogeneous catchment area in NU Health Care, western Sweden, meeting the right diagnostic criteria, were in their habitual condition and were unaffected by any other functionally debilitating disorder, in particular dementia. As a control patients diagnoses were used as the independent variable to exclude that they better explain outcome than remission. RESULTS It was found that patients that attainted the specified remission criteria showed a significantly superior outcome in all assessed areas with regard to activity of daily life, social functioning in society and consumption of health care. Remission patients functioned more effectively in social contexts in association with superior education, more often had occupations, possessed more established social networks and were more likely to be found living under family-like conditions. They exhibited a lower need for support in order to fulfill their everyday activities. Also, patients in remission required markedly less health care resources, both in the form of psychiatric treatment and community habitation support. In contrast diagnoses only made difference in 4 of 14 outcome parameters. DISCUSSION The results suggest that the concept of remission has important implications for the treatment of patients with chronic psychosis. One possible conclusion is that if more patients attain remission, the patients and societys burden resulting from the illness will decrease.

Remission in schizophrenia: applying recent consensus criteria to refine the concept.

Although the concept of remission has been widely accepted and utilized in depression and anxiety disorders, there has been much less emphasis on defining remission in schizophrenia. Recently, an expert consensus definition of remission in schizophrenia was proposed along specific operational criteria for the attainment of remission focusing on the three core dimensions of psychopathology identified within schizophrenia: psychoticism, disorganization and negative symptoms. To date, the criteria have been applied retrospectively to several clinical studies, and these have demonstrated that the proposed definition of remission correlates significantly with established measures of symptom severity, functioning and quality of life, and appears achievable for a significant proportion of patients receiving at least 3 months of pharmacotherapy. In this article we extend the notion of remission to include an examination of the possible association of several modifiable and unmodifiable factors and co-morbidities on remission status. We also propose an investigation into the likelihood of different patient populations in achieving remission as well as assessing the impact of remission on health care costs and family burden. Since cognitive dysfunction and negative symptoms may be strongly correlated with a lower likelihood of achieving remission, we recommend retrospective and/or prospective studies to determine the relationship between neurocognitive status and the predominance of negative symptoms at treatment start and the probability of achieving remission. Taken together, these studies should help identify key predictors of remission, further define the remitted state, reduce therapeutic pessimism, raise treatment expectations and chart a strategy for further research in this important area.

Illness-related components for the family burden of relatives to patients with psychotic illness

BackgroundPrevious research has shown that symptom severity often implies an increased family burden. Few other illness-related variables have, however, been investigated in this context. This study investigates how family burden is affected by symptom, function, and cognition, as well as how the patient perceives his/her illness and quality of life.MethodA total of 99 relatives, to as many patients diagnosed with psychosis and with their illness at a stable level, participated in this study. The relatives estimated their perceived burden, the patients rated the distress caused by their illness as well as the quality of their lives, and the care staff rated the patients’ symptom and function as well as tested their cognitive abilities.ResultsIncreased family burden can be tied to the patients’ increased symptom severity, to their impaired functioning as well as to the patients’ higher self ratings regarding distress. The family burden is also connected to the patient’s reduced working memory and reduced executive functioning, but this connection is not totally clear and should be further investigated. Of the variables that the patients were rated on, it was the overall functional ability measured with GAF that had the single most impact on perceived family burden.ConclusionsControlling of illness-related variables, such as symptoms, impaired functioning, impaired working memory and executive functioning, as well as the patients’ own experiences of distress, is important in order to lessen the burden for the relatives. All aspects of family burden are, however, not explained by these factors, which is why further research within this realm is required.

Culture as a predictor of resistance to change: A study of competing values in a psychiatric nursing context

It is well known that a conservative organizational culture can hinder the implementation of new organizational models. Prior to introducing something new it is important to identify the culture within the organization. This paper sets out to detect the feasibility of reform in a psychiatric clinic in a Swedish hospital prior to implementation of a new working method - a structured tool based on the International Classification of Functioning Disability and Health. A survey consisting of two instruments - an organizational values questionnaire (OVQ) and a resistance to change scale (RTC) - was distributed to registered and assistant nurses at the clinic. The association between the organizational subcultures and resistance to change was investigated with regression analysis. The results revealed that the dominating cultures in the outpatient centers and hospital wards were characterized by human relation properties such as flexibility, cohesion, belongingness, and trust. The mean resistance to change was low, but the subscale of cognitive rigidity was dominant, reflecting a tendency to avoid alternative ideas and perspectives. An instrument like the one employed in the study could be a useful tool for diagnosing the likelihood of extensive and costly interventions.

The importance of cross-sectional remission in schizophrenia for long-term outcome: A clinical prospective study

INTRODUCTION This study examines the relationship between having achieved cross-sectional remission and the need for future psychiatric and nursing home care. The study is a prospective long-term follow-up of patients with schizophrenia. MATERIALS AND METHODS Cross-sectional remission was defined by applying the Positive and Negative Syndrome Scale (PANSS) criteria requiring that none of the eight core positive and negative symptom items are scored greater than mild. Patients are followed-up by yearly clinical examinations and medical record review. Information on consumption of healthcare resources and residency status were also gathered. Visits to mental health professionals, number and duration of inpatient psychiatric or nursing home admissions were also recorded. The patients are enrolled in a 12 year prospective study, the Clinical Long-term Investigation of Psychosis in Sweden (the CLIPS study). This report covers the first seven years. RESULTS Those patients who achieved cross-sectional remission at baseline had a lower total consumption of healthcare services than those who were not in remission. The latter group displayed higher values for all measured variables. DISCUSSION Our results show that cross-sectional remission is likely to be an important goal to achieve in order to reduce future treatment needs. Patients in remission live a more independent life and have better preconditions for functioning in society.

