Clinical Global Impression-Schizophrenia Scale Research Articles

Effects of Token Economy Intervention on Hospitalized Patients With Schizophrenia

Objectives: The purpose of this study was to investigate the effect of token economy intervention on the clinical characteristics and global function of patients with schizophrenia.Methods: From June 1, 2022 to September 1, 2022, token economy intervention was conducted for hospitalized patients with schizophrenia in a mental hospital. Assessments were conducted before and after the intervention. Clinical Global Impression-Schizophrenia scale (CGI-SCH), Schizophrenia Quality of Life Scale (SQLS), Insight Scale for Psychosis (ISP), and Apathy Evaluation Scale (AES) were used to evaluate clinical characteristics. World Health Organization Disability Assessment Schedule (WHODAS) was used for global functional assessment.Results: A total of 51 patients were included in the study. Through token economy intervention, depressive (p=0.001), cognitive symptom domain scores (p<0.001) in CGI-SCH, and SQLS score were significantly decreased (p=0.044). In the WHODAS evaluated by the clinician, the scores of self-care (p=0.012), life activities (p=0.006), and participation in society (p=0.040) decreased significantly.Conclusion: It was confirmed that token economy intervention had a positive effect on depressive symptoms, cognitive symptoms, quality of life, self-care function, daily living function, and social participation function in hospitalized patients with schizophrenia.

Clinical symptoms and social functioning in schizophrenia

IntroductionThe aim of the present study was to assess the relationship between social functioning and clinical symptoms in people with schizophrenia, analyzing the influence of both global social functioning and the specific aspects of social functioning, assertiveness and communication skills in the explanation of type of symptoms. Material and methodsA cross-sectional descriptive study composed of 125 people diagnosed with schizophrenia was performed. Patients were assessed with the Communication Skills Questionnaire (CSQ), the Gambrill and Richey Assertiveness Inventory (GR), the Global Assessment of Functioning Scale (GAF) and the Global Assessment of Social Functioning Scale (SOFAS), Social Functioning Scale (SFS), Life Skills Profile (LSP) scale and the Clinical Global Impression scale for Schizophrenia (CGI-S). ResultsSOFAS, LSP and GR are related to each of the subscales and total scores of symptoms (p<0.05–0.001). The multiple regressions show that SOFAS and GR explained 59% of the total symptoms. SOFAS and GR, accounting for 65% of the variance, explain positive symptoms. GR and SOFAS explained 34% of the variance of negative symptoms. SOFAS, CSQ and LSP, accounting for 20% of the variance, explain depressive symptoms. SOFAS explained 46% of the variance of cognitive symptoms. ConclusionsOur findings suggest the usefulness of social functioning assessment in the explanation of clinical symptoms in people with schizophrenia. Moreover, our results point out that not only negative and cognitive symptoms, but also positive and depressive symptoms, should be taken into account in the rehabilitation process in order to improve patient adaptation in the community.

Efficacy and tolerability Aripiprazole once-monthly long-acting injectable in schizophrenia. Two-injection start regimen

IntroductionAripiprazole once-monthly is a long-acting intramuscular injectable formulation of aripiprazole. The starting dose can be administered by following one of two regimens: • One injection start: On the day of initiation, administer one injection of 400 mg Aripiprazole once monthly and continue treatment with 10 mg to 20 mg oral aripiprazole per day for 14 consecutive days • Two injection start (New regimen): On the day of initiation, administer two separate injections of 400 mg Aripiprazole once monthly at separate injection sites, along with one 20 mg dose of oral aripiprazole.ObjectivesTo assess the effectiveness and tolerability of Aripiprazole long-acting injectable (ALAI) in patients with schizophrenia. The starting dose was administered following the two injection start regimenMethodsSample:10 patients with schizophrenia (DSM 5 criteria) who started treatment with ALAI. The starting dose was administered following the two injection start regimen. On a tri-monthly basis, the following evaluations were performed during a follow-up period of 6 months: The Clinical Global Impression-Schizophrenia scale (CGI-SCH), treatment adherence, the number of hospitalizations and Side effects reportedResultsMean variations from baseline scores at 6 months was (-1.1 ±0.89) on the GCI-SCH. The percentage of patients who remained free of admissions at the end of the 6 months was 90%. The rate of adherence to treatment after 6 months was 80%. The most frequent side effect was transient mild insomnia (20%) .ConclusionsAripiprazole long-acting injectable (The starting dose was administered following the two injection start regimen) is effective, safe and well tolerated in clinical practice conditionsDisclosureNo significant relationships.

