Differential efficacy of olanzapine for deficit and nondeficit negative symptoms in schizophrenia.

OBJECTIVE: Atypical antipsychotic medications have generally been found to be more effective than conventional antipsychotics in the treatment of negative symptoms. Whether the benefits derived from the atypical agents are the result of improvements in primary versus secondary negative symptoms is unclear. The authors examined the effects of olanzapine on primary and secondary negative symptoms for patients with severe negative symptoms who did or did not have the deficit syndrome. METHOD: Thirty-nine outpatients with schizophrenia and severe negative symptoms were assessed for the presence of the deficit syndrome and entered into a 12-week, open-label study of olanzapine. Positive and negative symptoms, extrapyramidal side effects, quality of life, and level of functioning of the patients were assessed at baseline and endpoint. RESULTS: All 39 patients completed the 12-week protocol; 13 of the patients had deficit negative symptoms, and 26 had nondeficit negative symptoms. Patients who had nondeficit negative symptoms demonstrated improvements in positive and negative symptoms, level of functioning, and extrapyramidal side effects over baseline. In contrast, patients meeting criteria for the deficit syndrome improved significantly over baseline only in extrapyramidal side effects. CONCLUSIONS: The results of this study suggest that olanzapine is efficacious for secondary negative symptoms in schizophrenia but fail to support the contention that olanzapine has a direct beneficial effect on primary negative symptoms.

Assessing the efficacy of treatments for the deficit syndrome of schizophrenia.

The primary, enduring negative symptoms found in some patients with schizophrenia have become the focus of clinical treatment trials, but there has been no consensus on the best methods for approaching this area. In future trials, a number of issues need to be considered, including analytic strategies, the limitations in instruments used to measure negative symptoms, and study design. An appropriate design for establishing the efficacy of treatments for the deficit syndrome is proposed.

Psychosocial skills training for schizophrenia: lessons from the laboratory.

A large body of research supports the efficacy of psychosocial treatments for schizophrenia, particularly learning-based therapies. The Schizophrenia Patient Outcomes Research Team recommended that cognitive-behavioral therapies be used in schizophrenia, and skills training was included in the practice guideline for treating patients with schizophrenia published by the American Psychiatric Association. This article provides an updated review of empirical studies of psychosocial skills training, showing its value in treating patients with schizophrenia as well as its broader clinical effectiveness. Data supporting the efficacy of psychosocial skills training continue to accumulate. Such programs should continue to be included in best practices guidelines and treatment recommendations for schizophrenia. Future clinical service research could be directed toward integration of skills training with other psychosocial treatment methods.

Hemispheric asymmetry in depression and mania. A longitudinal QEEG study in bipolar disorder.

BACKGROUND: previous research has been inconclusive about the nature of hemispheric asymmetry in emotional processing. METHOD: 13 patients with DSM-IV bipolar disorder received repeated QEEGs over 2 years in different mood states. Z-score measures of asymmetry were assessed. RESULTS: asymmetry in frontotemporal slow-wave activity appeared to be in opposite directions in depression compared to mania/hypomania. CONCLUSIONS: mood change in bipolar disorder is associated with change in QEEG asymmetry. LIMITATIONS: study of larger numbers of more homogenous patients under similar conditions is needed. CLINICAL RELEVANCE: study of mood state-dependent asymmetry changes in bipolar disorder may lead to better understanding of hemispheric processing of emotion.

Teaching psychiatric inpatients to re-enter the community: a brief method of improving the continuity of care.

OBJECTIVE: The study evaluated the effects of a brief manualized treatment program that taught patients skills to re-enter the community and actively follow through with their own care. METHODS: A total of 59 recently admitted inpatients with schizophrenia or schizoaffective disorder were randomly assigned to either the community re-entry program or an equally intensive regimen of occupational therapy. The community re-entry program consisted of eight 45-minute sessions conducted with groups of six to eight patients on a continuous, twice-a-day, four-day-a-week schedule. The effects were measured by a review of the records of aftercare services that patients received in the month after discharge from the inpatient facility. Patients' knowledge and performance of the specific material taught in the community reentry program was ascertained through assessments conducted before and after training. RESULTS: Results indicated that patients in the community re-entry program significantly improved their knowledge and performance of the skills taught in the sessions, compared with patients in the occupational therapy group. Community re-entry participants were also significantly more likely to attend their first aftercare appointment than were occupational therapy participants (85 percent versus 37 percent). CONCLUSIONS: Not only can patients learn relatively complex material during a brief typical inpatient stay despite the acuteness of their illnesses, but they can also meaningfully improve the continuity of their own care by participating in a brief and highly structured training program. The program fits well within the time and staffing constraints of typical inpatient facilities.

