Massimo Tusconi

Gender Differences in Remission and Recovery of Schizophrenic and Schizoaffective Patients: Preliminary Results of a Prospective Cohort Study

The aim of the paper was to evaluate rates of clinical remission and recovery according to gender in a cohort of chronic outpatients attending a university community mental health center who had been diagnosed with schizophrenia and schizoaffective disorder according to DSM-IV-TR. A sample of 100 consecutive outpatients (70 males and 30 females) underwent comprehensive psychiatric evaluation using the Structured Clinical Interview for Diagnosis of Axis I and II DSM-IV (SCID-I and SCID-II, Version R) and an assessment of psychopathology, social functioning, clinical severity, subjective wellbeing, and quality of life, respectively by means of PANSS (Positive and Negative Syndrome Scale), PSP (Personal and Social Performance), CGI-SCH (Clinical Global Impression—Schizophrenia scale), SWN-S (Subjective Well-being under Neuroleptics—scale), and WHOQOL (WHO Quality of Life). Rates of clinical remission and recovery according to different criteria were calculated by gender. Higher rates of clinical remission and recovery were generally observed in females than males, a result consistent with literature data. Overall findings from the paper support the hypothesis of a better outcome of the disorders in women, even in the very long term.

Is it true remission? A study of remitted patients affected by schizophrenia and schizoaffective disorders.

UNLABELLED To date, few studies have reported analytical data relating to clinical remission, functional remission and subjective experience. The present study aimed to investigate these aspects in a sample of chronic outpatients. METHODS 112 schizophrenic or schizoaffective outpatients (Males=60; Females=52; mean age 43.5 ± 9.42 yr) were evaluated with regard to symptomatology (SCID-I; PANSS, CGI-SCH scales), functioning (PSP scale), subjective wellbeing (SWN-K scale) and Quality of Life (WHO-QoL-Bref scale). RESULTS 50% of patients were found to be in remission. Significantly higher scores at PANNS, CGI-SCH, PSP, but not at SWN and WHO-QoL, were found among remitted patients; a relevant proportion of remitted subjects continued to manifest a moderate level of symptoms (score >3) both at PANSS (35% of cases) and CGI-SCH (29% of cases), significant functional impairment (total score <70) at PSP (68% of cases ), and a lesser degree of wellbeing (total score <80) at SWN-K (34% of cases). CONCLUSION patients in whom clinical remission was confirmed may display persisting symptoms, relevant areas of functional impairment and a decreased sense of wellbeing.

Criteria for symptom remission revisited: a study of patients affected by schizophrenia and schizoaffective disorders

BackgroundThis study aims to compare severity criteria defined by the Remission in Schizophrenia Working Group (RSWGcr) with other criteria in relation to functional and neurocognitive outcome.Methods112 chronic psychotic outpatients were examined. Symptomatic remission according to RSWGcr was compared with the outcome achieved using criteria based on PANSS Positive and Negative Scales (PANSS-PNScr) and the entire PANSS (PANNS-TScr).ResultsRemission rates were 50%, 35% and 23% respectively at RSWGcr, PANSS-PNScr and PANNS-TScr; functional remission rates were 32%, 42% and 54%. Sensitivity, specificity, predictive value and ROC analysis demonstrated the superiority of PANSS-PNScr in identifying patients with higher functional and cognitive outcomes. Regression analysis showed a significant predictive effect of PANSS-TScr on functioning. General linear model analyses demonstrated significantly higher mean scores at PSP and BACS for patients remitted according to PANSS-TScr.ConclusionThe use of more restrictive severity criteria of remission seems to be associated with improved identification of truly remitted patients.

Clinical Global Impression-severity score as a reliable measure for routine evaluation of remission in schizophrenia and schizoaffective disorders

AimsThis study aimed to compare the performance of Positive and Negative Syndrome Scale (PANSS) symptom severity criteria established by the Remission in Schizophrenia Working Group (RSWG) with criteria based on Clinical Global Impression (CGI) severity score. The 6-month duration criterion was not taken into consideration.MethodsA convenience sample of 112 chronic psychotic outpatients was examined. Symptomatic remission was evaluated according to RSWG severity criterion and to a severity criterion indicated by the overall score obtained at CGI-Schizophrenia (CGI-SCH) rating scale (≤3) (CGI-S).ResultsClinical remission rates of 50% and 49.1%, respectively, were given by RSWG and CGI-S, with a significant level of agreement between the two criteria in identifying remitted and non-remitted cases. Mean scores at CGI-SCH and PANSS scales were significantly higher among remitters, independent of the remission criteria adopted. Measures of cognitive functioning were largely independent of clinical remission evaluated according to both RSWG and CGI-S. When applying RSWG and CGI-S criteria, the rates of overall good functioning yielded by Personal and Social Performance scale (PSP) were 32.1% and 32.7%, respectively, while the mean scores at PSP scale differed significantly between remitted and non-remitted patients, independent of criteria adopted. The proportion of patients judged to be in a state of well-being on Social Well-Being Under Neuroleptics-Short Version scale (SWN-K) were, respectively, 66.1% and 74.5% among remitters according to RSWG and CGI-S; the mean scores at the SWN scale were significantly higher only among remitters according to CGI-S criteria.ConclusionsCGI severity criteria may represent a valid and user-friendly alternative for use in identifying patients in remission, particularly in routine clinical practice.

