Robert A. Rosenheck

Long-Acting Risperidone and Oral Antipsychotics in Unstable Schizophrenia

BACKGROUND Long-acting injectable risperidone, a second-generation antipsychotic agent, may improve adherence to treatment and outcomes in schizophrenia, but it has not been tested in a long-term randomized trial involving patients with unstable disease. METHODS We randomly assigned patients in the Veterans Affairs (VA) system who had schizophrenia or schizoaffective disorder and who had been hospitalized within the previous 2 years or were at imminent risk for hospitalization to 25 to 50 mg of long-acting injectable risperidone every two weeks or to a psychiatrists choice of an oral antipsychotic. All patients were followed for up to 2 years. The primary end point was hospitalization in a VA or non-VA psychiatric hospital. Symptoms, quality of life, and functioning were assessed in blinded videoconference interviews. RESULTS Of 369 participants, 40% were hospitalized at randomization, 55% were hospitalized within the previous 2 years, and 5% were at risk for hospitalization. The rate of hospitalization after randomization was not significantly lower among patients who received long-acting injectable risperidone than among those who received oral antipsychotics (39% after 10.8 months vs. 45% after 11.3 months; hazard ratio, 0.87; 95% confidence interval, 0.63 to 1.20). Psychiatric symptoms, quality of life, scores on the Personal and Social Performance scale of global functioning, and neurologic side effects were not significantly improved with long-acting injectable risperidone as compared with control treatments. Patients who received long-acting injectable risperidone reported more adverse events at the injection site and more extrapyramidal symptoms. CONCLUSIONS Long-acting injectable risperidone was not superior to a psychiatrists choice of oral treatment in patients with schizophrenia and schizoaffective disorder who were hospitalized or at high risk for hospitalization, and it was associated with more local injection-site and extrapyramidal adverse effects. (Supported by the VA Cooperative Studies Program and Ortho-McNeil Janssen Scientific Affairs; ClinicalTrials.gov number, NCT00132314.).

Elucidating the transdiagnostic dimensional structure of trauma-related psychopathology: Findings from VA cooperative study 504 - risperidone treatment for military service related chronic post traumatic stress disorder

BACKGROUND Three of the most common trauma-related mental disorders-posttraumatic stress disorder (PTSD), major depressive disorder (MDD), and generalized anxiety disorder (GAD)-are highly comorbid and share common transdiagnostic symptom dimensions of threat (i.e., fear) and loss (i.e., dysphoria) symptomatology. However, empirical evaluation of the dimensional structure of component aspects of these disorders is lacking. METHODS Using structured clinical interview data from U.S. military veterans with chronic military-related PTSD, we evaluated the transdiagnostic dimensional structure of PTSD, MDD, and GAD symptoms. We then examined the relationship between the best-fitting transdiagnostic model of these symptoms, and measures of physical and mental functioning, and life satisfaction and well-being. RESULTS Exploratory factor analysis revealed that a 3-factor transdiagnostic model comprised of loss (i.e., dysphoria), threat (i.e., anxious arousal, re-experiencing, and avoidance symptoms), and somatic anxiety (i.e., physiological manifestations of anxiety) symptoms provided the best representation of trauma-related PTSD, MDD, and GAD symptoms. Somatic anxiety symptoms were independently associated with physical functioning, while loss symptoms were independently associated with mental functioning and life satisfaction and well-being. LIMITATIONS Evaluation of study aims in a relatively homogeneous sample of veterans with chronic, military-related PTSD. CONCLUSIONS Results of this study suggest that a 3-factor transdiagnostic model best characterizes the dimensional structure of PTSD, MDD, and GAD symptoms in military veterans with chronic military-related PTSD. This model evidenced external validity in demonstrating differential associations with measures of physical and mental functioning, and life satisfaction and well-being. Results provide support for emerging contemporary models of psychopathology, which emphasize transdiagnostic and dimensional conceptualizations of mental disorders. Such models may have utility in understanding the functional status of trauma survivors.

Early intervention in psychosis: p‐values, policy, and politics

toms, since antipsychotics tend to worsen these symptoms, probably also affecting functional outcome. However, the dopamine system, in a number of these patients, might be so brittle that dosage reduction inevitably leads to relapse. On the other hand, patients who use cannabis at baseline might have a more important environmental causation of their dopamine derangement, tend to show less negative symptoms, and may be less likely to respond unfavourably to dosage reduction. Several trials are now underway to clinically evaluate dosage reduction in remitted first-episode schizophrenia patients, that will hopefully answer some of these questions. Finally, the authors’ view that in later stages (3 and 4) dosage reduction will probably not be an answer, while the still underused and often delayed antipsychotic drug clozapine might substantially improve outcome, though convincing, requires a more substantial research support.

Risk Factors, Service Delivery, and Prevention of Veteran Homelessness

Homelessness among US veterans has been of public concern for over three decades. Although veterans have special access to Department of Veterans Affairs (VA) healthcare, disability and education benefits, and home-loan guarantees, veterans are at greater risk for homelessness than other adults of the same age group, especially those who have served since the draft ended in 1975. A considerable body of research has been conducted on homeless veterans in recent years reflecting national efforts to address and end veteran homelessness. The first part of the chapter provides an introduction to the problem of veteran homelessness and a case study. Then, the chapter describes the prevalence of veteran homelessness in the USA and reviews the research literature on risk factors for veteran homelessness. The strongest risk factors identified in veteran homelessness have been substance abuse problems, mental illness, and low income. A few studies have also identified lack of social support, criminal history, and adverse childhood events as potential risk factors. Next, this chapter describes primary and secondary prevention of veteran homelessness and the various homeless programs provided by the VA, including transitional housing and residential programs, permanent supported housing, rapid rehousing programs, as well as several non-VA community-based programs. Finally, the last sections of the chapter suggest areas for future research and the conclusions that can currently be drawn from work in this area.