Research and treatment strategies in first-episode psychoses. The Pittsburgh experience

BACKGROUND: Studies of first-episode patients allow investigation of the biological basis of psychotic disorders without the potential confounds of prior treatment and illness chronicity. Prospective studies of this population can clarify the impact of illness course and treatment on neurobiology. METHOD: We summarise preliminary findings from our ongoing magnetic resonance imaging and spectroscopy studies of first-episode schizophrenia patients being conducted prospectively from index evaluations through a period of two years; during this period, patients were treated with either a conventional antipsychotic such as haloperidol, or the atypical risperidone. RESULTS: Baseline neurobiological evaluations in first-episode schizophrenia patients have revealed evidence for structural and functional brain abnormalities consistent with a neurodevelopmental model of this illness. Our preliminary data support the value of risperidone as an antipsychotic drug of first choice among patients with early schizophrenic illness. CONCLUSIONS: Focused studies of first-episode patients have the potential to unravel pathophysiology of schizophrenic illness. Such knowledge is critical for more effective early detection, intervention and even prevention of this enigmatic disorder.     

Early intervention and prevention in schizophrenia--experiences from a study in Stavanger, Norway

The paper gives an overview of current literature and research that makes the foundation and rationale for early intervention in functional psychosis, i.e. schizophrenia. The duration of untreated psychosis (DUP) and its practical implications are demonstrated. An outline of the prerequisites of the psychiatric services and the societal preconditions for effective early intervention strategies is given. The development of working clinical treatment programmes within the county of Rogaland, Norway, is described, as well as strategies towards enhancing the knowledge of serious psychiatric disorders among the population and thus making the foundation for effective and early help-seeking. The different resistance factors in relation to early intervention are introduced. Preliminary results of an early intervention is presented, indicating that it is possible to shorten DUP (from 114 to 20 weeks), and showing that DUP is the single most important predictor for poor prognosis.     

Vascular access survival among incident hemodialysis patients in the United States

OBJECTIVES: To investigate: (i) if early psychosocial intervention after cystectomy for bladder cancer can assist psychosocial rehabilitation; (ii) if the outcome of such intervention correlates with the patient's psychological defensive strategies as revealed with the meta-contrast technique (MCT); and (iii) if the patient's general philosophical outlook is important in this context. PATIENTS AND METHODS: Of 50 patients who had undergone radical cystectomy for bladder cancer, 17 received an ileal conduit, 17 a continent urinary reservoir with abdominal stoma and 16 an orthotopic neobladder. Twenty-four of the patients were randomized to psychosocial intervention, comprising weekly counselling 4-9 weeks after surgery. All patients were then evaluated with the Sickness-Impact Profile (SIP) standard questionnaire and the MCT (a projective test of percept-genetic model) was used to reflect individual defensive strategies at the subconscious or unconscious level. The patient's general philosophical outlook was recorded before and after surgery. RESULTS: There was no significant difference in the results of the SIP between the intervention and the non-intervention group, as a whole or in its psychosocial dimension. However, intervention benefited patients with continent cutaneous diversion, whose scores on the psychosocial SIP dimension were lower than in the groups with ileal conduit diversion or orthotopic bladder replacement (P < 0.05). The MCT analysis of defensive strategies identified three clusters of patients characterized mainly by isolation and repression, repression and stereotypy or sensitivity and stereotypy. Analysis for cluster identification showed no significant SIP score differences between intervention and non-intervention groups. In an analysis of single defensive strategies, stereotypy was associated with higher total SIP score, but not significantly. Three clusters of philosophical outlook were identified; in one cluster, characterized by a belief in a supernatural power and philosophical interest, the psychosocial SIP scores were lower in the patients who obtained emotional support and the reverse in a cluster with contrary attitudes, although neither differences were significant. CONCLUSION: Psychosocial intervention assisted the psychosocial rehabilitation of patients with continent cutaneous urinary diversion. Defensive strategies and philosophical outlook generally did not influence the outcome of intervention. However, such programmes may be helpful for some patients, mainly those with a basically pessimistic disposition, a general interest in philosophical questions and often using defensive strategies of stereotypy and repression.     

Psychometric detection of schizotypy.

Genetic studies of typical schizophrenia require accurate means for the detection of carriers of the heritable diathesis. Psychometric methods have been developed, often for studying psychosocial transmission of schizophrenia, that might be useful for genetic studies. Studies of schizotypy detection using the Goldstein-Scheerer Object Sorting Test, Rorschach technique, TAT, and MMPI are reviewed. Most studies suffer from serious conceptual and methodological flaws that have made replication a rarity. Recent approaches emphasizing clinical signs and symptoms that bear a close content relationship to the typical schizophrenic syndrome are asserted to be more likely to bear fruit. (1? p ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Family Function and Stroke Recovery: A Review.