Efficacy of paliperidone palmitate 3-month formulation in preventing hospital admissions. 60 months of follow-up

IntroductionPaliperidone Palmitate 3-month formulation (PP3M) has shown a significantly longer time to relapse compared to placebo, with similar efficacy and safety to Paliperidone Palmitate 1-month (PP1M). However, studies of longer duration are required.ObjectivesThe main objective of this study is to determine the effectiveness of PP3M in the prevention of hospitalizations in patients with non-acute schizophrenia in a naturalistic outpatient psychiatric setting.MethodsSample: 30 patients diagnosed with schizophrenia (DSM 5) that started treatment with PP3M after being stabilized with PP1M (the treatment dose was not changed in the four months before study inclusion) The mean dose of PP3M was 401. 55 mg Quarterly basis, the following evaluations were performed during a follow-up period of 60 months: The Clinical Global Impression-Schizophrenia scale (CGI-SCH) Treatment adherence, concomitant medication, and the number of hospitalizations. Efficacy values: Percentage of patients who remained free of admissions at the end of 60 months of follow-up. Other evaluation criteria: Average change from baseline visit to the final evaluation as assessed by score obtained on the following scale: GSI-SCH; percentage of patients on antipsychotic monotherapy, and treatment adherence rate.ResultsThe percentage of patients who remained free of admissions at the end of the 60 months was 83.25%. Mean variations from baseline scores at 60 months were: (-0.36 ±0-37) on the GCI-SCH. The rate of adherence to treatment with PP3M after 60 months was 86.58%.ConclusionsIn our study, we found that paliperidone palmitate 3-month formulation effectively prevents admissions under daily clinical practice conditions.DisclosureNo significant relationships.

Comparison of Acute Followed by Maintenance ECT vs Clozapine on Psychopathology and Regional Cerebral Blood Flow in Treatment-Resistant Schizophrenia: A Randomized Controlled Trial.

In treatment-resistant schizophrenia (TRS), Clozapine is only approved treatment with undesirable side-effects, warranting better alternatives. Our hypothesis is acute followed by maintenance Electroconvulsive Therapy (M-ECT) will be comparable in efficacy and safety to Clozapine in TRS. In this open-label trial, 60 TRS patients were randomized equally to M-ECT (following an acute-course) or Clozapine. Positive and Negative Syndrome Scale (PANSS), Clinical Global Impression Schizophrenia Scale (CGI-SCH), Montreal Cognitive Assessment (MoCA), and Global assessment of functioning (GAF) were measured and compared within and between the groups at baseline, 6 weeks, 12 weeks, and 24 weeks. SPECT-CT brain was done at baseline and 24 weeks to compare the changes in regional cerebral perfusion between the groups and correlate with the changes in the outcome-measures. The PANSS-T scores changes from baseline over the observation-points were significant in both M-ECT and clozapine groups (P < .001), with comparatively better reduction with M-ECT (P < .001). Similar trends were observed in PANSS subscales, CGI-SCH and GAF in both groups, with significantly better improvement with M-ECT over the study-period. After 24 weeks, there was significantly better perfusion with M-ECT in bilateral prefrontal and temporal cortices (P < .05). With M-ECT, a positive correlation was found between changes in PANSS-P scores and left-lateral Temporal cortical perfusion (r = .465, P = .017). Acute followed by M-ECT was more effective than clozapine over 6 months in reducing the positive and negative symptoms, general psychopathology, illness-severity, and improving the global functionality in TRS [clinicaltrials.gov: NCT03807882].