Skills training versus psychosocial occupational therapy for persons with persistent schizophrenia.

OBJECTIVE: The authors compared the community functioning of outpatients with persistent forms of schizophrenia after treatment with psychosocial occupational therapy or social skills training, with the latter conducted by paraprofessionals. METHOD: Eighty outpatients with persistent forms of schizophrenia were randomly assigned to receive either psychosocial occupational therapy or skills training for 12 hours weekly for 6 months, followed by 18 months of follow-up with case management in the community. Antipsychotic medication was prescribed through "doctor's choice" by psychiatrists who were blind to the psychosocial treatment assignments. RESULTS: Patients who received skills training showed significantly greater independent living skills during a 2-year follow-up of everyday community functioning. CONCLUSIONS: Skills training can be effectively conducted by paraprofessionals, with durability and generalization of the skills greater than that achieved by occupational therapists who provide their patients with psychosocial occupational therapy.

Comparison of efficacy of social skills training for deficit and nondeficit negative symptoms in schizophrenia.

OBJECTIVE: The purpose of this pilot study was to compare the efficacy of social skills training for individuals with schizophrenia who did or did not have the deficit syndrome. METHOD: Three subjects with the deficit syndrome and three with nondeficit negative symptoms received 12 weeks of social skills training. Social skills and negative symptoms were evaluated before and after training and at 6-month follow-up. RESULTS: Patients with schizophrenia who did not have the deficit syndrome demonstrated significantly better social skills and lower negative symptoms both after training and at follow-up than did those who had the deficit syndrome. CONCLUSIONS: Schizophrenic patients with nondeficit negative symptoms appear amenable to intensive social skills training, but schizophrenic patients with the deficit syndrome may have significant deficits in skill acquisition.

Biobehavioral treatment and rehabilitation of schizophrenia.

The psychopathology and associated disabilities experienced by persons with schizophrenia have only partially responded to conventional pharmacological and psychosocial treatment approaches. Biobehavioral treatment and rehabilitation employs behavioral assessment, social learning principles, skills training, and a focus on the recovery process to amplify the effects of pharmacotherapy. Utilizing the Medline database, we review a selection of English-language studies published from 1970 to 1994 that support the effectiveness of each of the components of biobehavioral therapy, such as case management, psychopharmacology with behavioral assessment, psychoeducation, family involvement, and social skills training. An integrated biobehavioral therapy directed toward early detection and treatment of schizophrenic symptoms, collaboration between consumers and caregivers in managing treatment, family and social skills training, and teaching coping skills and self-help techniques has been documented to improve the course and outcome of schizophrenia, as measured by symptom recurrence, social functioning, and quality of life. A case vignette is presented to illustrate the successful integration of biobehavioral therapies into a treatment system that focuses on consumers' attempts to become increasingly responsible for recovering from illness.

Basic elements in biobehavioral treatment and rehabilitation of schizophrenia.

The psychopathology and associated disabilities experienced by persons with schizophrenia have only partially responded to conventional pharmacological and psychosocial treatment approaches. Biobehavioral therapy employs behavioral and symptomatic assessment, social learning principles, and skills training, to amplify the effects of pharmacotherapy. Comprehensive, continuous, and integrated biobehavioral therapy--aiming at early detection and treatment of schizophrenic symptoms, family and social skills training, and teaching coping and illness self-management skills--has been documented to improve the course and outcome of schizophrenia as measured by symptom recurrence, social functioning, and quality of life. Biobehavioral therapies must be delivered in the context of a collaborative relationship among patients, families and clinicians that together can optimize outcomes. Services need to be provided by assertive, outreach, community-based teams that tailor the type, frequency and scope of services to the phase of the individual's illness.