Objective: Literature on family function in stroke rehabilitation is reviewed in 3 areas: the impact of family function on recovery from stroke, the impact of stroke on family function, and psychosocial intervention in stroke. Study Design: Literature review. Results: Family function influences stroke rehabilitation. Family-based interventions are emerging but have not been proven effective. Health system changes have expanded the family's role in stroke care, increasing the need for psychosocial intervention research. Conclusions: Family function appears to influence stroke outcomes; a family-systems perspective promotes understanding of psychosocial outcomes in stroke; research has focused systems mainly on individual rather than family-systems models; tools to evaluate family process after stroke are inadequate; and more research is needed to develop and test optimal family intervention strategies. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Conversational repair in schizophrenic and normal children

OBJECTIVE: Children acquire the skills to monitor the adequacy of their spoken message and to self-initiate repair strategies that modify the message during early, middle, and late childhood. To characterize further the communication deficits of childhood-onset schizophrenia, this study compared self-initiated repair strategies in schizophrenic and normal children and their relationship with formal thought disorder, discourse deficits, and distractibility. METHOD: Measures of self-initiated repair, formal thought disorder, and cohesion were coded in 32 schizophrenic and 47 normal children, aged 5.6 to 12.4 years, from speech samples elicited with the Story Game. RESULTS: The schizophrenic children used some repair strategies (false starts, fillers, referential revision) more infrequently than the normal children. Within the schizophrenic group, the children who were receiving neuroleptic medication underutilized repair and had more discourse deficits than the unmedicated patients. Loose associations and distractibility were associated with increased use of false starts but not fillers. CONCLUSIONS: In addition to formal thought disorder and discourse deficits, schizophrenic children underutilize self-initiated repair when presenting their thoughts to the listener, particularly if they are being treated with neuroleptics, a potential sign of increased clinical morbidity. Impoverished communication skills might reflect negative signs in childhood-onset schizophrenia.     

Self-experienced vulnerability, prodromic symptoms and coping strategies before schizophrenic and affective episodes

For the first time, the present study explores self-experienced vulnerability, prodromal symptoms and coping strategies preceding schizophrenic and affective episodes. 33 schizophrenic and 29 depressive patients were assessed retrospectively for preepisodic alterations by means of the "Bonn Scale for the Assessment of Basic Symptoms- BSABS" after complete recovery from the acute episode. 97% of the schizophrenic and 93% of the depressive patients showed preepisodic alterations. In the schizophrenic group the first alteration occurred with a median of 10 weeks and in the depressive group with a median of 18 weeks before the onset of the acute episode. With regard to self-experienced vulnerability depressive cases were significantly less tolerant to stress, i.e work under time pressure or unusual, unexpected requirements. With regard to prodromal symptoms schizophrenics showed significantly more often interpersonal irritation and certain perception and thought disturbances, whereas depressive patients reported more often adynamia and certain disturbances of proprioception. 73% of the schizophrenic patients and 90% of the depressive patients reacted to early symptoms with coping strategies. The preepisodic alterations in schizophrenic patients could be described in terms of mild psychotic productivity, early symptoms of depressive patients could be described as a mild depressive syndrome. Prospective studies are necessary to show if assessment of mild psychotic productivity could be used for early diagnosis and early intervention in schizophrenia.     

Diazepam treatment of early signs of exacerbation in schizophrenia

OBJECTIVE: Therapeutic intervention at the earliest phase of symptom exacerbation in schizophrenia is an important clinical need, but specific pharmacotherapeutic interventions for this phase of illness have not been established. This study examined diazepam efficacy for this phase of treatment. METHOD: A double-blind, randomized clinical trial with 53 schizophrenic patients compared diazepam with placebo (with fluphenazine treatment for a comparison group). Treatment was initiated at the earliest signs of exacerbation, and symptom progression was the dependent measure used to evaluate efficacy. RESULTS: Diazepam was statistically superior to placebo in preventing symptom progression and was comparable to fluphenazine. CONCLUSIONS: Efficacy data support the use of diazepam in treating prodromal and early warning signs of symptom exacerbation in schizophrenia. This therapeutic strategy may be especially important for patients who refuse antipsychotic drugs or as a supplemental approach in a treatment plan that emphasizes low-dose antipsychotic therapy.     

Do atypical antipsychotic medications favorably alter the long-term course of schizophrenia?