Validation of a European Spanish-version of the Self-Evaluation of Negative Symptoms (SNS) in patients with schizophrenia

IntroductionNegative symptoms can be grouped into five domains: apathy/avolition, anhedonia, asociality, alogia, and affective flattening. There are few validate self-rated measures that assess these five dimensions. Therefore, this study aimed to validate the Self-Evaluation of Negative Symptoms (SNS) in Spanish patients with schizophrenia. Material and methodsCross-sectional, validation study in 104 outpatients with schizophrenia evaluated using the Spanish version of the following scales: Clinical Assessment Interview for Negative Symptoms (CAINS), Positive and Negative Syndrome Scale (PANSS), Clinical Global Impression Scale for Schizophrenia (CGI-SCH), Personal and Social Performance (PSP), Motivation and Pleasure Scale – Self-Report (MAP-SR), 36-item Short-Form Health Survey (SF-36) and the Self-Evaluation of Negative Symptoms (SNS). Results ReliabilityInternal consistency (Cronbach's alpha) was 0.915. Convergent validity: The Pearson correlation coefficient between MAP-SR and SNS Total scores was 0.660 (p<0.001). For PANSS-N, the correlation was 0.437 (p<0.005) and with the CAINS-Total was 0.478 (p<0.005). Divergent validity: The Pearson correlation coefficient between SNS and PSP was r=−0.372 (p≤0.001), and with SF-36 Physical and Mental Summary Component scores were r=−0.213 (p=0.066) and r=−0.144 (p=0.219), respectively. Discriminant validity: SNS Total scores were significantly statistically different according to the severity of the negative symptomatology rated by the CGI-SCH negative scale (p<0.001). ConclusionThe SNS is a reliable and valid instrument to self-rate the five domains of negative symptoms in patients with schizophrenia and seems to be appropriate for use in everyday clinical practice as a complementary measure to the evaluation performed by the clinician.

Burden on caregivers of schizophrenia outpatients in Brazil: Relationship to symptomatology and functioning.

To investigate the objective and subjective burden on caregivers of schizophrenia outpatients and their associations with sociodemographic factors, symptomatology, and functioning. This study included 60 schizophrenic outpatients aged 18 to 65 years who were clinically stable for at least 6 months, and 60 caregivers aged 18 to 80 years who were in contact with the patient for ⩾30 hours/week. The patients were assessed using a sociodemographic questionnaire, the Clinical Global Impression Scale for Schizophrenia (CGI-SCH), and the Personal and Social Performance scale (PSP). The caregivers were assessed using a sociodemographic questionnaire and the Family Burden Interview Schedule, Brazilian version (FBIS-BR). The objective burden was positively correlated with CGI-SCH cognitive symptom scores (p = .032) and number of hours spent weekly with the patient (p = .028), and negatively correlated with PSP score (r = -.346, p = .007). The subjective burden showed a negative correlation with age of disease onset (r = -.338, p = .08). The independent variables included in the regression model were family income (p = .005), PSP score (p = .009), patient marital status (p = .012), patient gender (p = .046), and reception of financial benefit (p = .027) for objective burden; and disease duration (p = .045) and father/mother or sibling relationship (p = .001) for subjective burden. The coefficient of determination (R2) of the linear regression model for objective burden was 39.4%; subjective burden, 21.6%. Caring for female, single patients with longer disease duration, more severe cognitive symptoms, impaired functioning, and more caregiving time required per week were associated with higher caregiver burden levels.

Clinical symptoms and social functioning in schizophrenia.

