Naturalistic pharmacotherapy of acute episodes of schizophrenic disorders in comparison to treatment guidelines.

INTRODUCTION: This study was designed to investigate to what extent guidelines regarding the pharmacological treatment of patients suffering from schizophrenia-like psychosis are adopted in a naturalistic treatment setting. METHODS: Medical records of n=819 patients undergoing inpatient treatment for schizophrenia-like psychosis in 11 psychiatric hospitals in northwestern Germany were retrospectively analyzed and findings were compared to current schizophrenia guideline recommendations. RESULTS: The prescription rate of second generation antipsychotics increased from 47.1% on admission to 62.5% at discharge. Only half the patients (52.3%) received antipsychotic monotherapy while 47.7% took between 2 and 4 antipsychotic substances at a time. Dosage increases occurred most frequently (in 60%) within the first week of inpatient treatment, 16.6% experienced an elevation between days 15 and 29. A change within the atypical medication was found in 19.3%. Clozapine prescriptions increased throughout the treatment but were combined with other antipsychotic substances in the majority of cases. CONCLUSION: Under naturalistic conditions guideline recommendations for treatment of schizophrenia-like psychosis are adhered to only partially. Combination therapy with 2 or more antipsychotic drugs is quite common despite a clear recommendation for monotherapy.

[Differential indications for atypical neuroleptics: Amisulprid, Clozapin, Olanzapin, Quetiapin und Risperidon. Results of a pilot study of prescription habits in psychiatric clinical usage in the BRD]. / Differenzialindikation atypischer Neuroleptika: Amisulprid, Clozapin, Olanzapin, Quetiapin und Risperidon. Ergebnisse einer Pilotstudie zu Verordnungsgewohnheiten in psychiatrischen Versorgungskliniken der BRD.

With the introduction of atypical neuroleptics, the therapy of schizophrenia has been improved by a group of antipsychotic substances characterized by better tolerability concerning extrapyramidal side effects and higher efficiency against negative symptoms. However, these atypical antipsychotics are not a homogeneous class of drugs but rather represent a group of substances with very different neurobiologic, pharmacologic, and clinical features. This fact and the growing variety of available atypical neuroleptics illustrate the difficulty in choosing the "right" antipsychotic drug for each patient. The aim of this investigation was to evaluate preliminary empirical data for possible differential indication of atypical neuroleptics by a questionnaire-based survey of 192 physicians in ten psychiatric hospitals active in the biological psychiatry work group of the German Federal Directors' Conference.

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.

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.

Electroconvulsive therapy vs. paroxetine in treatment-resistant depression -- a randomized study.

Failure to respond to adequate pharmacological treatment for major depression is now the most common indication for the use of electroconvulsive therapy (ECT). The advantages of ECT with respect to both speed and quality of response are clinically important issues, but surprisingly few studies have examined the efficacy of ECT in relation to newer antidepressant agents such as selective serotonin reuptake inhibitors (SSRIs). A total of 39 subjects with major depression and with at least two failed antidepressant trials (mean 4.9 trials) were randomized to either paroxetine treatment (n=18) or right unilateral (RUL) ECT (n=21). Up to the end of the study treatment we found a reduction in the HAMD score of 59% for the ECT group and of 29% for the paroxetine group (P<0.001 paired t-test). In the ECT group, 71% of subjects fulfilled the response criteria (at least a 50% decrease in total HAMD score). The present study found ECT to be superior to paroxetine in medication-resistant major depression, in terms of both degree and speed of response.

[The Munster Prognosis Score (MPS)--prognostic validity of a practical instrument for prediction of progress in schizophrenic psychosis]. / Der Münsteraner Prognosescore (MPS)--prognostische Validität eines praxisnahen Instruments zur Prädiktion des Verlaufs schizophrener Psychosen.