Schizophrenia is characterized by the greatest degree of clinical deterioration in the first decade following onset of psychosis; in fact, deterioration begins even prior to the onset of frank psychotic symptomatology. While somewhat controversial, it appears that effective early antipsychotic treatment might limit the extent of such deterioration. The newer, atypical antipsychotics such as clozapine, risperidone, olanzapine and quetiapine appear to have antipsychotic efficacy at least equal to the traditional neuroleptics, but with a much more favorable side effect profile. Clozapine is also effective in treating neuroleptic-refractory schizophrenic patients. Data suggest that in comparison to conventional agents, treatment with atypical antipsychotics may be associated with a more benign course of schizophrenic illness. Whether these atypical antipsychotics are associated with greater efficacy in limiting clinical deterioration in schizophrenic illness than traditional neuroleptics is, however, unclear. The following questions will be addressed in this paper: (i) Do atypical antipsychotics differ from traditional neuroleptics in modifying the natural course of symptomatology in schizophrenic illness? (ii) Do atypical antipsychotics differ from typical neuroleptics in modifying the natural course of neurobiological and cognitive abnormalities in schizophrenic illness? (iii) Do atypical antipsychotics differ from typical neuroleptics in modifying the natural course of psychosocial dysfunction in schizophrenic illness? (iv) Are there differences between typical and atypical antipsychotics with regard to their effects on the cost of care and resource utilization? The implications of the answers to these questions for the long-term treatment of schizophrenia will be discussed.     

Evaluation of indicated preventive intervention (secondary prevention) mental health programs for children and adolescents

Evaluated the outcomes of 130 indicated preventive interventions (secondary prevention) mental health programs for children and adolescents that seek to identify early signs of maladjustment and to intervene before full-blown disorders develop. Results indicate such programs significantly reduce problems and significantly increase competencies. In particular, behavioral and cognitive-behavior programs for children with subclinical disorders (mean ESs in the 0.50s) appear as effective as psychotherapy for children with established problems and more effective than attempts to prevent adolescent smoking alcohol use, and delinquency. In practical terms, the average participant receiving behavioral or cognitive-behavior intervention surpasses the performance of approximately 70% of those in a control group. Of particular interest was the high mean effect (0.72) achieved by programs targeting incipient externalizing problems which are customarily the least amenable to change via traditional psychotherapeutic efforts when they reach clinical levels. Priorities for future research include greater specification of intervention procedures, assessment of treatment implementation, more follow-up studies, and identifying how different participants respond to early intervention.     

Early intervention, untreated psychosis and the course of early schizophrenia

BACKGROUND: Studies have proved that early intervention can delay psychotic relapses, and prevent psychosocial deterioration in people with schizophrenia and related disorders. METHOD: Our study with young people with recent onset schizophrenia has shown that an intensive intervention programme had a beneficial effect on the occurrence of psychotic relapse and the course of psychotic syndromes. This effect lasted until the end of the 15-month intervention. No significant effect of the two different intervention conditions became apparent. RESULTS: The results of a follow-up study showed that this beneficial effect did not last. Fifteen per cent of the people had a psychotic relapse during the intervention, whereas 64% relapsed during follow-up. CONCLUSIONS: These results show that referral to other mental health agencies after intervention is not sufficient and that more support is required to continue disease management, medication compliance and stress management.     

Pediatric Psychopharmacology for Prepubertal Internalizing Disorders.

Evidence-based studies of drug, psychosocial and combined treatments for prepubertal internalizing disorders (depression, obsessive-compulsive disorder [OCD], and non-OCD anxiety) were reviewed. No age effects were found. Although no combined studies met evidence-based criteria, efficacious and possibly efficacious psychosocial and pharmacological treatments were identified, along with safety concerns for drug treatments. Evidentiary support favored psychosocial treatment for non-OCD anxiety disorders and pharmacological treatments for OCD, with mixed results for depression. Cost-benefit considerations suggest psychosocial treatments should be considered the first choice for at least anxiety and depression, except in unusual cases where stabilization may require pharmacological intervention first. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Prevention and early intervention for anxiety disorders: A controlled trial.

The Queensland Early Intervention and Prevention of Anxiety Project evaluated the effectiveness of a cognitive-behavioral and family-based group intervention for preventing the onset and development of anxiety problems in children. A total of 1,786 7- to 14-year-olds were screened for anxiety problems using teacher nominations and children's self-report. After recruitment and diagnostic interviews, 128 children were selected and assigned to a 10-week school-based child- and parent-focused psychosocial intervention or to a monitoring group. Both groups showed improvements immediately postintervention. At 6 months follow-up, the improvement maintained in the intervention group only, reducing the rate of existing anxiety disorder and preventing the onset of new anxiety disorders. Overall, the results showed that anxiety problems and disorders identified using child and teacher reports can be successfully targeted through an early intervention school-based program. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

New directions in the prevention and treatment of schizophrenia: a biological perspective

Our current treatments for schizophrenia are, at best, palliative. With the exception of counseling those families with a known high risk for having schizophrenic offspring, no preventive measures are currently available. The not too distant future, however, promises to bring improvements in somatic treatments as well as the possible introduction of preventive measures. We are fully aware that current biological treatments work best when they are combined with psychosocial intervention, and expect that future biological treatments and preventions will also involve appropriate nonbiological considerations. Psychosocial treatments are covered elsewhere in this issue. Here we look at how modern genetics, pre- and perinatal factors, early and sustained intervention, and new medications are likely to decrease both the number of individuals with schizophrenia and the severity of the illness.     