The aim of the present study was to assess the relationship between social functioning and clinical symptoms in people with schizophrenia, analyzing the influence of both global social functioning and the specific aspects of social functioning, assertiveness and communication skills in the explanation of type of symptoms. A cross-sectional descriptive study composed of 125 people diagnosed with schizophrenia was performed. Patients were assessed with the Communication Skills Questionnaire (CSQ), the Gambrill and Richey Assertiveness Inventory (GR), the Global Assessment of Functioning Scale (GAF) and the Global Assessment of Social Functioning Scale (SOFAS), Social Functioning Scale (SFS), Life Skills Profile (LSP) scale and the Clinical Global Impression scale for Schizophrenia (CGI-S). SOFAS, LSP and GR are related to each of the subscales and total scores of symptoms (p<0.05-0.001). The multiple regressions show that SOFAS and GR explained 59% of the total symptoms. SOFAS and GR, accounting for 65% of the variance, explain positive symptoms. GR and SOFAS explained 34% of the variance of negative symptoms. SOFAS, CSQ and LSP, accounting for 20% of the variance, explain depressive symptoms. SOFAS explained 46% of the variance of cognitive symptoms. Our findings suggest the usefulness of social functioning assessment in the explanation of clinical symptoms in people with schizophrenia. Moreover, our results point out that not only negative and cognitive symptoms, but also positive and depressive symptoms, should be taken into account in the rehabilitation process in order to improve patient adaptation in the community.

Validation of a European Spanish-version of the Self-Evaluation of Negative Symptoms (SNS) in patients with schizophrenia.

Negative symptoms can be grouped into five domains: apathy/avolition, anhedonia, asociality, alogia, and affective flattening. There are few validate self-rated measures that assess these five dimensions. Therefore, this study aimed to validate the Self-Evaluation of Negative Symptoms (SNS) in Spanish patients with schizophrenia. Cross-sectional, validation study in 104 outpatients with schizophrenia evaluated using the Spanish version of the following scales: Clinical Assessment Interview for Negative Symptoms (CAINS), Positive and Negative Syndrome Scale (PANSS), Clinical Global Impression Scale for Schizophrenia (CGI-SCH), Personal and Social Performance (PSP), Motivation and Pleasure Scale - Self-Report (MAP-SR), 36-item Short-Form Health Survey (SF-36) and the Self-Evaluation of Negative Symptoms (SNS). Internal consistency (Cronbach's alpha) was 0.915. Convergent validity: The Pearson correlation coefficient between MAP-SR and SNS Total scores was 0.660 (p<0.001). For PANSS-N, the correlation was 0.437 (p<0.005) and with the CAINS-Total was 0.478 (p<0.005). Divergent validity: The Pearson correlation coefficient between SNS and PSP was r=-0.372 (p≤0.001), and with SF-36 Physical and Mental Summary Component scores were r=-0.213 (p=0.066) and r=-0.144 (p=0.219), respectively. Discriminant validity: SNS Total scores were significantly statistically different according to the severity of the negative symptomatology rated by the CGI-SCH negative scale (p<0.001). The SNS is a reliable and valid instrument to self-rate the five domains of negative symptoms in patients with schizophrenia and seems to be appropriate for use in everyday clinical practice as a complementary measure to the evaluation performed by the clinician.

Clinical evolution of patients treated with aripiprazole long-acting injectable: a preliminary, prospective, observational study