Violence and mental disorders. A retrospective study of people in charge of a community mental health center

BACKGROUND Numerous studies conducted in inpatient settings have highlighted how mental disorders are associated with an increased risk of violence, particularly during acute phases. However, to date a more limited number of studies have been performed to assess the risk of violence in outpatients, particularly in Italy. The present study aims to evaluate the prevalence of violent events in a sample of patients in charge of a community mental health center in Italy. METHODS Based on data obtained from standardized clinical records, a retrospective study was undertaken to investigate acts of violence (physical aggression only) in a total of 678 patients (Males=308, 45.4%) in charge of a university mental health center; patients were mainly affected by anxiety disorders (30.7%), depressive disorder (17.2%), bipolar disorder (18.3%) and schizophrenia or other psychotic disorders (25.0%). RESULTS 27.6% of the sample had committed at least one act of violence during their lifetime, 10.5% over the previous year. 56.7% of those who committed violence acts had acted violently twice or more during their lifetime. A significant association of lifetime violence was found with gender (male), younger age, low education, unemployment, living with parents. With regard to diagnosis, a significant association was found with schizophrenia and other psychotic disorders, personality disorders, mental retardation, and comorbidity between two or more psychiatric disorders. Violence was moreover associated with early age at onset and at first psychiatric treatment, longer duration of the disorder, previous hospital admissions, previous violent events. CONCLUSION Violent behavior is relatively common among outpatients.

Diagnostic reliability in schizoaffective disorder.

Santelmann et al. (1) recently presented solid meta-analytical findings on the test–retest reliability of schizoaffective disorder (SZA). Since its introduction in 1933, the nosological definition of SZA has known contrasting conceptualizations (2–4). Indeed, the existence of SZA as an independent diagnostic entity has been questioned in recent years and the removal of SZA as a separate diagnostic category was proposed (5). The disorder was, however, ultimately maintained as an independent diagnostic category, as it was felt that there were not enough neurobiological and clinical data to support this motion (6, 7). Santelmann et al. (1) compared the reliability, assessed with Cohen’s kappa, of SZA diagnosis to that of the major differential diagnoses [schizophrenia (SCZ), bipolar disorder (BD), and unipolar depression (UD)] using data from 49 publications from 48 studies. The pooled sample size consisted of 14,314 patients. In summary, the test– retest reliability of SZA was consistently lower than that of SCZ, BD, and UD, which are considered as the main differential diagnoses. The mean difference in kappa between SZA and the other diagnoses was approximately 0.2, with a mean Cohen’s kappa of 0.50 (95% confidence interval: 0.40–0.59) for SZA. The meta-analysis carried out by Santelmann and colleagues has sound methodology and attempts to control for the very high rates of inconsistency and heterogeneity among the included studies using an elegant series of analyses. However, we would like to point out some methodological aspects that might need to be taken into account in interpreting Santelmann et al.’s results. First, the broad inclusion of studies where diagnoses were performed with different diagnostic criteria fulfils a need for increased statistical power, but leaves aside the clinical question of whether the sample of SZA patients included in the metaanalysis actually represents a homogenous population. For instance, six studies out of 49 considered ICD-10 diagnostic criteria (8), to diagnose 2,018 out of the total sample of 14,314 patients considered in the meta-analysis. ICD-10 defines SZA as episodic disorders in which both affective and schizophrenic symptoms are prominent within the same episode of illness, preferably simultaneously, but at least within a few days of each other (8). The diagnostic guideline states that SZA is a disorder in which schizophrenic and manic symptoms are both prominent in the same episode of illness, and, within the same episode, at least one and preferably two typically schizophrenic symptoms should be clearly present (8). The SZA category should be used both for a single schizoaffective episode of the manic type and for a recurrent disorder in which the majority of episodes are schizoaffective, manic type. This clearly contrasts with the DSM-IV-TR definition of SZA, which would consider ICD-10 patients as psychotic patients with bipolar I disorder, and requires psychotic symptoms to be present not simultaneously and for at least 14 days in the absence of an affective episode (9). This fundamental nosological difference might lead to an intrinsic clinical heterogeneity that should be controlled for if both diagnoses are included in the same analysis, for instance when conducting subgroup analyses of the studies using each set of diagnostic criteria. Similarly, the DSM-5 field trial was included in the meta-analysis, but the prevalence of affective symptoms is more strictly defined in the new diagnostic criteria of SZA than before, so that a proportion of patients formerly diagnosed as schizoaffective in DSM-IV-TR would not receive the same diagnosis with DSM-5 (10, 11). Second, reliability by diagnostic category followed a specific temporal pattern where studies with observation periods longer than 12 months showed the lowest kappa values, particularly for SCZ and BD diagnoses. This is an important and somewhat counterintuitive finding, given that the labile diagnostic stability of SZA has been consis-

