Two years of continued early treatment for recent-onset schizophrenia: a randomised controlled study.

OBJECTIVE: This random-controlled study evaluated benefits derived from continued integrated biomedical and psychosocial treatment for recent-onset schizophrenia. METHOD: Fifty cases of schizophrenia of less than 2 years duration were allocated randomly to integrated or standard treatment (ST) for 2 years. ST comprised optimal pharmacotherapy and case management, while IT also included cognitive-behavioural family treatment, that incorporated skills training, cognitive-behavioural strategies for residual psychotic and non-psychotic problems and home-based crisis management. Psychopathology, functioning, hospitalisation and suicidal behaviours were assessed two monthly and a composite index, reflecting overall clinical outcome was derived. RESULTS: IC proved superior to ST in reducing negative symptoms, minor psychotic episodes and in stabilising positive symptoms, but did not reduce hospital admissions or major psychotic recurrences. The composite index showed that significantly more IC patients (53%) had excellent 2-year outcomes than ST (25%). CONCLUSION: Evidence-based treatment achieves greater clinical benefits than pharmacotherapy and case management alone for recent-onset schizophrenia.

Structured assessment of current mental state in clinical practice: an international study of the reliability and validity of the Current Psychiatric State interview, CPS-50.

OBJECTIVE: To develop a reliable standardized assessment of psychiatric symptoms for use in clinical practice. METHOD: A 50-item interview, the Current Psychiatric State 50 (CPS-50), was used to assess 237 patients with a range of psychiatric diagnoses. Ratings were made by interviewers after a 2-day training. Comparisons of inter-rater reliability on each item and on eight clinical subscales were made across four international centres and between psychiatrists and non-psychiatrists. A principal components analysis was used to validate these clinical scales. RESULTS: Acceptable inter-rater reliability (intra-class coefficient > 0.80) was found for 46 of the 50 items, and for all eight subscales. There was no difference between centres or between psychiatrists and non-psychiatrists. The principal components analysis factors were similar to the clinical scales. CONCLUSION: The CPS-50 is a reliable standardized assessment of current mental status that can be used in clinical practice by all mental health professionals after brief training.

Integrated care in schizophrenia: a 2-year randomized controlled study of two community-based treatment programs.

OBJECTIVE: To evaluate the efficacy of two community-based programs that combined antipsychotic medication, family interventions and social skills training. METHOD: A randomized controlled trial with 2 years follow-up. The study included 84 patients with schizophrenic disorders, continuously managed in terms of care and treatment, and regularly assessed. Analysis was by intention-to-treat. RESULTS: Between-program comparisons showed significantly improved social function and consumer satisfaction in favour of the program 'Integrated Care' (IC) at the 2-year follow-up. The main clinically important differences between the two treatment programs studied were the procedures for shared decision making and patient empowerment in IC. CONCLUSION: The implementation of IC in clinical practice can improve social recovery and increase consumer satisfaction for patients with schizophrenic disorders. We identified specific procedures that might be added to improve the effectiveness of any program for severely mental ill people.

Clinical issues related to depression in schizophrenia: an international survey of psychiatrists.

OBJECTIVE: Depressive symptoms in schizophrenia are associated with a substantial morbidity and mortality burden. The 'International Survey of Depression in Schizophrenia' was designed to evaluate current awareness and clinical approaches in this area. METHOD: A 48-item questionnaire was distributed to approximately 80 000 consultant psychiatrists world-wide. Responses were analysed using descriptive statistics. RESULTS: Respondents demonstrated considerable awareness of the prevalence and consequences of depression in schizophrenia. Although there was widespread adjunctive use of antidepressants, one-third of respondents indicated that they rarely or never prescribe these agents in combination with antipsychotic medication. There were considerable variations in opinions about the best approach to the treatment of depressive symptoms associated with schizophrenia. CONCLUSION: The considerable clinical burden of depressive symptomatology in schizophrenia was acknowledged by the majority of respondents to this survey. There was, however, little agreement on the best management strategy.