Objective: To evaluate the effectiveness of 6-month treatment with aripiprazole long-acting injectable (LAI) in improving psychotic symptoms, social functioning and side effects and reducing co-administered antipsychotic drugs.Methods: Multicentre, observational, prospective study that enrolled 53 patients with diagnosis of schizophrenia spectrum disorders who initiated or switched to aripiprazole LAI. The effectiveness of aripiprazole LAI was assessed through the Positive and Negative Syndrome Scale (PANSS), the Udvalg for Kliniske Undersogelser scale for side effects, the Global Assessment of Functioning and the Clinical Global Impression-Schizophrenia (CGI-SCH).Results: Upon treatment with aripiprazole LAI, patients significantly improved all the domains of PANSS (p < .05). Adverse event severity significantly improved after a 6-month aripiprazole LAI treatment (p < .05). Differences from baseline to month 6 in Global Assessment of Functioning score were significant (p = .0002). The proportion of severely ill patients decreased upon treatment with aripiprazole LAI (CGI-SCH scale). Prolactin levels were normalised after a 6-month treatment (from 43.0 to 14.7 ng/mL). Co-administered antipsychotic drugs significantly decreased after a 6-month treatment with aripiprazole LAI.Conclusion: A 6-month treatment with aripiprazole LAI improved the clinical status of our patients without modifying their metabolic profile, and allowed the reduction of co-administered antipsychotic drugs.Practice implicationsLong-acting injectable antipsychotics are effective treatment options for the maintenance of patients with schizophrenia and related disorders, and to ensure treatment adherence. This study describes the evolution of patients over six months of treatment with aripiprazole long-acting injectable. The results from this study support previous data on the efficacy and safety of this atypical antipsychotic. This study may be of wide interest to the community of psychiatrists and may help clinicians optimise treatment adherence in patients with schizophrenia spectrum disorders.Key pointsAripiprazole long-acting injectable is an atypical antipsychotic intended to improve treatment adherence and prevent relapses.This multicentre prospective study evaluated the effectiveness of aripiprazole long-acting injectable over six months of treatment on the control of a comprehensive set of clinical variables.Clinical rating scales showed that treatment with aripiprazole long-acting injectable improved clinical symptoms and social functioning, and reduced the severity of adverse events.Aripiprazole long-acting injectable contributed to the maintenance of adequate metabolic profiles and the normalisation of prolactin levels.Patients significantly decreased co-administered antipsychotic drugs after 6-month treatment with aripiprazole.

&lt;p&gt;Correlation of Health-Related Quality of Life in Clinically Stable Outpatients with Schizophrenia&lt;/p&gt;

BackgroundGeneric health-related quality of life (HRQoL) scales are increasingly being used to assess the effects of new treatments in schizophrenia. The objective of this study is to better understand the usefulness of generic and condition specific HRQoL scales in schizophrenia by analyzing their correlates.MethodsData formed part of the Pattern study, an international observational study among 1379 outpatients with schizophrenia. Patients were evaluated with the Mini International Neuropsychiatric Inventory, the Clinical Global Impression-Schizophrenia (CGI-SCH) Scale and the Positive and Negative Syndrome Scale (PANSS) and reported their HRQoL using the Schizophrenia Quality of Life Scale (SQLS), the Short Form-36 (SF-36), and the EuroQol-5 Dimension (EQ-5D). The two summary values of the SF-36 (the Mental Component Score and the Physical Component Score, SF-36 MCS and SF-36 PCS) were calculated.ResultsHigher PANSS positive dimension ratings were associated with worse HRQoL for the SQLS, EQ-5D VAS, SF-36 MCS, and SF-36 PCS. Higher PANSS negative dimension ratings were associated with worse HRQoL for the EQ-5D VAS, SF-36 MCS, and SF-36 PCS, but not for the SQLS or the EQ-5D tariff. PANSS depression ratings were associated with lower HRQoL in all the scales. There was a high correlation between the HRQoL scales. However, in patients with more severe cognitive/disorganized PANSS symptoms, the SQLS score was relatively higher than the EQ-5D tariff and SF-36 PCS scores.ConclusionThis study has shown substantial agreement between three HRQoL scales, being either generic or condition specific. This supports the use of generic HRQoL measures in schizophrenia.Clinicaltrials.gov identifierNCT01634542 (July 6, 2012, retrospectively registered).

Developing clinical cut-off scores for the university of California San Diego performance-based skills assessment in patients with schizophrenia.

This study aimed to obtain University of California San Diego Performance-based Skill Assessment (UPSA) cut-off scores for the purpose of severity classification and to expand the clinical utility of the UPSA for the evaluation of cognitive function in patients with schizophrenia. In total, 191 patients with schizophrenia were recruited. The UPSA, Positive and Negative Symptom Scale (PANSS), Clinical Global Impression-Schizophrenia Scale (CGI-SCH), and Global Assessment Functioning Scale (GAF) were used for the evaluation. The cognitive symptoms item of the CGI-SCH was used as a reference and the subjects were divided into three groups: mild, moderate, and severe. The sensitivity and specificity of the UPSA were analyzed by receiver operating characteristic curves. There were significant differences in the UPSA, CGI-SCH, PANSS, and GAF scores among the groups. In the mild and moderate groups, a UPSA score of 59 was identified as the optimal cut-off score, and a score of 41 was identified as the optimal cut-off score in the moderate and severe groups. Severity can be classified using the UPSA score as follows: ≥ 60 for mild, 41-59 for moderate, and ≤ 40 for severe. The UPSA could be used to assess the degree of daily living dysfunction in patients with schizophrenia.

