Relationship between clinical outcomes measures and personal and social performance functioning in a prospective, interventional study in schizophrenia.

OBJECTIVES: To explore clinical and demographic characteristics impacting patient functioning by determining extent of overlap in factors driving change in Personal and Social Performance (PSP) and other clinical outcomes. METHODS: Post-hoc analysis from a single-arm trial of paliperidone extended release in adult patients with nonacute symptomatic schizophrenia. Psychosocial functioning measures: PSP, Clinical Global Impression-Severity (CGI-S), Positive and Negative Syndrome Scale (PANSS), Short-Form 36 (SF-36), treatment satisfaction, sleep quality/daytime drowsiness, and Extrapyramidal Symptoms Rating Scale. RESULTS: Highest correlations with PSP total score change included PANSS total score change (Spearman's r = 0.607), PANSS general psychopathology change (r = 0.579), and CGI-S change (r = 0.569). A PSP score change of -32 predicted 90% probability of deterioration in CGI-S (score change of ≥1). The power of PSP change to predict PANSS total score change was lower. Linear stepwise regression demonstrated independent relationships for PSP change and: PANSS total change; CGI-S change; SF-36 Mental Component change; treatment satisfaction at endpoint; PSP at baseline; previous psychiatric hospitalizations. R 2 = 0.55 meant that 45% of PSP variation could not be explained by other clinical outcome measures. CONCLUSIONS: Psychosocial functioning improvement is important in schizophrenia. PSP may be valuable for assessing functioning; it encompasses psychosocial and clinical factors not measured by other established assessments.

[Addressing maladherence in schizophrenia]. / Behandlungsbereitschaft bei schizophrenen Störungen aufbauen: Was hilft?

Addressing maladherence in schizophrenia Abstract. To prevent neurotoxic and demoralizing relapses in the course of schizophrenia maladherence was shown as one of the most important factors. Empirical evidence is presented and organized in a conceptual four level framework to organize an individually tailored approach to promote adherence more effectively and prevent the demoralizing function of classical insight by neglecting the underlying motivational processes in routine care. This four level framework to address maladherence encompasses (a) functional analysis of (mal-)adherence as an instrumental goal oriented behaviour, (b) addressing dysfunctional attitudes related to disorder and treatment,

The impact of thought disorder on therapeutic alliance and personal recovery in schizophrenia and schizoaffective disorder: An exploratory study.

Thought and language disorders are a main feature of schizophrenia. The aim of the study is to explore the impact of thought disorder on therapeutic alliance and personal recovery because of its interference with verbal communication. Thought disorder, positive and negative symptoms (Positive and Negative Syndrome Scale), functioning (Modified Global Assessment of Functioning scale), insight (Scale to Assess Unawareness of Mental Disorder), attachment insecurity (Psychosis Attachment Measure), therapeutic alliance (Scale to Assess the Therapeutic Relationship), and personal recovery (Recovery Assessment Scale, Integration Sealing-Over Scale) were assessed in 133 outpatients with schizophrenia or schizoaffective disorder at baseline and twelve months later. The data were analyzed by hierarchical multiple linear regression. Higher levels of thought disorder were significantly associated with lower clinicians' ratings, but not with patients' ratings of therapeutic alliance. In addition, lower clinicians' ratings of therapeutic alliance were significantly linked to a more sealing over and less integrative recovery style. In fact, the lower therapeutic alliance ratings mediated the association between thought disorder and a sealing over recovery style. The results highlight the importance of considering thought disorder in treatment of schizophrenia and schizoaffective disorder which may interfere with therapeutic alliance and treatment efforts towards recovery.

Treatment response, safety, and tolerability of paliperidone extended release treatment in patients recently diagnosed with schizophrenia.

