Rohan Ganguli

Assessment of strategies for switching patients from olanzapine to risperidone: a randomized, open-label, rater-blinded study.

BackgroundIn clinical practice, physicians often need to change the antipsychotic medications they give to patients because of an inadequate response or the presence of unacceptable or unsafe side effects. However, there is a lack of consensus in the field as to the optimal switching strategy for antipsychotics, especially with regards to the speed at which the dose of the previous antipsychotic should be reduced. This paper assesses the short-term results of strategies for the discontinuation of olanzapine when initiating risperidone.MethodsIn a 6-week, randomized, open-label, rater-blinded study, patients with schizophrenia or schizoaffective disorder, on a stable drug dose for more than 30 days at entry, who were intolerant of or exhibiting a suboptimal symptom response to more than 30 days of olanzapine treatment, were randomly assigned to the following switch strategies (common risperidone initiation scheme; varying olanzapine discontinuation): (i) abrupt strategy, where olanzapine was discontinued at risperidone initiation; (ii) gradual 1 strategy, where olanzapine was given at 50% entry dose for 1 week after risperidone initiation and then discontinued; or (iii) gradual 2 strategy, where olanzapine was given at 100% entry dose for 1 week, then at 50% in the second week, and then discontinued.ResultsThe study enrolled 123 patients on stable doses of olanzapine. Their mean age was 40.3 years and mean (± standard deviation (SD)) baseline Positive and Negative Syndrome Scale (PANSS) total score of 75.6 ± 11.5. All-cause treatment discontinuation was lowest (12%) in the group with the slowest olanzapine dose reduction (gradual 2) and occurred at half the discontinuation rate in the other two groups (25% in abrupt and 28% in gradual 1). The relative risk of early discontinuation was 0.77 (confidence interval 0.61–0.99) for the slowest dose reduction compared with the other two strategies. After the medication was changed, improvements at endpoint were seen in PANSS total score (-7.3; p < 0.0001) and in PANSS positive (-3.0; p < 0.0001), negative (-0.9; p = 0.171) and anxiety/depression (-1.4; p = 0.0005) subscale scores. Severity of movement disorders and weight changes were minimal.ConclusionWhen switching patients from olanzapine to risperidone, a gradual reduction in the dose of olanzapine over 2 weeks was associated with higher rates of retention compared with abrupt or less gradual discontinuation. Switching via any strategy was associated with significant improvements in positive and anxiety symptoms and was generally well tolerated.Trial registrationClinicalTrials.gov NCT00378183

The VAGUS insight into psychosis scale – Self-report and clinician-rated versions

The aim of this study was to develop self-report and clinician-rated versions of an insight scale that would be easy to administer, sensitive to small changes, and inclusive of the core dimensions of clinical insight into psychosis. Ten-item self-report (VAGUS-SR) and five-item clinician-rated (VAGUS-CR) scales were designed to measure the dimensions of insight into psychosis and evaluated in 215 and 140 participants, respectively (www.vagusonline.com). Tests of reliability and validity were performed. Both the VAGUS-SR and VAGUS-CR showed good internal consistency and reliability. They demonstrated good convergent and discriminant validity. Both versions were strongly correlated with one another and with the Schedule for the Assessment of Insight and Birchwood Insight Scale. Exploratory factor analyses identified three possible latent components of insight. The VAGUS-CR and VAGUS-SR are valid, reliable and easy to administer. They are build on previous insight scales with separate clinician-rated and self-report versions. The VAGUS-SR exhibited a multidimensional factor structure. Using a 10-point Likert scale for each item, the VAGUS has the capacity to detect small, temporally sensitive changes in insight, which is essential for intervention studies with neurostimulation or rapidly acting medications.

Health-related quality of life, adiposity, and sedentary behavior in patients with early schizophrenia: preliminary study

Objective: To examine adiposity and sedentary behavior in relation to health-related quality of life (QoL) in patients with early schizophrenia. Methods: A cross-sectional study was used to assess adiposity by dual-energy X-ray absorptiometry scans, habitual physical activity and idle sitting time by the Short Form International Physical Activity Questionnaire, and health-related QoL by the RAND Medical Outcomes Study SF-36. QoL scores were compared with age-adjusted Canadian normative population data. Results: There were 36 participants with early schizophrenia, average age 25.1 (±3.6). Twenty-nine (72.5%) were males. Mean illness duration was 30 (±18) months, and mean body mass index was 28.3 (±5). Females had higher body fat content than males (30.8 ±6.9 vs 24.7 ± 10.6; t = −2.6, df = 34; P = 0.015). Total body fat (F = 14; P = 0.001), lean body mass (F = 10.2; P = 0.001), and sedentary behavior (F = 5; P = 0.013) significantly increased across body mass index categories. Total body fat was correlated with sedentary behavior (r = 0.62; P = 0.001), and total lean body mass was negatively correlated with sedentary behavior (r = 0.39; P = 0.03). Based on SF-36 scores, participants had significantly lower physical functioning (P = 0.0034), role physical (P = 0.0003), general health (P < 0.0001), vitality (P = 0.03), and physical component scores (P = 0.003) than Canadian population comparisons. Habitual sedentary behavior, more than activity or adiposity levels, was associated with health-related QoL in early schizophrenia. Conclusion: Health-related QoL is lower in early schizophrenia and is predominantly experienced in the physical domain. QoL in early schizophrenia relates to sedentary behavior more than to activity and adiposity levels.

