Dysglycemia in a community sample of people treated for schizophrenia: the Diabetes in Schizophrenia in Central-South Ontario (DiSCO) study.

OBJECTIVE: Despite increasing recognition of schizophrenia as a risk factor for diabetes, the prevalence and correlates of dysglycemia in people with schizophrenia have not been adequately studied. Discerning the modifiable risk factors is crucial for developing diabetes prevention strategies in schizophrenia. METHODS: Socio-demographic, clinical and recent laboratory data were compiled from the case records and supplemental sources of 1123 people treated for schizophrenia who were living across five different communities in the region. RESULTS: Screening rates for fasting plasma glucose (FPG) varied between 63-100% across the five communities, while other metabolic indices were monitored less frequently. 39 subjects (3.5%) in the sample had an existing diagnosis of type 2 diabetes. Among the others, 845 (78%) had FPG measured in the preceding 6 months, with the following results: FPG < or = 5.6 mmol/l in 474 (56%), 5.6-6.9 mmol/l in 268 (31%), and > or = 7 mmol/l in 103 (12.2%) subjects. Dysglycemia (FPG > or = 5.6 mmol/l) was significantly associated with older age (odds ratio [OR] 1.031), longer duration of schizophrenia (OR 1.062), self reported family history of diabetes (OR 8.87), body mass index (OR 1.081), excess weight (OR 1.014) and independent living status (OR 1.779), while European ethnicity (OR 0.706) and regular physical activity (OR 0.958) lowered the risk. No statistically significant correlations were noted with gender, level of education or functioning, or the type of antipsychotic drug prescribed. CONCLUSIONS: There was a two-fold increase in the prevalence of dysglycemia, while there was a substantial under-recognition of and intervention for, diabetes and pre-diabetes in this sample of people treated for schizophrenia.

Cognition, functioning and quality of life in schizophrenia treatment: results of a one-year randomized controlled trial of olanzapine and quetiapine.

BACKGROUND: Cognitive deficits are recognized as a critical determinant of functional outcomes in schizophrenia; and second generation antipsychotic drugs have been touted for their potential to enhance cognitive functioning and community tenure. OBJECTIVES: The study examined the relative merits of olanzapine and quetiapine in improving cognitive deficits and enhancing psychosocial functioning in a sample of community dwelling adults previously treated with first generation antipsychotic drugs for schizophrenia. METHODS: In a prospective, rater-blinded study, 86 participants were randomized to receive either olanzapine or quetiapine, and assessed at baseline and after 3, 6, 9 and 12 months. Outcome measures included, besides symptoms and side effects rating scales, the subjective scale to investigate cognition in schizophrenia (SSTICS), a computer-assisted cognitive test battery (COGLAB), the sickness impact profile (SIP), the global assessment of functioning (GAF) scale, and the drug attitude inventory (DAI). RESULTS: Both olanzapine and quetiapine were equally effective in improving symptom severity and decreasing the neurological side effects. Quetiapine was significantly better tolerated (p=0.002), improved self-rated cognitive dysfunction (p=0.002) and subjects' performance on selected neurocognitive tasks (p=0.01). Olanzapine use was associated with greater symptom stability, fewer drop outs (p=0.01) and frequent metabolic aberrations (p=0.001). The accrued benefits of drug therapy, however, were not reflected as significant gains in daily functioning and quality of life. CONCLUSIONS: Quetiapine is noted to have specific cognition enhancing properties in schizophrenia that warrants further exploration. The observed clinical and cognitive benefits associated with quetiapine may likely be attributable to its loose binding to, and fast dissociation from the dopamine receptors. Olanzapine has proved to be a reliable antipsychotic drug with a greater liability to cause metabolic abnormalities.

Brain imaging research on subjective responses to psychotropic drugs.

OBJECTIVE: Neuroimaging studies on subjective responses to psychotropic drugs in humans were reviewed to examine progress in the field and identify gaps in knowledge. METHOD: An exhaustive search of computerized databases identified two categories of in vivo imaging studies: i) correlates of negative(dysphoric) subjective responses to neuroleptic use in schizophrenia, and ii) research on positive (euphoric) subjective responses, mostly from substance abuse population. RESULTS: Research has been largely confined to neurochemical imaging of dopamine in the striatal complex, confirming earlier speculations that impaired or deficient dopaminergic function is associated with dysphoric responses, and enhanced activity is associated with euphoric or pleasurable responses. Cerebral blood flow, regional metabolic rate and glucose utilization studies provided preliminary clues to the putative neuroanatomical sites. CONCLUSION: Neuroimaging techniques added credibility to the study of subjective responses; however, further studies are required to identify the underlying anatomical and neurochemical interactions in order to enhance their applied value.

The relationship of symptoms and level of functioning in schizophrenia to general wellbeing and the Quality of Life Scale.

