Impact of clozapine on negative symptoms and on the deficit syndrome in refractory schizophrenia. Department of Veterans Affairs Cooperative Study Group on Clozapine in Refractory Schizophrenia.

OBJECTIVE: This study compared the effect of clozapine and haloperidol on positive and negative symptoms of schizophrenia and in patients with high levels of negative symptoms or the deficit syndrome. METHOD: Patients were participants in a 15-site double-blind, random-assignment Veterans Administration trial comparing clozapine (N=205) and haloperidol (N=217) in hospitalized patients with refractory schizophrenia. Analysis of covariance examining change at 6 weeks, 3 months, and 1 year evaluated 1) clozapine's effect on positive and negative syndromes; 2) clozapine's effect on each syndrome, statistically controlling for the other; and 3) the interaction of clozapine treatment and the presence or absence of high levels of negative symptoms at baseline and the deficit syndrome. RESULTS: Patients treated with clozapine showed significantly greater improvement than control subjects on positive symptoms at all time points and on negative symptoms at 3 months. Clozapine had no independent effect on negative symptoms at any time after control for positive symptoms, but its effects on positive symptoms persisted after control for negative symptoms at 6 weeks only. There were no significant differences in response to clozapine between patients with high and low levels of negative symptoms at baseline or between patients with and without the deficit syndrome. CONCLUSIONS: The greater effectiveness of clozapine as compared to conventional medications in refractory schizophrenia is not specific to either negative clinical symptoms or clinical subtypes defined by prominent negative symptoms or evidence of the deficit syndrome.

A psychoeducational program for caregivers of the chronic mentally ill residing in community residencies.

The objective of this study was to develop a psychoeducational program for caregivers of the chronically mentally ill residing in community residencies. An evaluative component was added to determine how well the program was received by caregivers and what impact the program had on the residents. A total of 20 caregivers and 63 residents participated in the program. In general, the psychoeducational program was well received by the caregivers. They especially liked the mental health component and opportunity to meet and interact with other caregivers. There was a significant drop in hospital admissions following the program. There was also improvement in a number of quality of life activities such as trips to the local coffee shop and mall.

Olanzapine compared with chlorpromazine in treatment-resistant schizophrenia.

OBJECTIVE: The purpose of this study was to compare the efficacy of olanzapine with that of chlorpromazine plus benztropine in patients with treatment-resistant schizophrenia. METHOD: One hundred three previously treatment-resistant patients with schizophrenia diagnosed according to the DSM-III-R criteria were given a prospective 6-week trial of 10-40 mg/day of haloperidol. Eighty-four of them failed to respond to that trial and agreed to be randomly assigned to an 8-week fixed-dose trial of either 25 mg/day of olanzapine alone or 1200 mg/day of chlorpromazine plus 4 mg/day of benztropine mesylate. RESULTS: Fifty-nine (70%) of the 84 subjects completed the trial. The primary outcome measures were Brief Psychiatric Rating Scale total score and positive symptom score, Scale for the Assessment of Negative Symptoms global score, and Clinical Global Impression score. An analysis of variance for the subjects who completed the study showed no difference in efficacy between the two drugs. Seven percent of the olanzapine-treated patients responded according to a priori criteria; no chlorpromazine-treated patients responded. The olanzapine-treated patients had fewer motor and cardiovascular side effects than the chlorpromazine-treated patients. Extrapyramidal symptoms and akathisia were similar in the two groups, although no antiparkinsonian drugs were used in the olanzapine group. CONCLUSIONS: Olanzapine and chlorpromazine showed similar efficacy, and the total amount of improvement with either drug was modest. Olanzapine-treated patients had fewer side effects than chlorpromazine-treated patients.

Impact of treating involuntarily admitted schizophrenics on an open unit.

When involuntary psychiatric patients are treated on unlocked units, problems may arise as to resource expenditure and the ability to provide optimal psychiatric care. This study investigates the problem and possible solutions.

Perceived statutory applicability versus clinical desirability of emergency involuntary hospitalization.

The authors used a questionnaire survey conducted by mail in 1975 to assess psychiatrists' perceptions of the applicability of two jurisdictions' statutes for emergency involuntary hospitalization and the desirability of such hospitalization in four case vignettes. The great majority of the 287 respondents agreed that the statutes were applicable and hospitalization was desirable for individuals who were at risk for suicide and who were psychotic. Most of them also agreed that such hospitalization was neither legally applicable nor desirable for nonpsychotic, nonsuicidal people. Their perceptions of applicability versus desirability differed, however, regarding people who were nonsuicidal but psychotic or nonpsychotic but suicidal.

Studies of platelet monoamine oxidase activity in Epstein-Barr and dengue virus infections.

As part of a prospective, psychosocial, and biochemical study of infectious mononucleosis, platelet monoamine oxidase (MAO) activity has been evaluated as a host factor. It was found that platelet MAO activity may be a possible predisposing host factor but not a precipitating factor. The results on infectious mononucleosis, a viral disease which involves the host's cell-mediated immune system, are compared with an evaluation of platelet MAO activity in dengue, a viral disorder involving the host's humoral immune system. The platelet MAO activity in these disorders has been compared to that in schizophrenia, a disease for which low platelet MAO activity has been postulated, from retrospective and twin studies, to be a risk factor. One hypothesis suggests that low platelet MAO activity predisposes to development of schizophrenia, but also increases cell-mediated immune system responses.

Competency evaluations in Connecticut.

New procedures for conducting competency evaluations were adopted in Connecticut in 1975 as a result of a change in the state law. The accused person is now evaluated in the setting in which he finds himself by virtue of his conflict with the criminal justice system, rather than automatically being remanded to the state hospital for evaluation. The criteria used are legal rather than medical-psychiatric, and the evaluations are conducted by a mental health team consisting of a psychiatric social worker, a psychiatrist, and a psychologist. The authors describe the procedures and discuss the benefits deriving from them, as well as some of the real and potential problems.

Psychiatrists' familiarity with legal statutes governing emergency involuntary hospitalization.

The authors sent out questionnaires regarding knowledge of statutes governing emergency involuntary hospitalization to psychiatrists in Connecticut and in the District of Columbia. Fifty-five percent (N=207) of the sample in Connecticut and 25% (N=87) of the sample in the District of Columbia responded. The responses showed that few of these psychiatrists had a thorough familiarity with the legal statutes governing emergency involuntary hospitalization in their jurisdictions. The most frequently cited criterion was the dangerousness standard, especially in the District of Columbia sample, and many psychiatrists were not sure of the nature of their statutory authority when their patients met the criteria for emergency hospitalization.

Is dangerousness an issue for physicians in emergency commitment?

The laws of many of the states require a physician to determine that a mentally ill individual presents a danger to others before the disturbed person can be civilly committed for involuntary treatment. The author contends that the prediction of dangerousness is not and should not be within the competence of medicine, but that physicians are competent to judge whether or not the severity of mental illness impairs a patient's competence to make an informed decision regarding treatment. The basic issue in emergency commitment is the patient's welfare, not his potential dangerousness. Dr. Alan A. Stone comments on Dr. Peszke's presentation.