OBJECTIVE: This study was designed to explore the efficacy and tolerability of oral paliperidone extended release (ER) in a sample of patients who were switched to flexible doses within the crucial first 5 years after receiving a diagnosis of schizophrenia. METHODS: Patients were recruited from 23 countries. Adults with nonacute but symptomatic schizophrenia, previously unsuccessfully treated with other oral antipsychotics, were transitioned to paliperidone ER (3-12 mg/day) and prospectively treated for up to 6 months. The primary efficacy outcome for patients switching for the main reason of lack of efficacy with their previous antipsychotic was at least 20% improvement in Positive and Negative Syndrome Scale (PANSS) total scores. For patients switching for other main reasons, such as lack of tolerability, compliance or 'other', the primary outcome was non-inferiority in efficacy compared with the previous oral antipsychotic. RESULTS: For patients switching for the main reason of lack of efficacy, 63.1% achieved an improvement of at least 20% in PANSS total scores from baseline to endpoint. For each reason for switching other than lack of efficacy, efficacy maintenance after switching to paliperidone ER was confirmed. Statistically significant improvement in patient functioning from baseline to endpoint, as assessed by the Personal and Social Performance scale, was observed (p < 0.0001). Treatment satisfaction with prior antipsychotic treatment at baseline was rated 'good' to 'very good' by 16.8% of patients, and at endpoint by 66.0% of patients treated with paliperidone ER. Paliperidone ER was generally well tolerated, with frequently reported treatment-emergent adverse events being insomnia, anxiety and somnolence. CONCLUSIONS: Flexibly dosed paliperidone ER was associated with clinically relevant symptomatic and functional improvement in recently diagnosed patients with non-acute schizophrenia previously unsuccessfully treated with other oral antipsychotics.

Is living with psychosis demoralizing? Insight, self-stigma, and clinical outcome among people with schizophrenia across 1 year.

Lack of insight is a major target in the treatment of schizophrenia. However, insight may have undesirable effects on self-concept and motivation that can hinder recovery. This study aimed to examine the link between insight, self-stigma, and demoralization as predictors of symptoms and functioning. Insight, self-stigma, depressive and psychotic symptoms, and functioning were assessed among 133 outpatients with schizophrenia at baseline and 12 months later. The data were analyzed by hierarchical multiple linear regressions. More insight at baseline and an increase in self-stigma over 12 months predicted more demoralization at follow-up. Insight at baseline was not associated with any outcome variable, but self-stigma at baseline was related to poorer functioning and more positive symptoms at follow-up. More demoralization at baseline predicted poorer functioning 12 months later. Demoralization did not mediate the relationship between self-stigma at baseline and functioning after 1 year. Given the decisive role of self-stigma regarding recovery from schizophrenia, dysfunctional beliefs related to illness and the self should be addressed in treatment. Different psychotherapeutical approaches are discussed.

Therapeutic alliance in schizophrenia: the role of recovery orientation, self-stigma, and insight.

The present study examined variables related to the quality of the therapeutic alliance in out-patients with schizophrenia. We expected recovery orientation and insight to be positively, and self-stigma to be negatively associated with a good therapeutic alliance. We expected these associations to be independent from age, clinical symptoms (i.e. positive and negative symptoms, depression), and more general aspects of relationship building like avoidant attachment style and the duration of treatment by the current therapist. The study included 156 participants with DSM-IV diagnoses of schizophrenia or schizoaffective disorder in the maintenance phase of treatment. Therapeutic alliance, recovery orientation, self-stigma, insight, adult attachment style, and depression were assessed by self-report. Symptoms were rated by interviewers. Hierarchical multiple regressions revealed that more recovery orientation, less self-stigma, and more insight independently were associated with a better quality of the therapeutic alliance. Clinical symptoms, adult attachment style, age, and the duration of treatment by current therapist were unrelated to the quality of the therapeutic alliance. Low recovery orientation and increased self-stigma might undermine the therapeutic alliance in schizophrenia beyond the detrimental effect of poor insight. Therefore in clinical settings, besides enhancing insight, recovery orientation, and self-stigma should be addressed.

Validation of the Illness Perception Questionnaire for Schizophrenia in a German-speaking sample of outpatients with chronic schizophrenia.

