Feasibility and acceptability of cognitive rehabilitation during the acute phase of schizophrenia.

AIM: Although numerous studies have demonstrated promising results for the cognitive rehabilitation in subjects with schizophrenia, the efficacy of cognitive rehabilitation for everyday and social functioning is not yet sufficient. Although consideration of the contents and methods are vital, the timing for implementing cognitive rehabilitation also seems to be crucial. The aim of this study was to examine the feasibility and acceptability of cognitive rehabilitation during the acute phase of schizophrenia. METHODS: Patients were recruited from consecutive acute admissions to the inpatient unit during a 15-month period and were evaluated to determine whether they could be enrolled in an 8-week cognitive rehabilitation program within 14 days of their hospital admission. Cognitive rehabilitation programs with a workbook style were adopted, taking the patients' conditions and burdens into consideration. RESULTS: Eighty-three patients were newly admitted during the entry period, and 49 patients (59.0%) were eligible for inclusion. Of them, 22 patients (44.9%) agreed to participate and started the program. Sixteen patients completed the program and underwent a second assessment. Thus, 32.7% (16/49) of all the eligible patients actually completed the study. The participants were quite satisfied with the program. CONCLUSIONS: This preliminary study yielded encouraging data demonstrating the feasibility and acceptability of cognitive remediation for patients with schizophrenia during the acute phase. The provision of cognitive rehabilitation during the acute phase of the first episode can reasonably be expected to lead to better functional outcomes.

Differences between subjective experiences and observed behaviors in near-fatal suicide attempters with untreated schizophrenia: a qualitative pilot study.

BACKGROUND: In cases of untreated schizophrenia, the patients' entourage often does not recognize the psychotic symptoms of the patient and the possibility that the patient may attempt suicide. The aim of this study was to investigate the discrepancies between the subjective experiences and observed behaviors in near-fatal suicide attempters with untreated schizophrenia. METHODS: A semi-structured interview was carried out with seven near-fatal suicide attempters with untreated schizophrenia to examine the subjective experiences at the time of the suicide attempt. The families of the patients were also interviewed to determine their recognition of the patients' psychotic symptoms and the suicidal ideation. The interview data were analyzed qualitatively. RESULTS: Six subjects were undergoing exacerbation of the psychotic symptoms at the time of exhibiting the suicide-related ideation. One subject had been in a prolonged depressive state before attempting suicide. Although all the patients experienced severe distress due to psychotic symptoms and depressive mood, they all exhibited only low level or no help-seeking behavior, and six of seven families had not recognized the change in the patient's mental condition. CONCLUSIONS: Appropriate information about schizophrenia should be provided to the general public so that any help-seeking by the patients with this disease is not overlooked. In addition, accessible early intervention services for psychosis should be established.

Poor outcome associated with symptomatic deterioration among help-seeking individuals at risk for psychosis: a naturalistic follow-up study.

AIMS: It remains debatable whether early intervention for psychosis is capable of meeting the needs of at-risk subjects. The aims of this study were to describe the actual impact of interventions on subjective difficulties and to explore the factors that may be associated with a poor outcome. METHODS: Participants were help-seeking outpatients at a university hospital who met the Criteria of Prodromal Syndromes. Changes in the symptoms, subjective experience and current insight were assessed using the Scales of Prodromal Symptoms, the Subjective Well-being under Neuroleptics, and the Scale to Assess Unawareness of Mental Disorder, respectively. Global functioning, social functioning and subjective quality of life were evaluated using the Global Assessment of Functioning Scale, the Social Functioning Scale, and the WHO-Quality of Life 26, respectively. These measures were assessed both at baseline and after 1 year. RESULTS: Forty-six patients agreed to participate. Of the 27 patients who completed the reassessment at the follow-up point, 13 patients (48%) showed little improvement in their positive/negative symptoms, subjective well-being or awareness of their symptoms. Additionally, less severe negative symptoms, more severe general symptoms and lower subjective well-being at baseline significantly predicted a deterioration of positive/negative symptoms after 1 year. CONCLUSION: Our findings suggest that the current strategy for reducing psychosis risk based on positive symptoms should be reappraised.

[The significance of the early detection and intervention for schizophrenia].

Early detection of, and intervention for, schizophrenia improve the social and functional outcome of the schizophrenia patient. A shorter duration of untreated psychosis (DUP) is an indication of a good prognosis for schizophrenia, but the DUP in Japan is comparatively long. There are some reports which have suggested shortening the DUP, for example, the Buckingham project and TIPS. They show early intervention services reduce the rate of onset of schizophrenia, and improve functions of schizophrenia patients. Intervention for patients with At Risk Mental State (ARMS) may stop or delay the onset of schizophrenia. Furthermore, intensive cares for patients in the critical period can also induce better clinical and functional outcomes. A shorter DUP and an intensive and comprehensive approach within the critical period are eagerly awaited in Japan.

[Efforts toward comprehensive early intervention at Early Psychosis Unit "II Bosco"].

Recently, shortening of the duration of untreated psychosis (DUP) and intensive treatment within the critical period are taken as determinants of a favorable prognosis, and various service systems and treatment approaches for early intervention in schizophrenia have been proposed in the world. At the Toho University Omori Medical Center, Early Psychosis Unit "Il Bosco" was established as an intervention service from the viewpoint of preventing full-blown psychosis at the prodromal stage, where cognitive training for a direct therapeutic approach to brain function and psychosocial treatment for patients at puberty and adolescence are administered. In this article, we introduce the practice at "Il Bosco" and consider future prospects.

Early psychosis in Asia: Insights from Japan.