Designing a psychosocial intervention to teach coping flexibility.

Describes a theory-driven psychosocial intervention that was designed to teach coping flexibility to people with chronic illness. This 8-wk coping skills group addresses dealing with feelings and images about the illness, teaching new methods of setting goals, developing strategies to compensate for cognitive deficits, and improving communication with caregivers. Groups ranged from 4 to 9 patients, plus support people. Qualitative impressions gleaned from group participants and some of their physicians suggest that the group intervention has been effective in alleviating some psychological and physical problems. The methodological process and human factors of import to the delivery of this intervention are discussed, emphasizing the nonspecific therapeutic factors that may interact with intervention content to affect participants' quality of life. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Hypoglossal and phrenic responses to central respiratory inhibition in piglets

The authors present and discuss, within a systems frame of reference, the main aspects of family interventions with adults affected by long-term schizophrenic disorders involved in psychosocial rehabilitation. Special attention is paid to mutual influence between the interventions aimed at individual disability and those centered on family attitudes, beliefs and interactional patterns.     

Verbal interactions in the families of schizophrenic and bipolar affective patients.

Do verbal interactions between psychiatric patients and family members covary with the diagnosis of the patient? This study compared relatives (usually parents) of schizophrenic (n?=?42) and bipolar (n?=?22) patients on affective style (AS) or emotional-verbal behavior toward patients in family interaction. Patients were compared on coping style or verbal interactional behavior toward relatives. Relatives of schizophrenic patients made more negative AS (particularly intrusive) statements to patients than relatives of bipolar patients. Schizophrenic patients made fewer supportive statements and more self-denigrating statements to relatives than bipolar patients. Among families of bipolar patients, negative AS in relatives was associated with oppositional, "refusing" styles in patients. Implications for psychosocial interventions with these disorders are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Are two interventions worse than none? Joint primary and secondary prevention of eating disorders in college females.

Prevention programs for eating disorders attempt to simultaneously prevent new cases from arising (primary prevention) and encourage students who already have symptoms to seek early treatment (secondary prevention), even though ideal strategies for these 2 types of prevention may be incompatible with each other. In the present study, an eating disorder prevention program was evaluated in a sample of female college freshmen. In the intervention, classmates who had recovered from eating disorders described their experiences and provided information about eating disorders. At follow-up, intervention participants had slightly more symptoms of eating disorders than did controls. The program may have been ineffective in preventing eating disorders because by reducing the stigma of these disorders (to encourage students with problems to seek help), the program may have inadvertently normalized them. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Impaired generation and use of strategy in schizophrenia: evidence from visuospatial and verbal tasks

BACKGROUND: The aim of this study was to investigate mnemonic strategic deficits in schizophrenic patients. METHODS: Analogous tasks were used that required the self-generation of an efficient strategy and its implementation in two domains: visuospatial and verbal. The tasks were given to 20 IQ preserved schizophrenics and 20 matched normal controls. A number of different scores was derived from each task including strategy, short-term memory capacity and perseveration. RESULTS: Overall, the schizophrenic patients were significantly impaired in their ability to generate effective mnemonic strategies on both tasks. In addition, on the visuospatial task there was no difference between the groups on the memory scores, but the schizophrenic patients made significantly more perseverative errors than controls. They were disproportionately worse on the verbal strategy task, showing impairment on memory as well as on strategy scores and were also impaired at semantically classifying the words. Performance was similar to the deficit seen in patients with frontal lobe excisions and Parkinson's disease, in terms of the inability to generate an effective strategy. The deficit on the verbal task was similar to patients with temporal lobe excisions who show impaired verbal memory. However, the pattern differed in the sense that the temporal lobe patients were able to generate effective strategies, unlike the patients with schizophrenia. CONCLUSIONS: High functioning schizophrenic patients are impaired in utilizing visuospatial and verbal mnemonic strategies. By comparing the results with those of neurosurgical excision patients, further evidence is provided for both frontal and temporal lobe involvement in schizophrenia.