Cognitive Remediation for Individuals with Psychosis in a Supported Education Setting: A Pilot Study

Cognitive remediation (CR) is a treatment approach that is being increasingly examined as a means through which the cognitive impacts of schizophrenia might be ameliorated. While CR has demonstrated good outcomes when paired with supported employment, little is known regarding how it might be integrated within supported education contexts. In this study CR was examined in a supported education context with 16 individuals with psychosis. The findings indicated that CR aligned well with the academic curriculum with very low attrition, was found useful by students, and showed similar pre-post differences on cognitive measures as those found in previous work.

Adherence to Diabetes Medication in Individuals with Schizophrenia: A Systematic Review of Rates and Determinants of Adherence.

INTRODUCTIONnDespite the importance of medication adherence for the effective treatment of type II diabetes mellitus (T2DM), little research has examined adherence with diabetes medication treatment in schizophrenia. The purpose of this systematic review was to: 1) evaluate rates of adherence and determinants of adherence with medication for T2DM in individuals with schizophrenia; and, where possible, 2) examine the relationship between medication adherence and glycemic control.nnnMETHODSnStudies were included if they presented information on dosing regimens and adherence or compliance rates for T2DM and included samples where at least 50% of the participants were individuals with schizophrenia.nnnRESULTSnSix studies were included in this review that predominantly examined men over the age of 50 years. Studies confirmed that many individuals with schizophrenia were not adhering to their diabetes medication as adherence rates ranged from 51-85%. Two studies that compared medication adherence in individuals with and without schizophrenia found those with the mental illness had higher rates of adherence. One study reported that blood glucose control levels were not statistically different between those who did and did not adhere to their medication, indicating more research is necessary in this area. Factors that improved adherence included disease and medical service and medication-related factors.nnnCONCLUSIONSnInterventions to increase diabetes medication adherence in schizophrenia need to address disease and medical service and medication-related factors. Further research needs to examine diabetes medication adherence in women, younger individuals, and those recently diagnosed with diabetes as these individuals have been underrepresented in the literature.

Testing a modification of cognitive adaptation training: streamlining the model for broader implementation.

Cognitive adaptation training (CAT) is a home-based, manualized treatment that utilizes environmental supports to improve target behaviors and functional outcomes in persons with schizophrenia. Although clinical trials have shown CAT to be effective across functional, clinical, and treatment adherence domains, when the intervention is withdrawn clients experience significant declines. The aim of the current study was to test a modified version of CAT, which decreases the duration of intensive CAT intervention while utilizing ongoing case management-supported CAT to maintain the fundamental components of the treatment. Twenty-three people participated in an outcome study of the modified version of CAT, evaluating improvements after 4months of CAT specialist intervention and after an additional 5months of case manager support. Analysis revealed significant improvements in adaptive functioning, psychiatric symptomatology, and goal attainment, which were maintained throughout case management follow-up. This suggests that an intervention that has previously demonstrated good functional outcomes in randomized trials might sustain its impacts in an abbreviated format with support from existing case managers.

Body composition, pre‐diabetes and cardiovascular disease risk in early schizophrenia

This preliminary study examines the relationship between body composition, insulin resistance and NCEP‐III‐defined cardiovascular disease risk factors in persons early in the course of schizophrenia exposed to commonly prescribed atypical antipsychotic medications.

Diabetes Resolution Following Discontinuation of a Second-Generation Antipsychotic: Three Cases

Introduction Schizophrenia patients have higher rates of type 2 diabetes mellitus (T2DM) than population comparisons and, in conjunction with highly prevalent obesity and cardiovascular disease, this translates into a 20% reduced life expectancy (1). Unfortunately, despite arguably better outcomes in several psychiatric domains including symptoms, cognition and quality of life, the mortality gap for patients is not narrowing but may indeed be widening (2). Preferential use of second-generation antipsychotics (SGAs) as opposed to older (first-generation antipsychotics, FGAs) antipsychotics may account for the widening mortality gap (3). This is because research has confirmed a link between SGA use and development of T2DM and other metabolic complications (1). Conversely, very little evidence has accumulated that would support a connection between discontinuation of SGAs and diabetes resolution, although implications in the prevailing context would be important. Here, we describe three cases of diabetes onset with SGA treatment and confirmed resolution after switch to an FGA.

Smoking, caffeine intake and eating habits in community dwelling patients with schizophrenia

In a survey of nutritional habits of 146 community dwelling patients with schizophrenia, we examined the prevalence, severity and duration of smoking and its association with caffeine intake, caloric intake, socio-demographic factors and body weight. Caffeine and caloric intake were calculated from a 24-hour diet recall interview using commercially available software and Body Mass Index (BMI) was calculated from measurements of weight and height as per guidelines. Information regarding the severity and duration of smoking was obtained by using a smoking history questionnaire. The sample consisted of 78 male (42 Caucasian, 36 African-American (A-A)) and 68 female patients (37 Caucasian, 31 A-A). There were no differences between the proportion of smokers among male and female patients. However, in this sample, the prevalence of smokers among A-A patients (49 of 67, 73%) was significantly higher than the prevalence of smokers among Caucasian patients (38 of 79, 48%; P2 = 9.4, p = 0.002). Even though the representation of smokers among A-A patients was high, Caucasian patients smoked significantly more number of cigarettes per day as compared to A-A patients (Mean + SD number of cigarettes smoked daily, Caucasian patients (n=38): 31.1 + 16.6, A-A patients (n=49): 18.3 + 9.0, t = 4.6, p<0.001). Similarly, Caucasian patients also consumed more caffeine than A-A patients (Mean + SD mg of caffeine consumed daily, Caucasian patients (n=79): 618.7 + 707.8, A-A patients (n=67): 298.0 + 319.7, t = 3.4, p = 0.001). The implication of these findings with regard to the associations between smoking, caffeine and caloric intake, BMI, psychotropic medication and socio-economic status will be discussed and comparison with national norms will be presented.