BACKGROUND: Because the mere definition of insight from the therapist's viewpoint may not be sufficient to identify treatment targets for adherence enhancement, we need assessment strategies which are more sensitive to the patient's perspective. Illness perception (IP), defined as the beliefs a patient holds about his/her health problems, has been shown to affect coping in the context of a physical or mental illness, e.g. compliance behaviour. To assess IP in people diagnosed with schizophrenia, the Illness Perception Questionnaire for Schizophrenia (IPQS) was developed. The aim of the present study was to analyse the psychometric properties of the German version of the IPQS. SAMPLING AND METHODS: The study sample consisted of 128 German-speaking outpatients suffering from chronic schizophrenia or schizoaffective disorder. To achieve comparability with the validation of the English scale version, the same constructs were assessed: psychopathology, depression, and beliefs about medication. Furthermore, insight into one's illness was assessed. Internal consistency, test-retest reliability and construct validity including convergent and discriminant validity were analysed. RESULTS: Five of eight IPQS subscales were found to be internally reliable and all subscales demonstrated high stability over time. Correlations with validity measures indicated that the subscales assess dimensions of a construct, which is distinct from psychopathology, depression, beliefs about medication and insight, except for the Identity subscale which substantially overlapped with measures of insight. CONCLUSIONS: The German version of the IPQS is an essentially reliable and valid measure of IP for German-speaking people with a schizophrenia spectrum disorder. This may encourage its usage in further studies investigating the impact of subjective beliefs about mental health problems on outcome and recovery in schizophrenia.

The role of subjective illness beliefs and attitude toward recovery within the relationship of insight and depressive symptoms among people with schizophrenia spectrum disorders.

OBJECTIVE: Low levels of insight are a risk factor for treatment nonadherence in schizophrenia, which can contribute to poor clinical outcome. On the other hand, high levels of insight have been associated with negative outcome, such as depression, hopelessness, and lowered quality of life. The present study investigates mechanisms underlying the association of insight and depressive symptoms and protective factors as potential therapeutic targets. METHODS: One hundred and forty-two outpatients with schizophrenia or schizoaffective disorder (35.2% women, mean age of 44.83 years) were studied using questionnaires and interviews to assess insight, depressive symptoms, recovery attitude, and illness appraisals with regard to course, functional impairments, and controllability. Psychotic and negative symptoms were assessed as control variables. The cross-sectional data were analyzed using structural equation models and multiple linear regression analyses with latent variables. RESULTS: Higher levels of insight and psychotic symptoms were associated with more depressive symptoms. The association of negative symptoms with depressive symptoms was not significant. The relationship between insight and depressive symptoms was mediated by the participants' perception of their illness as being chronic and disabling, as well as suppressed by their expectation of symptom control due to treatment. Finally, the association of insight and depressive symptoms was less pronounced in the patients with a positive recovery attitude than in those without this protective factor. CONCLUSIONS: To achieve recovery, which includes symptom reduction, functional improvement, and subjective well-being, it is necessary to prevent depressive symptoms as indicators of a demoralization process, which may arise as a consequence of growing insight. Possible treatment strategies focusing on changes of dysfunctional beliefs about the illness and the self and inducing a positive recovery attitude are discussed.

Do patients with schizophrenia distinguish between attitudes toward antipsychotic medication and pharmacotherapy in general? Validation of the Beliefs About Medication Questionnaire.

Attitudes toward medication are important predictors of medication adherence in schizophrenia. However, monitoring their strength and influence in clinical settings is challenged by the absence of assessments separating them from adherence and subjective response and distinguishing between attitudes toward pharmacotherapy in general and antipsychotic medications. This study examined the applicability of the Beliefs about Medication Questionnaire (BMQ) in outpatients with schizophrenia (N = 131). Confirmatory factor analysis (CFA) could not support the original four-factor structure. A subsequent exploratory factor analysis revealed the factors Antipsychotics Necessity, Antipsychotics Concern, and Pharmacotherapy Distrust were supported by an acceptable fit of a completing CFA. These subscales have satisfactory internal reliability, test-retest reliability, and local fit indices. Modest correlations with insight and illness perception indicate construct validity. Criterion validity was supported by a significantly higher medication adherence of accepting patients compared with skeptical patients. The BMQ is a psychometrically sound and valid measure of attitudes toward medication in outpatients with schizophrenia.

Focusing on the adult attachment style in schizophrenia in community mental health centres: validation of the Psychosis Attachment Measure (PAM) in a German-speaking sample.

