The influence of familial loading on the course of schizophrenic symptoms and the success of psychoeducational therapy.

This prospective study examines the influence of familial loading on the course of schizophrenic illness and the extent to which this is modifiable by psychoeducational training as a form of psychotherapy. 182 schizophrenic patients enrolled in the study were allocated at random into four different treatment groups and one control group. 40% of the patients had mentally ill relatives, 20% with some form of schizophrenia. Patients attending the treatment group and those in the control group were examined before and immediately after psychoeducational training and at 2-year and 5-year follow-ups. Control group patients with mentally ill relatives displayed a significant increase in psychopathological symptoms and rehospitalization rate compared to those without. The psychoeducational training arrested or even improved the increase in psychopathological symptoms in patients with mentally ill relatives. Familial loading contributes substantially to a high rehospitalization rate and a poor outcome in schizophrenic patients. Psychoeducational interventions are an appropriate means of arresting this unfavorable development.

Long-term psychiatric patients in vocational rehabilitation programmes: a naturalistic follow-up study over 3 years.

OBJECTIVE: This paper aims at assessing the vocational integration attained after a 3-year period by psychiatric patients who participated in different vocational rehabilitation programmes. METHOD: In the north-western German region of Westphalia-Lippe a naturalistic follow-up study was carried out on 471 patients from three different types of vocational rehabilitation programmes. The sample comprised chronically ill patients with a history of repeated and long-term hospitalization. RESULTS: After 3 years 11% of the patients were in competitive employment, 67% (still) in sheltered employment, 7% in out-patient work therapy programmes and 15% were unemployed. It is important to notice that 74% achieved their subjective rehabilitation goals expressed at baseline. CONCLUSION: Vocational rehabilitation programmes are an essential part in the treatment of people with chronic mental illness. Integration into work varies markedly while patients' satisfaction is comparably good. Competitive employment represents a realistic objective only for patients with high motivation and favourable preconditions.

[Prognostic and therapeutic relevance of cognitive characteristics for the long-term course of schizophrenic illness following psychoeducational psychotherapeutic treatment]. / Prognostische und therapeutische Relevanz kognitiver Ressourcen für den Langzeitverlauf schizophrener Erkrankung nach psychoedukativ-psychotherapeutischer Behandlung.

In a prospective, randomized clinical trial cognitive characteristics of schizophrenic patients were examined as predictors of the efficacy of a psychoeducational psychotherapeutic intervention. The aim of this study was to select adequate cognitive predictors. The reduction of the selected cognitive deficits by means of a psychoeducational psychotherapy was measured. Additionally, the prophylactic effects of the improvement of cognitive deficits were examined. Predictors of the course of illness were basic cognitive deficits and metacognitive constructs of 106 schizophrenic outpatients. Additionally, the modification of the cognitive skills of these patients was taken into account. Relevant factors of the course of illness representing the therapeutic effect of the intervention were investigated within a five-year follow-up. By means of logistic regression analyses thought disorders (AMDP system) and idiosyncratic and fatalistic assumptions (KK-scale) were obtained as appropriate cognitive predictors of the long-term course of illness. Thought disorders and attentional deficits could not be improved significantly. Though, there was a correlation between the therapeutic improvement of idiosyncratic and fatalistic assumptions and the rehospitalization rate within the follow-up.

[The connection between labor integration and prognosis of schizophrenic patients: an 8-year follow-up study]. / Zusammenhang zwischen der Arbeitsintegration schizophrener Patienten und mittelfristigem Krankheitsverlauf. Ergebnisse einer 8-Jahres-Katamnese.

This study reflects the labour-situation of 67 DSM-III schizophrenic outpatients in an 8-year follow-up. About 50% of the patients had less than 20 hours of work a week on the average--most of them in work therapy or sheltered work-places. Many of them changed their location of work. Patients with an initially good prognosis (MPS) had a good outcome, regardless if they had a normal job and worked about 30 hours a week or worked about 20 hours in a sheltered place. For patients with a poor prognosis even the integration in a sheltered working place was difficult.

Long-term effects of a psychoeducational psychotherapeutic intervention for schizophrenic outpatients and their key-persons--results of a five-year follow-up.

The study examines long-term effects on rehospitalization rates of a psychoeducationally and cognitive-behaviorally oriented intervention for schizophrenic outpatients and their key-persons. 191 patients and their key-persons were allocated by random into four different treatment groups and one control group. Five years after completion of treatment 126 patients were reexamined by interviews or case notes. The rate of patients experiencing psychiatric rehospitalization during the follow-up was assessed in each respective treatment group. Concerning rehospitalization rates there was no significant difference between controls (n = 35) and patients of the four treatment groups (n = 91). There were, however, fewer rehospitalized patients in the group with combined psychoeducational and cognitive treatment, including key-person counselling (42%), than in the control group (69%). Regarding the overall functioning, the patients in this treatment group did slightly better than those in the control group. These results are in accordance with the findings of comparable studies.