The largest task for psychiatry in Japan today is the deinstitutionalization of patients with psychiatric disorders. In Japan, all citizens are covered by a national health plan, and about 70% of the total cost is covered by the national health insurance scheme. At present, however, there is still no category for early intervention in the national health reimbursement schedule. Recent research has shown that the mean duration of untreated psychosis (DUP) at seven university hospitals in Japan was 17.6 months. We present data using case vignettes suggesting that pharmacotherapy might be overused in prodromal cases. The concept of an At-Risk Mental State (ARMS)/prodromal state might not yet be widely recognized among Japanese psychiatrists. We outline early intervention initiatives in Japan; The Japanese Society for Prevention and Early Intervention in Psychiatry (JSEIP), and a representative early intervention facility for young people is the "Il Bosco" in Tokyo. There are several leading centers for early intervention research and practice in Japan. Most of them are driven by university departments of psychiatry with respect to both research and clinical activities. The development of services for early intervention is expected to reduce stigmatization, prevent suicide among young persons, and promote general knowledge about mental health. There are several common or similar issues among Asian countries, including service systems, community attitudes to psychiatric illness including stigma, and dependence on pharmacotherapy.

Reduced prefrontal cortex activation during divergent thinking in schizophrenia: a multi-channel NIRS study.

Relationships between deficits in verbal fluency and poor social functioning have been revealed in patients with schizophrenia. In previous studies, we demonstrated that deficits in idea fluency, which is ranked as a more complex type of verbal fluency and reflects divergent thinking ability, were more closely related to social dysfunction than deficits in simple word fluency. Although functional neuroimaging studies have provided detailed data regarding prefrontal dysfunction during word fluency tasks, the regions that relate to deficits in fluency of ideas and thoughts have not yet been clarified in schizophrenia patients. The purpose of the present study was to identify the prefrontal sub-regions responsible for deficits in idea fluency using near-infrared spectroscopy (NIRS), which is more practical than other imaging methods, and to investigate the relationships between lesions and idea fluency deficits and social dysfunction in patients with schizophrenia. Eighteen outpatients with schizophrenia and 16 healthy subjects were recruited for this case-controlled study. Using 24-channel NIRS, we measured changes in hemoglobin concentration in the prefrontal cortical surface area during idea and letter fluency tests. The analyses revealed that schizophrenia patients generally exhibited a smaller increase in the concentration of oxyhemoglobin in the frontopolar region than the controls during both the tests. However, the areas in which reduced activations were demonstrated in the patients differed remarkably between the idea and letter fluency tests: reduced activations were observed in the ventral region during the former test and in the dorsal region of the frontopolar cortex during the latter test. The reduced activations in each sub-region appeared to affect the related cognitive impairment, since the patients showed significant poorer performances than the controls on both the tests. Moreover, hypoactivity during idea fluency was significantly correlated with poor social functioning as assessed using the Global Assessment of Functioning (GAF) in the patient group. The results of the present study suggest that the ventral region within the frontopolar cortex is responsible for divergent thinking, which is associated with poor social functioning in patients with schizophrenia.

Effects of aripiprazole on insight and subjective experience in individuals with an at-risk mental state.

INTRODUCTION: Although medication with antipsychotic for the psychosis prodrome has often caused some ethical issues, recent studies have shown that some novel antipsychotics are safer and more tolerable for young people. This study aimed to investigate whether the administration of aripiprazole would not only relieve the prodromal symptoms but also be tolerable for prodromal subjects and to evaluate the effect of medication on improvements in insight and subjective well-being. METHODS: The Structured Interview for Prodromal Syndromes was performed for patients identified as having the psychosis prodrome. Psychiatric measures included the Scale of Prodromal Symptoms. Clinical insight was measured using the Scale to Assess Unawareness of Mental Disorder, and changes in subjective experience were assessed using the Subjective Well-being Under Neuroleptics, Short version. The time frame was the first 8 weeks after beginning study medication. RESULTS: Thirty-six treatment-seeking prodromal patients (men, 42%; mean [SD] age, 23.4 [5.6] years) were enrolled. At the 12-week follow-up point, 30 participants (83%) remained in the trial. Improvements on the Scale of Prodromal Symptoms and Scale to Assess Unawareness of Mental Disorder scores were statistically significant at end point. Although the Subjective Well-being Under Neuroleptics, Short version total scores improved significantly at 4 weeks, however, they did not change significantly from baseline at 8 weeks. CONCLUSIONS: This trial suggests that aripiprazole not only produces a clinical benefit in prodromal subjects but also results in a high adherence to medication with immediate improvements in insight and subjective well-being. Although further placebo-controlled studies are needed, aripiprazole might be a first-line treatment for individuals at imminent risk for psychosis.

Clinical practice and research activities for early psychiatric intervention at Japanese leading centres.

AIM: To describe clinical practice and research activities for early psychiatric intervention in Japan, a country with a huge number of psychiatric beds and a history of long-stay, hospital-based psychiatry. METHODS: The characteristics, methods and activities of early intervention studies and implementation at four leading institutions in Japan are described. RESULTS: The Tokyo Youth Club (Tokyo), the Department of Neuropsychiatry of Toyama University Hospital (Toyama), the Sendai At-risk Mental State and First Episode (SAFE) service (Sendai), and the Il Bosco of Toho University Omori Medical Center (Tokyo) have unique and active psychiatric programmes. Eachcentre has its own clinical research programme and treatment strategies. The Japanese Society for the Prevention of Psychiatric Disorders, founded in 1996, has made a steady contribution to psychiatric care by providing a forum for members to promote best practices for early intervention and by hosting annual meetings to discuss research and treatment. CONCLUSIONS: The Japanese psychiatry service is continuing its transition from hospital-based psychiatry to community-based psychiatry. Despite these difficult circumstances, the publication of data on the duration of untreated psychosis in Japan along with evidence that early detection determines outcome has encouraged new attempts to promote early psychiatric intervention.