BACKGROUND: Assessing attachment style in people with schizophrenia may be important to identify a risk factor in building a strong therapeutic relationship and so indirectly to understand the development of mal-compliance as one of the major obstacles in the treatment of schizophrenia. AIMS: The present study analysed the psychometric properties of the German version of the Psychosis Attachment Measure (PAM), which assesses avoidant and anxious attachment style. METHODS: A sample of 127 patients suffering from chronic schizophrenia or schizoaffective disorder participated in this study. In testing discriminant validity, we assessed psychopathology, depression, therapeutic relationship and service engagement. Internal consistency, test-retest reliability and factor structure were analysed. RESULTS: The German version of PAM exhibited acceptable to good internal and test-retest reliabilities and the two-factor structure of the English version could be replicated. Avoidant attachment style was related to higher levels of positive symptoms and to a poorer therapeutic relationship. In the context of external validation, a regression analysis revealed that a poor therapeutic relationship correlated with avoidant attachment style, independent of anxious attachment style and depressive symptoms. Anxious attachment was associated with higher treatment adherence. Both insecure attachment styles (avoidant and anxious) were found to be correlated with higher levels of depression, but only attachment anxiety had an independent predictive value for self-reported depression in regression analysis. CONCLUSIONS: The German version of PAM displayed satisfactory psychometric properties and seems to be a reliable measure for assessing attachment style in individuals with schizophrenia. Validation of PAM led to the finding that only the avoidant attachment style might be a risk factor when building a strong therapeutic relationship in schizophrenia. In future studies, other factors influencing therapeutic relationship should be taken into account. Anxious attachment style may be a risk factor for depression, but it also has an enhancing effect on treatment adherence.

Self-stigma and its relationship with insight, demoralization, and clinical outcome among people with schizophrenia spectrum disorders.

BACKGROUND: Paradoxically, insight is associated with positive outcomes, such as better treatment adherence and recovery, and negative outcomes, such as depression, hopelessness, low self-esteem, and quality of life. Self-stigma as a moderating variable can be decisive whether more insight leads to better or worse outcome. On the other hand, self-stigma can act as a mediator between insight and outcomes. We therefore examined self-stigma both as a moderator and a mediator. METHODS: Insight, self-stigma, demoralization, symptoms, and functioning were assessed among 145 outpatients with schizophrenia spectrum disorders using questionnaires and structured interviews. Structural equation modeling was used to analyze the cross-sectional data. RESULTS: Results confirmed self-stigma as a moderator: The association of insight and demoralization was stronger as self-stigma increased. Self-stigma also partially mediated the positive relationship between insight and demoralization. Moreover, demoralization fully mediated the adverse associations of self-stigma with psychotic symptoms and global functioning. DISCUSSION: Given the decisive role of self-stigma regarding the detrimental consequences of insight, interventions should address self-stigma, particularly if psychoeducational or other interventions have increased insight. Therapeutic implications for changes of dysfunctional beliefs related to illness and self and change of self-concept in the context of recovery at the level of narrative identity are discussed.

Are we addressing the 'right stuff' to enhance adherence in schizophrenia? Understanding the role of insight and attitudes towards medication.

BACKGROUND: Despite the fact that medication adherence is among the most important health related behaviors in relapse prevention and recovery in schizophrenia, it is often not sufficiently endorsed by patients. Poor insight and negative attitudes towards medication are risk factors for non-adherence. Their relationship and the influence of more general attitudes towards pharmacotherapy besides attitudes towards antipsychotics have not been fully understood. The present study investigated whether these factors independently influence adherence or whether they mediate one another. METHODS: A cross-sectional sample of 150 outpatients completed the Beliefs about Medication Questionnaire. It assesses patients' beliefs about antipsychotic medication in terms of necessity and concerns and more general beliefs about pharmacotherapy in terms of distrust. Additionally, the patients' global awareness of illness (Scale to assess Unawareness of Mental Disorder), and medication adherence (Brief Adherence Rating Scale, Service Engagement Scale) were assessed. RESULTS: Using structural equation modeling, the study found evidence for a mediational model. Awareness of illness contributed to medication adherence via patients' perceived necessity of antipsychotics. The model further revealed a direct negative relationship between concerns regarding antipsychotics and adherence and an indirect negative effect of a general distrust regarding pharmacotherapy and adherence via antipsychotic specific attitudes. CONCLUSION: Interventions to enhance medication adherence may be more effective if they focus on treatment related attitudes rather than on global insight into illness. Clinicians may not only enhance the patients' perceived necessity of antipsychotic treatment but also explore and address concerns and the patients' distrust in pharmacotherapy in a more personalized way.

