Working with and for parents to create a Family Focus DVD.

TOPIC: Consumer and carer participation can improve the quality of health care. Active collaboration with family members is critical when developing and evaluating resources designed to meet their needs. The Australian Children of Parents with a Mental Illness National Initiative developed a DVD resource, Family Focus, to promote family communication about parental mental illness. PURPOSE: This column describes how families were involved in all stages of the DVD development and post production pilot evaluation. SOURCES USED: This description draws from published material, family involvement, and interagency collaboration. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The parent-led development of the DVD provides a resource that is congruent with the unique needs and circumstances of individual families. The collaborative approach yields a DVD resource that is authentic, engaging, hopeful and helpful and 1 that empowers parents and strengthens families in their recovery.

Estrogens and men with schizophrenia: is there a case for adjunctive therapy?

Adjunctive use of estrogen therapy has been shown to be effective in enhancing the treatment of schizophrenia in women. In men, consideration of estrogen therapy has been impacted by concerns of feminising side effects, however, clinical trials of the use of estrogen in treating prostate cancer, bone density loss and even aggression and psychosis in dementia or traumatic brain injury, show this to be a safe and effective therapy. The current 14-day randomised placebo-controlled trial in 53 men with schizophrenia was conducted to evaluate the efficacy of 2 mg oral estradiol valerate as an adjunct to atypical antipsychotic treatment. Results demonstrated for estradiol participants a more rapid reduction in general psychopathology that occurred in the context of greater increases in serum estrogen levels and reductions in FSH and testosterone levels. Approximately 28% of estradiol participants did not achieve an increase (at least a 50% from baseline) in serum estrogen suggesting that further research is needed to refine the type, dose and administration route for estrogen therapy in men. Findings do, however, suggest further exploration of a therapeutic role for adjunctive estradiol treatment in men with schizophrenia is warranted.

Preliminary findings from the National Register of Antipsychotic Medication in Pregnancy.

OBJECTIVE: Following the presentation of a case study and an overview of current data highlighting the need for further research into the use of antipsychotic medication during pregnancy, the aim of the present paper was to outline the establishment of, and present preliminary data from, the National Register of Antipsychotic Medication in Pregnancy (NRAMP). METHOD: Australian women with a history of psychosis, including schizophrenia, bipolar affective disorder with psychosis, schizoaffective disorder and first-episode psychosis, who are pregnant, are currently being invited to participate. The confluence of speculated national pregnancy rates and epidemiological data regarding child-bearing-age women with psychosis suggested an enrollment target of 100 women over a 24 month period. Details of antipsychotic medication are recorded throughout the pregnancy and for 1 year postnatally. Interviews with the mother are conducted 6 weekly antenatally, and then at 6 and 12 weeks, and 6 and 12 months postnatally, to assess symptoms of psychosis and depression, and attitudes towards parenting. In addition, consultations are conducted with the women's health-care providers to collate information regarding pharmacology and related side-effects, obstetric outcomes, psychiatric diagnoses and symptoms during pregnancy and for 1 year after delivery, and the provision of details on the baby's health and well-being. RESULTS: NRAMP was launched in 2005. Ethics approvals have been gained at 14 sites nationally. Thirty women have consented, and 11 have completed. Data including demographics, health-care provision and medication for the first 30 participants are presented. CONCLUSIONS: The establishment of NRAMP is an important strategy in improving the management of serious mental illness such as schizophrenia and related disorders, in women who are pregnant. This project involves extensive collaboration between many different clinical groups and industry, and shall culminate in an important resource to improve the quality of life for both patients and future generations.

Hormone modulation: a novel therapeutic approach for women with severe mental illness.