[Psychoeducational-psychotherapeutic treatment of schizophrenic patients and their caregivers. II. Supplementary findings at a 2-year follow-up]. / Psychoedukativ-psychotherapeutische Behandlung von schizophrenen Patienten und ihren Bezugspersonen. II. Ergänzende Befunde der 2-Jahres-Katamnese.

In this study we investigated whether, in conjunction with neuroleptics, a psychoeducational and cognitively oriented treatment for schizophrenic outpatients and their key-persons can improve the course of schizophrenic illness within a 2-year follow-up. This prospective randomized study covered a total of 191 schizophrenic patients (according to DSM-III-R) and comprised a psychoeducational training and cognitive psychotherapy for patients and counseling for their key persons in various combinations. Patients were examined before, immediately after and 2 years after the end of the intervention. Patients in the treatment groups reduced their overall psychopathology and their attention deficit. For patients receiving all three treatment conditions, there was a relevant preventive effect with regard to the rehospitalization rate appearing during the second year of the follow-up. We conclude that in the mid-term, a combination of psychoeducational and cognitively oriented therapy for patients and their keypersons can improve the course of schizophrenic illness.

Differential therapy effects of psychoeducational psychotherapy for schizophrenic patients--results of a 2-year follow-up.

There is increasing evidence of the efficacy and effectiveness of psychosocial interventions in schizophrenic patients. However, little research has been done on differential therapy effects. In a prospective, randomized clinical trial we carried out psychoeducational medication management training, cognitive psychotherapy, and key-person counseling. The patients of the control group participated in structured free-time activities for control of therapeutic commitment. Data from a total of 156 schizophrenic patients (DSM-III-R, no first-admissions) were available at 2-year follow-up. We analyzed in this study whether there are differential therapy effects of these interventions, depending on patient characteristics at baseline. There was a significant statistical interaction between treatment condition (specific/non-specific) and prognosis with respect to treatment outcome. Patients with a favorable prognosis and better social functioning had a better course under the specific treatment but a less favorable outcome in the non-specifically treated control group. These results suggest that more vulnerable patients are not sufficiently capable of learning and using coping strategies for relapse prevention. We need to learn more about differential indications for psychosocial treatment.

[Prevalence and treatment of depressive syndromes in homes for the aged. Survey of a rural catchment area]. / Prävalenz und Behandlung von depressiven Syndromen in Altenheimen. Erhebung in einem ländlichen Versorgungssektor.

PURPOSE: The investigation aimed at assessing the prevalence of depression among residents in a nursing home. METHODS: In a rural area of Germany a representative sample was examined by means of the "Brief Assessment Interview" (BAI). RESULTS: 17% had a depressive disorder without dementia, 9% had a mild dementia syndrome and a depressive disorder; a total of 47% suffered from symptoms of dementia without depression. Most of the patients were treated by general practitioners or internists. 11% of the patients with depression were treated with antidepressants, 19% with neuroleptics, 17% with minor tranquillizers, and 17% with hypnotics. Only 20% of the depressive patients had ever been examined by a psychiatrist, 4% underwent an actual psychiatric therapy. CONCLUSION: Elderly patients with depressive disorders living in nursing homes need a more specific psychiatric treatment.

Postexcitatory inhibition after transcranial magnetic stimulation of the motor cortex in patients with drug-induced parkinsonism and in healthy individuals.

The duration of the postexcitatory inhibition after transcranial magnetic stimulation was investigated in 16 patients with drug-induced parkinsonism and in 20 healthy control individuals. In the patients, the chlorpromazine-equivalent of the neuroleptic medication was determined, and the severity of the drug-induced parkinsonism was measured using the Simpson-Angus Scale score. Group comparison (U-test) revealed a significant shorter postexcitatory inhibition in patients than in control individuals. Regression analyses showed a negative correlation between the Simpson-Angus scale score and the duration of the postexcitatory inhibition. The correlation only reached significance for a group of patients who received at least one butyrophenone derivate. No clear-cut relation was found between the chlorpromazine equivalent and the postexcitatory inhibition. These results indicate that drug-induced parkinsonism shares features of genuine Parkinson's disease. Furthermore, it seems possible to assess the extrapyramidal side effect of butyrophenone derivates, but not for other neuroleptic drugs, by means of the method described.

Collaboration with drug treatment by schizophrenic patients with and without psychoeducational training: results of a 1-year follow-up.