How do socio-demographic and clinical factors interact with adherence attitude profiles in schizophrenia? A cluster-analytical approach.

Knowledge regarding socio-demographic and clinical risk factors of medication nonadherence does not always help in addressing adherence in individual patients. Classifying patients according to subjective adherence influencing factors may aid practitioners in choosing adequate strategies for improving medication adherence. A total of 171 outpatients with schizophrenia and schizoaffective disorder were classified according to factors influencing their medication adherence assessed using the Rating of Medication Influences Scale. Additionally, psychotic symptoms, depression, and insight, also known to influence pharmacological treatment motivation, were assessed. A cluster analysis yielded 3 groups that were distinguished both by the relative ranking of adherence influences and by specific associations with risk factors of nonadherence. For the "Interpersonal, Future-oriented Group" (n=59, 35% of the sample), interpersonal factors (positive therapeutic relationship, positive attitudes of significant others towards medication), immediate positive consequences of the medication intake (daily benefits, no perceived pressure to take medication), and avoiding future negative consequences of non-compliance, such as relapse and re-hospitalization, were essential for adherence. The "Autonomous, Future-oriented Group" (n=69, 40% of the sample) appraised interpersonal factors as being less important as compared to the other groups. This group exhibited significantly fewer depressive symptoms than the first group and had significantly more stable partnerships as compared to the other groups. The "Autonomous, Present-oriented Group" (n=43, 25% of the sample) was mainly motivated by immediate positive consequences and displayed higher levels of cognitive disorganization and negative symptoms than the second group, as well as the lowest level of insight of all groups. Treatment strategies addressing adherence enhancement in schizophrenia may profit by considering both the patient's subjective adherence attitude profile as well as the specific pattern of risk factors for nonadherence including depression, lack of insight, negative syndrome, cognitive disorganization and socio-demographic factors, which are differentially associated with each adherence attitude profile.

Self-efficacy and empowerment as outcomes of self-stigmatizing and coping in schizophrenia.

The concept of internalized stigma or self-stigma is central to the understanding of the psychological harm caused by stigma. In this study, we aim to demonstrate how the evaluative dimension of self-concept (self-efficacy and empowerment) mediates the psychological effects of self-stigmatizing and coping with stigma. As important examples of psychological effects, depression and quality of life were focussed on. In 172 outpatients with DSM-IV schizophrenia, measures of self-stigma and devaluation, coping with stigma, self-efficacy, empowerment, quality of life and depression were assessed. It was hypothesized that withdrawal and secrecy as important coping strategies yielded to higher levels of anticipatory anxiety of future stigmatizing. Higher levels of perceived discrimination and devaluation were hypothesised to undermine self-efficacy and illness-related empowerment. Lowering of empowerment was supposed to enhance depression and reduce quality of life. This hypothesis was tested by Structural Equation Modeling as a method of data analysis. The results supported the hypothesized model; i.e., 46% of depression and 58% of quality of life reduction could be explained by eroded empowerment. Moreover, 51% of the empowerment reduction was explained by reduction in self-efficacy at a more general level by dysfunctional coping and higher levels of anticipated stigma. Taken together, our data suggest an avoidant coping style as a risk factor for anticipatory stigma, which erodes self-efficacy and empowerment. These data have implications for cognitive behavioral approaches, which should focus on anticipated stigma to improve recovery in schizophrenia.

Symptom control, functioning and satisfaction among Swiss patients treated with risperidone long-acting injectable.