OBJECTIVES: Accumulating evidence describes the effects of oestrogen and other gonadal hormones on the central nervous system and, in particular, on the mental state of women. Evidence supporting the psychotherapeutic effects of exogenous oestrogen has started to emerge only over the past two decades. The purpose of the present paper was to provide an overview of different applications of adjunctive hormones, as treatments for symptoms of severe mental illness in women. METHODS: Three case reports are presented: in each case the woman selected had participated in large, double-blind, randomized controlled trials exploring hormone modulation. Case study 1 presents a premenopausal woman with schizophrenia, who received an 8 week trial of daily adjunctive 200 microg transdermal oestradiol. Case study 2 presents a postmenopausal woman with schizophrenia on a 12 week trial of adjunctive raloxifene hydrochloride 120 mg per day. Case study 3 presents a woman with schizoaffective disorder, in the manic phase, who received tamoxifen 40 mg per day for 28 days. RESULTS: Adjunctive oestradiol was associated with an improvement in symptoms of psychosis in a premenopausal woman with schizophrenia; adjunctive raloxifene was associated with an improvement in cognitive functioning in a postmenopausal woman with schizophrenia; and adjunctive tamoxifen was associated with an improvement in symptoms of mania in a woman with schizoaffective disorder. CONCLUSIONS: These findings are consistent with preliminary research trials suggesting that adjunctive hormone modulation is a promising area of gender-specific treatment for serious mental illness.

Australian Schizophrenia Care and Assessment Programme: real-world schizophrenia: outcomes.

OBJECTIVE: It has been increasingly recognized that there is need to assess patient outcomes in schizophrenia across a broad range of dimensions. But few studies have attempted to do this in clinical populations and no systematic study has broadly assessed outcomes in schizophrenia in Australia using a longitudinal design. Thus, a real-world study, the Schizophrenia Care and Assessment Programme (SCAP), was structured to collect comprehensive information over time to inform policy debate and extend current knowledge about the course of schizophrenia in an Australian context. METHODS: A cohort of 347 patients with schizophrenia was followed up over 3 years. Clinical outcomes, occupational and psychosocial functioning and quality of life were assessed at 6 monthly intervals, and resource utilization and costing data were collected continuously from internal and external databases as well as from participants directly. RESULTS: The participants as a group experienced an overall decline in positive and negative symptoms of schizophrenia, a reduction in general psychopathology and a reduction in severity of depression. There was an improvement in functioning, a reduction in mental health-related disability and an improvement in patient- and observer-rated quality of life. Change of severity within the variously assessed domains over time appeared to be relatively independent. CONCLUSIONS: In the present sample of schizophrenia patients treatment was associated with positive health outcomes; but outcomes across assessment domains did not closely correlate across time. The scrutiny of a broad range of patient outcomes will assist with the assessment of new treatment modalities and with service planning.

A double-blind sham-controlled trial of repetitive transcranial magnetic stimulation in the treatment of refractory auditory hallucinations.

BACKGROUND: Previous research suggests that repetitive transcranial magnetic stimulation (rTMS) applied to the temporoparietal cortex may have therapeutic benefits for patients with schizophrenia and treatment-resistant auditory hallucinations. We aimed to test this hypothesis in a randomized double-blind trial. METHODS: Thirty-three patients with treatment-resistant auditory hallucinations entered a randomized sham-controlled, double-blind trial. rTMS was applied for 10 consecutive weekdays, for 15 minutes at 1 Hz and 90% of the resting motor threshold. We assessed clinical symptoms and cognitive function. RESULTS: rTMS was safe with no adverse effects on memory and cognitive parameters assessed. Active treatment did not result in a greater therapeutic effect than sham on any measure except for the loudness of hallucinations where there was a significant reduction in the active versus the sham group over time. CONCLUSIONS: The study does not support the effectiveness of rTMS using the stimulation parameters provided. However, it does suggest that rTMS methods may have a therapeutic role and indicates the need for further exploration of alternative and more effective stimulation methods.

Motor cortical excitability and clinical response to rTMS in depression.

BACKGROUND: The relationship between frontal lobe activity in the left and right hemispheres and the pathophysiology of depression remains unclear. In addition, it is uncertain whether levels of frontal or motor cortical excitability relate to clinical response to treatment modalities. We aimed to explore whether motor cortical excitability as assessed with single and paired pulse transcranial magnetic stimulation (TMS) could be used to predict the response to treatment with repetitive TMS (rTMS) applied to the left or right prefrontal cortex. METHODS: Motor thresholds, cortical excitability and cortical inhibition (CI) were assessed prior to a trial of rTMS in patients with treatment resistant depression. RESULTS: There was no consistent pattern of differences in hemispheric activity, although there was a relationship between the degree of psychopathology and cortical excitability (right hemisphere) and an inverse relationship between inhibitory activity and clinical response (left hemisphere). CONCLUSIONS: The study does not support a simple model of laterality in motor cortical excitability in depression. The TMS measures used in this study appear to be of limited use in the prediction of clinical response to rTMS.