Within a controlled prospective intervention study, schizophrenic outpatients randomly assigned to four treatment groups and one control group were assessed with regard to collaboration with drug treatment. In total, 39.3% of 84 regular attenders of the psychoeducational training programme and 26.6% of 64 control patients reported having persuaded their psychiatrists to modify their medication prescriptions. A total of 8.3% and 7.8%, respectively, modified their medication on their own initiative, although with subsequent approval by the psychiatrist, and 20.2% and 15.6%, respectively, modified their medication after consulting their psychiatrist. With regard to medication management, the groups did not differ either at post-treatment or at follow-up. At follow-up, regular attenders showed a reduced fear of side-effects, increased confidence in their medication and stable confidence in their physician. Among the control subjects, confidence in the medication and in their physician declined, and fear of side-effects increased. Psychoeducational training therefore led to an optimization of patients' attitudes toward treatment, but not to changes in medication management.

[Schizophrenic prelingual deaf and hearing patients. A comparison of premorbid and current data after several years of progression]. / Schizophrenien prälingual gehörloser und hörender Patienten. Eine Vergleichsuntersuchung prämorbider und aktueller Daten nach mehrjährigem Krankheitsverlauf.

Prelingually deaf persons belonging to a linguistic and cultural minority have to cope with a particular sociocultural situation. The present study endeavours to analyse possible effects of this situation in the course and outcome of schizophrenia. Two samples, one comprising 27 prelingually deaf and one 27 hearing patients, all with schizophrenic psychoses, were parallelised on the basis of gender, age, duration of illness and number of previous hospitalisations. Data were then collected on the premorbid and current social situation and on the psychopathometric outcome after an (on the average) ten-year course. The prelingually deaf patients were much more profoundly impaired with regard to the rating of their residual symptoms and their social situation than those of the hearing control group. Only with respect to vocational rehabilitation did the prelingually deaf patients record a slightly more favourable situation than the hearing patients, as a greater proportion of them had regular employment, in most cases in workshops for the disabled.

[Medication-related attitudes of chronic schizophrenic patients. A follow-up study after psycho-educational intervention]. / Medikationsbezogene Einstellungen chronisch schizophrener Patienten. Eine Follow-up Untersuchung 24 Monate nach psychoedukativer Intervention.

OBJECTIVE: To evaluate the effect of a psychoeducational training, compliance, medication management, and illness-related attitudes were assessed among schizophrenic outpatients. METHODS: Study patients who attended at least 70% of 10 psychoeducational sessions (n = 74) and the 57 patients of the control group were reexamined 2 years after the end of intervention. RESULTS: Attenders had better compliance, were more confident in medication codetermination and more satisfied with their knowledge about medication. Confidence in medication and physician increased whereas in the control both decreased. CONCLUSIONS: Although there were no statistically significant differences the results show impressive longterm effects of psychoeducational training.

Expressed-emotion development and course of schizophrenic illness: considerations based on results of a CFI replication.

This study examines the correlation between development of expressed emotion (EE) in relatives and course of illness of 99 DSM-III schizophrenic patients. Patients whose relatives were high EE at baseline and at the 2nd CFI approximately 20 months later had a poor prognosis at the very outset of the study and an unfavourable course of illness. They had a higher rehospitalisation rate, more symptoms, lower psychosocial assessment, and a poorer 2-year and even 8-year outcome. Patients from families with a fluctuating EE or a consistently low EE had better courses. Expressed emotion is therefore a valid predictor not only of symptomatic relapses, but also of other important aspects of schizophrenia. The connection between EE index and course of illness seems not to be simply reactive or causal, but complex and non-uniform.

Psychoeducational psychotherapy for schizophrenic patients and their key relatives or care-givers: results of a 2-year follow-up.

Psychoeducational medication management training (PMT), cognitive psychotherapy (CP) and key-person counselling (KC) were carried out in various combinations in this randomized, controlled intervention study of schizophrenic out-patients (according to DSM-III-R). Special design characteristics of the study were a control group consisting of non-specifically treated patients and a 2-year follow-up after completion of treatment in order to evaluate medium-term effects. A total of 132 patients underwent a follow-up examination 2 years after completion of treatment and were evaluated with an intention-to-treat approach. In the second follow-up year, all treatment groups had lower but not significantly different relapse rates compared to the control group. The most intensive treatment (PMT+CP+KC) produces a clinically relevant reduction in rehospitalization rate (a 26% reduction compared to the control group). In comparison with the non-specifically treated control group, whose original effect decreased, at least a medium-term therapeutic effect was recorded in the treatment groups.

Psychoeducational training for schizophrenic patients: background, procedure and empirical findings.