Longitudinal assessment of brain-derived neurotrophic factor in Sardinian psychotic patients (LABSP): a protocol for a prospective observational study

Introduction Brain-derived neurotrophic factor (BDNF) plays a crucial role in neurodevelopment, synaptic plasticity and neuronal function and survival. Serum and plasma BDNF levels are moderately, but consistently, decreased in patients with schizophrenia (SCZ) compared with healthy controls. There is a lack of knowledge, however, on the temporal manifestation of this decline. Clinical, illness course and treatment factors might influence the variation of BDNF serum levels in patients with psychosis. In this context, we propose a longitudinal study of a cohort of SCZ and schizophrenic and schizoaffective disorder (SAD) Sardinian patients with the aim of disentangling the relationship between peripheral BDNF serum levels and changes of psychopathology, cognition and drug treatments. Methods and analysis Longitudinal assessment of BDNF in Sardinian psychotic patients (LABSP) is a 24-month observational prospective cohort study. Patients with SAD will be recruited at the Psychiatry Research Unit of the Department of Medical Science and Public Health, University of Cagliari and University of Cagliari Health Agency, Cagliari, Italy. We will collect BDNF serum levels as well as sociodemographic, psychopathological and neurocognitive measures. Structured, semistructured and self-rating assessment tools, such as the Positive and Negative Syndrome Scale for psychopathological measures and the Brief Assessment of Cognition in Schizophrenia for cognitive function, will be used. Ethics and dissemination This study protocol was approved by the University of Cagliari Health Agency Ethics Committee (NP2016/5491). The study will be conducted in accordance with the principles of good clinical practice, in the Declaration of Helsinki in compliance with the regulations. Participation will be voluntary and written informed consent will be obtained for each participant upon entry into the study. We plan to disseminate the results of our study through conference presentations and publication in international peer-reviewed journals. Access to raw data will be available in anonymised form upon request to the corresponding author.

Assessment of functioning in patients with schizophrenia and schizoaffective disorder with the Mini-ICF-APP: a validation study in Italy

BackgroundThe aim of the study was to evaluate validity of the Italian Mini-ICF-APP (Mini-ICF Rating for Limitations of Activities and Participation in Psychological Disorders) in schizophrenia and related disorders.Methods74 outpatients affected by schizophrenia or schizoaffective disorders attending a University-based community mental health centre were recruited to the study. All participants underwent comprehensive evaluation using standardized instruments to assess clinical, neurocognitive and functional status. Concurrent validity of Mini-ICF-APP was evaluated and compared to severity scores obtained using the Clinical Global Impression-Schizophrenia scale (CGI-SCH), Positive and Negative Syndrome scale (PANSS), Mini Mental State Examination test (MMSE), Brief Assessment of Cognition in Schizophrenia scale (BACS) and Personal and Social Performance scale (PSP). Construct validity was evaluated by comparing scores obtained at Mini-ICF-APP by remitted versus non-remitted patients, and by recovered versus unrecovered patients. Discriminant validity was evaluated comparing scores on Mini-ICF-APP and Subjective Well-being (SWN) scale. Results: the total score and 12 out of the 13 Mini-ICF-APP items correlated significantly with total score at PSP; Mini-ICF-App total score was moreover significantly correlated with total scores at CGI-SCH, PANSS, MMSE, as well as with several BACS items. Total scores obtained at Mini-ICF-APP were significantly higher among remitted and recovered patients. No relevant correlations were found between scores of Mini-ICF-APP and SWN scales.ResultsThe total score and 12 out of the 13 Mini-ICF-APP items correlated significantly with total score at PSP; Mini-ICF-App total score was moreover significantly correlated with total scores at CGI-SCH, PANSS, MMSE, as well as with several BACS items. Total scores obtained at Mini-ICF-APP were significantly higher among remitted and recovered patients. No relevant correlations were found between scores of Mini-ICF-APP and SWN scales.Conclusionthe Italian version of Mini-ICF-APP is a valid instrument for use in evaluating functioning in chronic patients with schizophrenia and related disorders.