Reduced plastic brain responses in schizophrenia: a transcranial magnetic stimulation study.

BACKGROUND: Abnormalities in brain plasticity, possibly related to abnormal cortical inhibition (CI), have been proposed to underlie the pathophysiology of schizophrenia. Transcranial magnetic stimulation (TMS) provides a dynamic method for non-invasive study of plastic processes in the human brain. We aimed to determine whether patients with schizophrenia would exhibit an abnormal response to repetitive TMS (rTMS) applied to the motor cortex and whether this would relate to deficient cortical inhibition. METHODS: Measures of motor cortical excitability and cortical inhibition were made before and after a single 15-min train of 1-Hz rTMS applied to the motor cortex in medicated and unmedicated patients with schizophrenia as well as healthy controls. RESULTS: All three groups had equal motor cortical excitability prior to rTMS, although both patient groups had a shorter cortical silent period (CSP) and less cortical inhibition than the control group. Cortical excitability, as assessed by motor threshold levels, did not reduce in both medicated and unmedicated patients in response to rTMS as was seen in the control group. Significant differences were also seen between the groups in response to the rTMS for motor-evoked potential (MEP) size and cortical silent period duration. CONCLUSIONS: Both medicated and medication free patients with schizophrenia demonstrated reduced brain responses to rTMS and deficits in cortical inhibition.

Transcranial magnetic stimulation in the treatment of depression: a double-blind, placebo-controlled trial.

BACKGROUND: High-frequency left-sided repetitive transcranial magnetic stimulation (HFL-TMS) has been shown to have antidepressant effects in double-blind trials. Low-frequency stimulation to the right prefrontal cortex (LFR-TMS) has also shown promise, although it has not been assessed in treatment-resistant depression and its effects have not been compared with those of HFL-TMS. OBJECTIVE: To prospectively evaluate the efficacy of HFL-TMS and LFR-TMS in treatment-resistant depression and compared with a sham-treated control group. DESIGN: A double-blind, randomized, sham-controlled trial. SETTING: Two general psychiatric services. PARTICIPANTS: Sixty patients with treatment-resistant depression who had failed to respond to therapy with multiple antidepressant medications were divided into 3 groups of 20 that did not differ in age, sex, or any clinical variables. All patients completed the double-blind phase of the study. INTERVENTIONS: Twenty 5-second HFL-TMS trains at 10 Hz and five 60-second LFR-TMS trains at 1 Hz were applied daily. Sham stimulation was applied with the coil angled at 45 degrees from the scalp, resting on the side of one wing of the coil. Main Outcome Measure Score on the Montgomery-Asberg Depression Rating Scale. RESULTS: There was a significant difference in response among the 3 groups (F56,2 = 6.2), with a significant difference between the HFL-TMS and sham groups and between the LFR-TMS and sham groups (P<.005 for all) but not between the 2 treatment groups. Baseline psychomotor agitation predicted successful response to treatment. CONCLUSIONS: Both HFL-TMS and LFR-TMS have treatment efficacy in patients with medication-resistant major depression. Treatment for at least 4 weeks is necessary for clinically meaningful benefits to be achieved. Treatment with LFR-TMS may prove to be an appropriate initial repetitive TMS strategy in depression taking into account safety, tolerability, and efficacy considerations.

A transcranial magnetic stimulation study of abnormal cortical inhibition in schizophrenia.

Previous research suggests that patients with schizophrenia demonstrate deficits in a range of parameters of motor cortical and cognitive inhibition. I-wave facilitation and long-interval cortical inhibition (LICI) are two paired pulse transcranial magnetic stimulation paradigms that appear to assess aspects of cortical inhibitory function that have not previously been assessed in this patient group. Eighteen patients with schizophrenia (nine medication-free) were compared with eight control subjects. We assessed resting motor threshold (RMT) levels, LICI and I-wave facilitation. RMT levels did not differ between the three groups. There was a significant overall difference in I-wave facilitation levels. Both patient groups as compared with the control group showed increased facilitation. There were no differences between the groups in the measure of LICI. Patients with schizophrenia appear to have increased I-wave facilitation. Increased I-wave facilitation suggests deficient function of cortical inhibitory GABAergic activity. This is consistent with previous research that has found deficient cortical inhibition in patients with schizophrenia.