As neuroleptic therapy alone still fails to other effective relapse prevention in schizophrenic patients, psychoeducational therapeutic approaches have been developed as an additional aid for patients and their families. This article details the central characteristics of these approaches. A psychoeducational group program for schizophrenic outpatients, the efficacy of which was investigated within the scope of a German controlled intervention study on 191 patients, is also presented. The article describes in detail the methods used and the therapeutic objectives, reporting on changes in the attitudes of patients to their medication. At the end of the training program, patients who had attended regularly showed significantly better medication compliance and were more reserved with respect to their medication self-management. After 1 year the positive effects had diminished. However, booster sessions or participation of the psychiatrist in charge as group therapist would have had longer lasting effects.

[Psychoeducational-psychotherapeutic treatment of schizophrenic patients and their caregivers. Results of a 1-year catamnestic study]. / Psychoedukativ- psychotherapeutische Behandlung von schizophrenen Patienten und ihren Bezugspersonen. Ergebnisse einer 1-Jahres- Katamnese.

In this study we look into the question of whether, in addition to neuroleptic treatment, relapse rates among schizophrenic patients can be reduced by means of a combined psychoeducational and psychotherapeutic intervention strategy for patients and their relatives. In a randomized controlled intervention study in an outpatient routine treatment setting, psychoeducational training for medication management, cognitive therapy and work with relatives' groups were compared with each other and with a control group. The patients continued their standard treatment, including neuroleptic relapse prevention. The study comprised 191 chronic DSM-III-R schizophrenics. Data were collected before and after an 8-month intervention phase and at the 1-year follow-up. The group receiving all three treatments had the lowest relapse rates. Moreover, numerous gains recorded in subjective findings suggest that therapeutic work with schizophrenic patients and their relatives is of clinically significant benefit.

What provision is made by practicing physicians for psychogeriatric patients in western Germany?

This study examined some aspects of psychogeriatric care in Münster, Germany. The diagnostic and therapeutic attitudes of 94 general practitioners/internists and neurologists/psychiatrists toward demented patients were investigated by questionnaire. This figure represents a return rate of approximately 55% on the questionnaires. As is typical in Germany, no physicians were specializing in geriatric patients, and fewer general practitioners/internists than neurologists/psychiatrists had undergone supplementary psychogeriatric training. A higher percentage of the latter group estimated more than 10% of their elderly patients were demented. Both estimated Alzheimer's disease as less frequent than multi-infarct dementia. Physicians with training in psychogeriatrics claimed to treat more elderly patients than physicians without it. With regard to therapeutic procedure, physicians with psychogeriatric training prescribed nootropics more guardedly. The data from this pilot study suggest that there are no eminent discrepancies between the different medical groups with regard to psychogeriatric care, but there is a great need for supplementary training.

[Experiences of schizophrenic patients in ambulatory care with oral neuroleptics--baseline for psychoeducational interventions]. / Erfahrungen ambulanter schizophrener Patienten mit oralen Neuroleptika--Befundbasis für psychoedukative Interventionen.

In the run-up to a prospective intervention study to assist the preparation of psychoeducational therapeutic measures, schizophrenic out-patients were questioned on their experiences with two oral neuroleptics, Clozapine and Perazine. The two drugs, which are known to have similar side effects, find equal acceptance among patients. Subjective attitudes to medication and general evaluations of drug therapy are extremely positive. Numerous patients had already modified their neuroleptic dosage on their own initiative, in most cases discontinuing their medication but in some cases increasing or reducing the dose. These experiences can be used in designing a psychoeducational intervention directed towards individual needs.

[Can psycho-education of chronic schizophrenic patients have a short-term effect on drug-related attitude and behavior?]. / Kann Psychoedukation bei chronisch schizophrenen Patienten kurzfristig medikationsbezogene Einstellungen und Verhaltensweisen beeinflussen?

Within a controlled intervention study with schizophrenic outpatients we investigated the question of whether regular attendance at psychoeducational training for medication management has an influence on patients' illness-related behavior. The patients in the treatment group show better outcome of compliance and some treatment-related attitudes, though without statistical significance. Despite extensive information they are no more content with their knowledge of drugs than the control group, but more aware of problems, i.e. more cautious in medication co-determination.

[Patient modified medication: how do schizophrenic patients manage their neuroleptics?]. / Patientmodifizierte Medikation: Wie gehen schizophrene Patienten mit ihren Neuroleptika um?

191 DSM-III-R schizophrenic outpatients were interviewed about their experiences in self regulation of medication by means of a structured questionnaire. 59% of the 178 patients giving relevant replies claimed to have varied their neuroleptic dosage; i.e. augmented, reduced or discontinued it without consulting their doctor. Modifiers reported more often that their relatives were in favour of the medication, but less often that they themselves thought it important for their health. Augmenters were older on average than non-modifiers. Patients' appraisals of their experience appeared to be realistic, so that psychiatrists could make use of them to co-determine treatment in the individual case.