OBJECTIVE: Reports suggesting that quality of life in schizophrenia is more highly related to negative rather than positive symptoms are largely based on use of the Quality of Life Scale which was devised to assess deficit symptoms and does not include an assessment of subjective general wellbeing. In the current paper we examined symptoms, level of community functioning as well as living circumstances as correlates of Quality of Life Scale scores and scores on the General Well-Being Scale. METHOD: One hundred and twenty-eight patients completed the General Well-Being Scale and were rated on the Quality of Life Scale as well as scales assessing positive and negative symptoms. RESULTS: While negative symptoms, level of functioning and positive symptoms all were related to the scores on the Quality of Life Scale, General Well-Being Scale scores were primarily related to positive symptoms, particularly reality distortion. CONCLUSION: The results highlight the importance of recognizing the complex nature of the concept of quality of life. They demonstrate that varying indices of quality of life are likely to have different predictors.

Psychiatric emergency rates during the Christmas season in the years 1991 to 1997.

We compared the number of psychiatric admissions from the emergency room during the Christmas season, defined as the rate for the month of December, with those in other months. The psychiatric emergency rates were recorded for each month over six consecutive years, 1991 to 1997. The average number of emergency patients in none of the 12 months differed significantly from any of the remaining months (ANOVA, p > .05). Our data and those of other authors do not support the clinical lore that Christmas season is associated with higher rate of psychiatric emergencies.

Cost-utility analysis in schizophrenia.

Estimation of quality of life is important to the study of the pharmacoeconomics of schizophrenia. The subject has gained popularity among policymakers, clinicians, and patients and their families, since the advent of new antipsychotic medications that are more expensive than older drugs yet have been shown to cause fewer side effects. Quantifying quality of life has been difficult, since studies often inconsistently define the concept or use rating scales that are inappropriate for the patient population. Utility analysis is a procedure that calculates subjects' preferences regarding living with various health states, given such options as trading more years of life at a lowered health state for dying sooner but having a strong health state during the last years of life. The feasibility of performing utility analysis among patients with schizophrenia was recently examined in a study carried out by the authors. This article reflects initial observations from that study of utility analysis and includes a discussion of problems still facing the study of quality of life and utility analysis.

Symptoms and cognition as predictors of community functioning: a prospective analysis.

OBJECTIVE: It has been suggested that level of cognitive functioning as assessed by formal neurocognitive tests may be as important as, or even more important than, symptoms in predicting level of community functioning for patients with schizophrenia. The results of past prospective studies, when carefully examined, do not consistently support this hypothesis. In the current study, the authors used symptom and neurocognitive data to predict subsequent level of functioning in the community. METHOD: Neurocognitive and symptom data collected as part of an earlier study were used to predict the community functioning of 50 patients with a diagnosis of schizophrenia. Using the Life Skills Profile, staff of a community mental health program assessed community functioning while blind to the earlier symptom ratings and neurocognitive performance. RESULTS: Symptoms were more predictive of community functioning than were neurocognitive measures. Disorganization symptoms were generally more predictive of community functioning than was either psychomotor poverty or reality distortion. CONCLUSIONS: The results of this study and of previous longitudinal studies suggest the importance of using symptom levels after optimal treatment, rather than symptoms during acute episodes, as predictors of community functioning. They also indicate the need to evaluate the effects of treatment on disorganization as a separable dimension of symptoms.

An integrated medical and psychosocial treatment program for psychotic disorders: patient characteristics and outcome.

OBJECTIVES: To provide an overview of a comprehensive and integrated case-management program that incorporates principles of assertive community treatment and combines effective medical and psychosocial interventions and to present the results of a process and outcome evaluation of the program, with particular emphasis on its impact on service utilization and consumer satisfaction. METHOD: Data on demographic, clinical, and several outcome measures were collected on all patients who received care in the program for a minimum of 6 months. For process evaluation we assessed the extent to which the program adhered to its goals and satisfied the patients, their families, and community-service agencies. Outcome-evaluation data on the number and length of hospital admissions were compared for each subject with individual historical data for a period equal to the time spent in the program. In addition, relapses of psychotic symptoms that did not result in hospital admissions were calculated for each patient while in the program. RESULTS: Demographic, clinical, and treatment characteristics of clients show that the program has succeeded in maintaining its focus on providing services to relatively chronically ill patients with psychotic disorders over a mean period of 3 years. The process-evaluation data indicated a high level of satisfaction by patients, families, and other service agencies with the services received. Information on outcome variable showed that the program achieved significantly lower rates of hospital admissions and relapse of psychosis than expected. There was a highly significant reduction achieved in the utilization of inpatient hospital resources for patients receiving care in the program. Most of the inpatient service utilization was attributed to patients either who were resistant to treatment with antipsychotic agents or who refused to accept or comply with medication. CONCLUSIONS: It is possible to provide effective continuity of care from inpatient treatment to community adjustment for most individuals with psychotic disorders across the spectrum by blending hospital and community resources within an integrated case-management model of care.