The prognostic validity of a short and easy to handle prognostic instrument (Münster prognosis score, MPS) for schizophrenic patients is proved in this study. The MPS consists of 4 items: number of hospitalisations, stability of course of illness in the last year, premorbid development, and stability of psychosocial environment. Each item has to be rated as favourable or unfavourable. With three or four favourable ratings the prognosis is good, otherwise bad. The interrater reliability proved with 50 DSM-III schizophrenic patients had a kappa of 0.84, which is sufficient. In an 8-years follow-up with 66 DMS-III schizophrenic outpatients, the MPS had a comparably good prognostic validity according to the Strauss-Carpenter scale and the Philips scale in respect of the total symptom score (AMDP) and psychosocial functioning (GAS). According to prognosis of rehospitalisations, the MPS was as good as the SCS, and both were better than the Phillips scale.

Family interaction and the course of schizophrenic illness. Results of a multivariate prospective study.

The aim of the present study was to assess the prognostic relevance of relatives' interactive behaviour towards the patient, as covered by the Münster Family Interview (MFI), to the further course of the schizophrenic illness. The MFI is a family interview (of the whole family, including the patient) designed to record the emotional family atmosphere based on the concept of expressed emotion (EE). The ratings take place directly after the interview on five scales (criticism, hostility, overinvolvement, resignation and warmth), the resignation scale being added to the 'classic' EE scales. Ninety-nine families of outpatients diagnosed with schizophrenia according to the DSM-III were examined with the MFI during a home visit. The patients were seen 1 and 2 years after the first examination. The target criteria selected for the prognostic significance of the interaction measurements were: rehospitalisation within 2 years; extent of symptoms after 1 year, and psychosocial skills after 1 year. The significance of the interaction dimensions was verified in regression models. The control variable used in the regression models was the Strauss-Carpenter scale. Regression models were produced for the total group and for a subgroup of moderately ill patients. All target criteria yielded serviceable prediction models. The most important variable for prediction was the control variable, the Strauss-Carpenter scale. However the interaction variables made additional contributions to the prognosis, especially in the subgroup of moderately ill patients. The best MFI scale for all the outcome criteria was resignation; criticism predicted only the symptomatology, and emotional overinvolvement the level of social functioning after 1 year. In conclusion, practical work with families of schizophrenic patients should emphasise the protective function of relatives towards patients more strongly.

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.

Expressed emotion in an 8 year follow-up.

This study addresses the questions if and for which patients expressed emotion (EE) has a predictive validity in an 8 year follow-up study and if this is dependent on the residential form, especially on patients and relatives living together. Eight years after a baseline examination (Camberwell Family Interviews [CFI], global assessment scale [GAS], symptom score) 69 of 99 patients were reexamined. The number and duration of rehospitalizations as well as the symptom and GAS scores were recorded. These was no difference between outcome of high and low EE patients with a duration of illness of less than 4.5 years and for those living with partners. Patients from high EE parents with a longer duration of illness (> 4.5 years) at the outset of the study were significantly more often and longer in hospital. They had significantly higher symptom and GAS scores at the outset of the study and after 8 years. The EE effect was equal in the first and second 4 years of the follow-up and was independent from patients and parents living together. The results emphasize the significance of the EE index as a long-term predictor for the course of schizophrenic illness. The independence of the prediction from living together is an argument against a simple causal interpretation of the connection between EE and the course of schizophrenia.

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.

Galactorrhea and hyperprolactinemia in schizophrenic patients on neuroleptics: frequency and etiology.

The frequency of galactorrhea and the subjective response to it were investigated in 150 schizophrenic patients. The incidence rate was 14% and the prevalence rate 19%. The latency periods between start of neuroleptic medication and manifestation of galactorrhea were subject to substantial scatter, as were the prolactin values. Patients who had undergone neuroleptic relapse prevention prior to the index episode and/or had been pregnant were affected significantly more frequently by galactorrhea.

[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.

Emotional family atmosphere and relapse: investigations on the role of relapse definition, duration of illness and resignation of relatives.