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.

General practice recruitment for people at risk of schizophrenia: the Buckingham experience.

OBJECTIVE: The process of detecting people at high risk of schizophrenia from a community sample is a major challenge for prevention of psychotic disorders. The aim of this paper is to describe early detection procedures that can be implemented in primary care settings. METHODS: A selected literature review is supplemented by experiences and data obtained during the Buckingham Integrated Mental Health Care Project. RESULTS: General medical practitioners have been favoured as the agents most likely to prove helpful in detecting the key risk factors that predict the onset of schizophrenic disorders, as well as in recognising the earliest signs and symptoms of these conditions. However, the practical problems of screening for multiple and subtle risk factors in general practice are substantial, and general practitioners (GPs) often have difficulty recognising the earliest signs of a psychotic episode. A range of strategies to assist GPs detect early signs of psychosis in their patients are considered. CONCLUSIONS: It is feasible to implement primary care setting early detection procedures for people at risk of schizophrenia. Implementation is aided by the use of a brief screening questionnaire, training sessions and case supervision; and increased collaboration with mental health services and other community agencies.

Problem solving as a core strategy in the prevention of schizophrenia and other mental disorders.

OBJECTIVE: To outline the rationale for implementing training in structured problem solving as a primary prevention strategy for major mental disorders. METHOD: The evidence that training people in a structured method of solving their personal problems is an effective strategy in the treatment of established cases of schizophrenic and major mood disorders, is selectively reviewed. RESULTS: Most of the relevant research focused on the prevention of major recurrent episodes of psychosis. There is some evidence to support the hypothesis that this strategy may assist many people to achieve a full and sustained recovery from the clinical and social impairments of these disorders, especially when patients are taught to use structured problem solving with members of their personal resource groups, and they continue to take optimal doses of psychoactive medication. There is support for the hypothesis that the key therapeutic factor associated with these benefits is the improved efficiency of the management of life stress. CONCLUSIONS: The simplicity of problem solving, the educational methods used, and the widespread application to a person's lifestyle would appear to make this a possible candidate for a primary prevention program for major mental disorders. Guidebooks and teaching aids have been developed and show excellent consumer acceptance.

The stress of caring for people with obsessive compulsive disorders.

This paper presents a survey of stress of key carers of 46 consecutive cases of chronic obsessive-compulsive disorders who were receiving combined drug and cognitive-behavioral therapy in an out-patient clinic. A reliable semi-structured interview was used to estimate the overall stresses in various aspects of life. The effects of the disorder were most commonly expressed by carers in their marital relationship and in home management. Twenty-eight percent were severely burdened by their carer role, and 35% were extremely distressed at the prospect of ongoing care provision. Caregivers require support, and may be considered to be consumers of mental health services themselves.

Family therapy of schizophrenia.

Family therapy of schizophrenia has long been conceived and practised under etiological premises. Familial disturbances as pathological regression/fixation (psychoanalytical) and individuation-impairing family dynamics (systemic) were addressed directly in the hope of "curing" the disorder. The efforts to prove the viability of the concepts and/or the efficacy of the therapeutic approach were largely unsuccessful. Newer strategies of family therapy of schizophrenia are both more precise in their theoretical assumptions and more performing in the pursuit of their therapeutic goals. We analyse the basis of modern family therapy in the "Expressed-Emotions (EE)"--research and propose a newer, more adequate understanding of the EE phenomenon. From our own studies and from a general review of relevant studies we derive an understanding of the rationale of family work and family therapy of schizophrenia. We discuss the results of a meta-analysis on the active ingredients and the conditions of efficacy of family interventions.