Measuring adult attention deficit hyperactivity disorder using the Quantified Behavior Test Plus

Attention Deficit Hyperactivity Disorder (ADHD) occurs in approximately 5% of the adult population and includes cardinal symptoms of hyperactivity, inattention, and impulsivity that may be difficult to identify with clinical routine methods. Continuous performance tests are objective measures of inattention and impulsivity that, combined with objective measures of motor activity, facilitate identification of ADHD among adults. The aim of the present study was to examine the sensitivity, specificity, and a composite measure of ADHD using objective measures of the ADHD-cardinal symptoms in adult participants with ADHD and non-ADHD normative participants. Cardinal symptoms were measured in 55 participants having ADHD, 202 non-ADHD normative participants, as well as 84 ADHD normative participants using the Quantified Behavior Test Plus. This test measures inattention and impulsivity using a continuous performance test, and hyperactivity using a motion-tracking system. A predictive variable for the detection of ADHD called Prediction of ADHD yielded 86% sensitivity and 83% specificity. A composite measure of ADHD cardinal symptoms was developed using a Weighed Core Symptoms scale that indicated the total amount of ADHD symptoms on a numeric scale from 0 to 100. The total amount of ADHD symptoms was measured on a scale and predicted with the categorical variable in a majority of the cases in the present study. Further studies are needed in order to confirm the results with regard to additional clinical and normative samples. Careful consideration of potential sex and diagnostic subtype differences are noteworthy aspects for future examinations of the new instruments.

Objective Measures of Behavior Manifestations in Adult ADHD and Differentiation from Participants with Bipolar II Disorder, Borderline Personality Disorder, Participants with Disconfirmed ADHD as Well as Normative Participants.

Background: The present study evaluated two psychometric instruments derived from the objective measurement of adult ADHD using the Quantified Behavior Test Plus. The instruments were examined in ADHD versus a clinical group with overlapping symptoms including borderline personality disorder and bipolar II disorder, and another clinical group with participants assessed for but disconfirmed a diagnosis of ADHD as well as adult normative participants. Methods: The Quantified Behavior Test Plus includes Continuous Performance Testing and a Motion Tracking System with parameters related to attention and activity operationalized as the cardinal symptoms of ADHD and then summarized into a Weighed Core Symptoms scale with ten cut-points ranging from 0 to 100. A categorical predictor variable called Prediction of ADHD was used to examine the levels of sensitivity and specificity for the Quantified Behavior Test Plus with regard to ADHD. Results: The Weighed Core Symptoms scale separated ADHD and normative participants from each other as well as from the two clinical reference groups. The scale reported highest levels of core symptoms in the ADHD group and the lowest level of core symptoms in the normative group. Analyses with Prediction of ADHD yielded 85 % specificity for the normative group, 87 % sensitivity for the ADHD group, 36 % sensitivity for the bipolar II and borderline group and 41 % sensitivity for the group with a disconfirmed diagnosis of ADHD. Conclusions: The Weighed Core Symptoms scale facilitated objective assessment of adult ADHD insofar that the ADHD group presented more core symptoms than the other two clinical groups and the normative group. Sensitivity for the Quantified Behavior Test Plus was lower in complex clinical groups with Bipolar II disorder, Borderline disorder and in patients with a disconfirmed diagnosis of ADHD. The psychometric instruments may be further evaluated with regard to well-documented and effective treatment programs for ADHD core symptoms.

Psychometric properties of the burden inventory for relatives of persons with psychotic disturbances.

Earlier studies have shown that close relatives are heavily burdened when a family member has schizophrenia. The current purpose was twofold: (1) to examine the psychometric properties for a test of the burden of family members, one used in Swedish clinical practice (the Care Burden Scale for Relatives), and (2) develop a shortened version with the same or better psychometric properties. 99 close relatives, 34 men and 65 women of the same number of patients who had been diagnosed with schizophrenia, schizoaffective disorder, or delusional disorder, completed the Care Burden Scale for Relatives and a visual analog scale measuring perceived global burden on which the total burden was assessed. Patients of the close relatives were assessed on clinical tests often used in psychiatric care to validate the external criteria, such as severity of symptoms and level of functioning. The resulting version, the Burden Inventory for Relatives of persons with psychotic disturbances, showed good psychometric properties which simplifies data collection from relatives of patients with psychotic disturbances. In this study, relatives of those patients not in remission evinced a significantly greater family burden.

Psychometric properties of a performance-based measurement of functional capacity, the UCSD Performance-based Skills Assessment - Brief version

The UCSD Performance-based Skills Assessment - Brief version (UPSA-B) describes the functions of patients without negative influences of environmental factors such as unemployment or shortage in housing. The aim of the present study is to further explore the psychometric properties of the UPSA-B as well as to ensure that the Swedish version can be used in clinical practice and for research purposes. Participants were 211 patients, 135 men and 76 women, diagnosed with schizophrenia, schizoaffective disorder, or delusional disorder. Results indicate that the UPSA-B is a reliable instrument with good psychometric properties regarding validity and reliability. The instrument also had a capacity to reveal differences between various patient groups, both diagnostic groups and groups based on remission status. The conclusion drawn is that the UPSA-B is a valuable instrument that could be used in future cross-national studies to describe the level of functioning for patients with schizophrenia and other psychotic illnesses.