An analysis of existing studies on the expressed emotion (EE) concept shows that the predictive validity of the EE index depends on the definition of relapse. Whilst symptomatic relapses are recorded in patients from high-EE families, about 3 times as often as in patients from low-EE families, a comparison of hospitalization rates reveals a difference of only approximately 1.5 times. In the Münster Families Study, a prospective intervention study to evaluate the therapeutic impact of relatives' groups, the predictive value of the familial emotional atmosphere could be measured in a prospective design. Ninety-nine DSMIII Schizophrenics, 72 male, 27 female, mean age 27 (SD 6.6), mean duration of illness 5.5 (SD 4.3) were followed up. In the first eighteen months patients from high-EE- families had a risk of rehospitalisation approximately 1.5 (p < 0.05). Further analysis showed that relapse rates among patients from high-EE and low-EE families were roughly the same for patients with a duration of illness of less than 4.5 years but were significantly different after a longer duration (p = 0.019). Besides a high EE rating, resignation of relatives was also a significant (p = 0.000) predictor of rehospitalisation for high and - even more - low EE families. Possible causes of these findings and therapeutic consequences are discussed.

Self-help groups for families of schizophrenic patients: formation, development and therapeutic impact.

In recent years, self-help groups for relatives of schizophrenic patients have become a vital organization in Germany. The commitment of group members is often impressive, but an empirical study investigating the impact of the activity in such groups has yet to be published. An initial approach was made possible by the Münster Families Study, a prospective evaluation study designed to register the impact of relatives' self-help schizophrenic patients. Following a 1-year therapeutic phase, two relatives' self-help groups were formed; these were followed for 2 years. The study showed that relatives of severely mentally ill male patients with high levels of expressed emotion (EE) were most likely to join self-help groups. In the 2-year follow-up period, there was a tendency towards a more favourable development among these patients than among the comparably ill patients forming a control group, whose relatives were not involved in self-help. What was more marked, however, was the positive development among involved relatives, whose EE levels remained unchanged but who displayed higher levels of social contacts and fewer physical complaints. When encouraging the formation of such self-help groups, however, it has to be borne in mind that only a small proportion of relatives can be motivated to, or are capable of, active long-term involvement.

Lithium treatment of a patient with Addison's disease and affective psychosis.

A female patient born in 1941, who suffers from affective psychosis and Addison's disease, first received lithium carbonate in 1983 during a severe, therapy-resistent depression. With lithium treatment she showed a considerable improvement. In the following months, with a daily dosage of 24.4 mmol, the blood lithium levels were between 0.8 and 0.9 mmol/l. One year later she suffered a severe lithium intoxication after a virus infection. Shortly afterwards, she had a manic and then a depressive phase. She was now put on a regimen of with 12.2 mmol lithium carbonate per day, which produced blood levels between 0.3 and 0.4 mmol/l. In the following years, values of about 0.9 mmol/l were observed several times, therapy and clinical condition remaining unchanged. These spontaneous fluctuations of the blood lithium level, a hitherto unreported phenomenon are discussed as a possible cause of the lithium intoxication. The consequences for clinical practice are outlined.

[Family groups and family self-help groups for schizophrenic patients. Concepts, establishment, problems in implementation]. / Angehörigengruppen und Angehörigen-Selbsthilfegruppen bei schizophrenen Patienten. Konzepte, Etablierung, Probleme bei der Durchführung.

In Münster/W.-Germany the effect of therapeutical work with relatives of young schizophrenic patients is investigated in a government supported prospective study. In this paper we reveal therapeutical concepts and difficulties dealing with the formation and guidance of the relatives groups. After a personal interview about one third of the relatives was interested in relatives groups (151 relatives of 99 patients). Relatives of younger patients with a shorter duration of illness were somewhat more interested. During the one-year-period of group-work about one third of the relatives left the groups. The motivation for a regular participation dependent on the symptoms of the patients. A special training produced better motivation for taking part in long-term self-help-groups.

[Aspects of ambulatory occupational therapy]. / Aspects of ambulanter Arbeitstherapie.

The authors report on the organisation and structure of a work therapy system set up at the Department of Psychiatry of the University of Münster which also looks after outpatients. The authors' presentation takes into account that there are not yet enough setups of this kind in the Federal Republic of Germany. A comprehensive survey is given of the patients' motives to participate, their attitude towards their activities, and the therapeutic effects as experienced by the patients. The ranking of work therapy within the overall framework of comprehensive outpatient care is discussed.