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

OBJECTIVE: The aims of this study were (i) to assess the inter-rater reliability of the latest Italian expanded 24-item version of the Brief Psychiatric Rating Scale, BPRS version 4.0 and (ii) to assess the feasibility of obtaining reliable BPRS 4.0 ratings by reliability training of clinically less experienced trainees (medical and rehabilitation students). METHOD: A videotape-training procedure was used, and the inter-rater agreement scores of three different groups of raters, namely psychiatrists and psychologists (n=28), psychosocial rehabilitation students (n=27) and medical students (n=54) were calculated and compared. RESULTS: The results indicated that both experienced raters (psychiatrists and psychologists) and inexperienced raters (medical and psychosocial rehabilitation students) were able to achieve high levels of inter-rater reliability. CONCLUSION: Our results are of particular interest in view of the increasing need to draw upon professionals, other than psychiatrists and psychologists, for cost-effective and standardized evaluation of rehabilitation interventions.

Early intervention for schizophrenic disorders. Implementing optimal treatment strategies in routine clinical services. OTP Collaborative Group.

BACKGROUND: Early detection and intervention in schizophrenic disorders is an important challenge for psychiatry. METHOD: Review of literature on effective biomedical and psychosocial intervention strategies. RESULTS: Comprehensive programmes of drug and psychosocial interventions with adults who show early signs and symptoms of schizophrenic disorders may contribute to a lower incidence and prevalence of major episodes of schizophrenia. These programmes combine early detection of psychotic features by primary care services, with close liaison with mental health professionals. Long-term monitoring of signs of recurrence, with further intervention, appears essential to maintain these benefits. CONCLUSIONS: Field trials demonstrate that effective early treatment strategies can be routinely applied in clinical practice.

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, career-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.

The role of general practitioners in mental health care: a survey of needs and problems.

OBJECTIVE: To assess the attitudes of general practitioners to central Auckland mental health service provision, and their perceived role and educational needs for clinical management of patients with mental disorders. METHOD: A postal questionnaire survey of all general practitioners within the Auckland Healthcare (Central Auckland CHE) area. RESULTS: 140 (49%) valid responses were returned from 287 sampled. 94% supported a shared care role with mental health services; 57% considered their role as main case manager to be important. 79% of the general practitioners considered they had insufficient time to manage patients with mental disorders. 69% of respondents reported difficulties receiving information about changes to treatment; 65% were unsure whether patients had a case manager, and 64% reported general difficulties with liaison with the mental health services. Education about a range of mental health issues was sought by three quarters of the group. CONCLUSION: This survey suggested that liaison between general practice and specialist mental health services in central Auckland is poor, but that general practitioners are eager to seek ways to improve the care of people suffering mental disorders.

Early detection and intervention for initial episodes of schizophrenia.

Comprehensive programs of drug and psychosocial interventions with adults who show early signs and symptoms of schizophrenic disorders may contribute to a lower incidence and prevalence of florid episodes of schizophrenia. These programs combine (1) early detection of psychotic features by family practitioners and other primary care providers and (2) close liaison with mental health professionals well trained in psychiatric assessment and treatment strategies effective in reducing the prevalence of established cases of schizophrenia. Long-term monitoring for signs of recurrence of these subthreshold psychotic episodes, with further intervention as needed, appears essential to maintain these benefits.

Family treatment for schizophrenia : the design and research application of therapist training models.

The NIMH Treatment Strategies in Schizophrenia (TSS) collaborative study group investigated the efficacy of antisychotic drug maintenance strategies involving reduced medication exposure in interaction with applied and supportive family management for the long-term treatment of schizophrenia. Therapy was provided at five centers by 25 clinicians who did not participate in the development of the therapies. They were trained by two of the authors, I.R.H.F and C.W.M, in applied family management, a homebased treatment derived from the behavioral family therapy developed by them. Clinicians' characteristics, selection, and training methods, as well as patient rehospitalization rates, are reported for the two family management conditions. The TSS study represents a bridge between the development of a novel therapy and its dissemination in general clinical practice.