OBJECTIVE: To investigate antipsychotic efficacy and tolerability of risperidone long-acting injectable (RLAI) in Swiss patients with schizophrenia or other psychotic disorders, changed directly from their previous antipsychotic medication. METHODS: Patients symptomatically stable for ≥1 month on their previous medication and considered to require a treatment change, received 25 mg RLAI (increased to 37.5 or 50 mg, if required) every 2 weeks for 6 months. RESULTS: Of 60 patients enrolled (68.3% male, average age 40.4 years), most (81.7%) had DSM-IV schizophrenia (mainly paranoid). Previous treatments were with atypical antipsychotics (58.3% of patients), depot (38.3%) and conventional oral (13.3%) neuroleptics. Mean total PANSS scores were significantly reduced from baseline to treatment endpoint (76.1 vs. 64.4, P<0.001), as were all PANSS subscale and symptom factor scores. The CGI, GAF, and patient satisfaction with treatment were also significantly improved at endpoint (P<0.001). At endpoint, 37.0% of patients rated their satisfaction as "very good" compared with only 4.3% at baseline. Mean scores for total ESRS and Parkinsonism subscales were significantly reduced at endpoint (P<0.001). CONCLUSION: Treatment with RLAI significantly improved disease symptoms, functioning, patient satisfaction, and reduced movement disorders. It provides an important option for long-term treatment of patients with psychotic disorders.

Cognitive strategies versus self-management skills as adjunct to vocational rehabilitation.

Cognitive dysfunctions and negative symptoms are "rate-limiting factors" for community outcome and response to psychosocial intervention in people with schizophrenia. Therefore, two cognitive-behavioral group therapies were developed-computer-assisted cognitive strategy training (CAST) and training of self-management skills for negative symptoms (TSSN)-to target these barriers to rehabilitation readiness. One hundred thirty-eight DSM-IV schizophrenia inpatients on a rehabilitation ward were randomly assigned to CAST plus vocational rehabilitation, TSSN plus vocational rehabilitation, or vocational rehabilitation alone. CAST included computer-based training in coping strategies focusing on deficits in attention, verbal memory, and planning. TSSN focused on social withdrawal/social anhedonia, lack of drive/volition, and affect flattening using techniques such as time scheduling, mastery, and pleasure techniques. Treatment outcome was assessed at intake and at discharge after 8 weeks. Analyses of covariance controlling for basis-level functioning demonstrated that patients receiving CAST plus vocational rehabilitation showed greater improvement on attention and verbal memory but not on planning ability. Patients receiving TSSN plus vocational rehabilitation failed to demonstrate improvement in negative symptoms. CAST plus vocational rehabilitation was found to be associated with a higher rate of successful job placement at the 12-month followup interval. Hierarchical logistic regression analyses demonstrated that improvement in short- and long-term verbal memory predicted a higher proportion of variance of successful job placement in the followup than pretreatment history of employment alone. Cognitive training as an adjunct to inpatient vocational rehabilitation demonstrated cognitive improvement, which was found to be associated with successful job placement in the followup. TSSN's efficacy was less clear; reasons for this uncertainty are provided.

Does social cognition influence the relation between neurocognitive deficits and vocational functioning in schizophrenia?

Research on barriers to treatment and rehabilitation readiness in people with schizophrenia, especially focusing on risk factors of poor outcome in social and vocational functioning, has focused on the role of social cognition and neurocognition. Others have hypothesized that social cognition (i.e., encoding and understanding of social cues guided by social schemas or scripts) may be one mediator between basic neurocognition and functional outcome. Our study analyzes data from 133 DSM-IV schizophrenic inpatients on a rehabilitation ward using structural equation modeling (SEM) to test whether social cognition has a stronger and more direct influence on vocational functioning than nonsocial cognition. The results supported the hypothesized model; that is, 25% of work-related social skills could be explained by social cognition and nonsocial cognition. The direct impact of nonsocial cognition on vocational functioning was smaller than the impact of social cognition on work-related social skills. Nevertheless, an overwhelming proportion of social cognition (83%) could be explained by nonsocial cognition.

Understanding adherence to neuroleptic treatment in schizophreniaí.

Understanding the factors that impede and promote adherence by people with schizophrenia to neuroleptic medication is important for treatment planning and relapse prevention. A total of 184 DSM-IV schizophrenia inpatients were examined with the Rating of Medication Influences (ROMI) scale within a context of inpatient vocational rehabilitation. Confirmatory factor analysis was used to evaluate the underlying dimensions of compliance behavior. The three-dimensional model of Weiden and his associates was confirmed by this study; specific factors included influence of others, medication affinity, and prevention. Additional analyses examined cognitive variables, symptoms, and course variables as predictors of individual factors. Verbal memory and cognitive flexibility were found to be associated with influence of others. Possible consequences for designing compliance enhancing therapeutic interventions are discussed.