One-year mirror-image study of the impact of olanzapine long-acting injection on healthcare resource utilization and costs in severe schizophrenia

Olanzapine long-acting injections (OLAIs) are often prescribed to patients with severe schizophrenia who are typically excluded from randomized clinical trials. To date, no mirror-image study has examined the impact of OLAIs on healthcare resource utilizations in these patients. We conducted a retrospective, one-year mirror-image study of OLAIs on 40 patients with severe schizophrenic disorder. Illness severity was defined by failure to respond to two sequential antipsychotics. Outcomes included: (i) healthcare resource utilizations via hospitalization admissions, bed days, outpatient visits, and inpatient service costs computations (ii) clinical efficacy through changes in the Brief Psychiatric Rating Scale (BPRS) and in the Clinical Global Impression-Schizophrenia Scale (CGI-SCH), and (iii) adverse effects. After one year, OLAIs were associated with significant decreases of 65.7%, 86.2% and 86.2% in hospitalization admissions, bed days, and inpatient service costs respectively. A significant mean change of −0.47 and −0.63 was determined the BPRS and the CGI-SCH scores, respectively. There were no significant differences in the number of outpatient visits and adverse effects, except for post-injection sedation/delirium syndrome whose incidence was 0.30% per injection. This mirror-image study provides the first evidence that prescribing OLAIs reduces in a cost-effective manner average bed days and hospital admissions in patients with severe schizophrenia.

Adjunct transcranial direct current stimulation improves cognitive function in patients with schizophrenia: A double-blind 12-week study

ObjectivesCognitive impairment is a common symptom of schizophrenia that has significant effects on quality of life and the activities of daily living. The present study examined the ability of transcranial direct current stimulation (tDCS) to improve cognitive function and clinical symptoms in patients with schizophrenia. MethodsFifty-six patients with schizophrenia were randomized to real-tDCS and sham-tDCS groups. The participants were stable for a period of 3months before study enrollment. Each group received 30min of active 2-mA tDCS or sham stimulation over the left dorsolateral prefrontal cortex (anode F3, cathode F4) once per day for 10 consecutive weekdays. The Measurement and Treatment Research to Improve Cognition in Schizophrenia Consensus Cognitive Battery (MCCB) and Wisconsin Card Sorting Test (WCST) were used to evaluate cognitive function, and the Positive and Negative Syndrome Scale (PANSS), Clinical Global Impression-Schizophrenia scale (CGI-SCH), and Calgary Depression Scale for Schizophrenia (CDSS) were used to evaluate symptoms at baseline, after 10 sessions, and at 3-month follow-up. ResultsThere was a significant time×group interaction, indicating that MCCB working memory (P=0.008) and overall scores (P=0.031) improved over time in the real-tDCS group compared to the sham-tDCS group. There was also a significant time×group interaction for depressive symptoms as evaluated by the CGI-SCH, which decreased over time in the real-tDCS group (P=0.041). tDCS treatment combined with antipsychotic medication was generally well-tolerated and safe. ConclusionsAdjunct tDCS treatment is safe and effective for improving cognitive status in patients with schizophrenia.

Prescription and Underprescription of Clozapine in Dutch Ambulatory Care.

Purpose: To our knowledge, no study has examined in a structured way the extent of underprescription of clozapine in ambulatory patients with Non-Affective Psychotic Disorder (NAPD). In the Netherlands, psychiatric care for such patients is provided by Flexible Assertive Community Treatment (FACT) teams and by early intervention teams. In 20 FACT teams and 3 early intervention teams we assessed the proportion of patients who: use clozapine (type 1 patients), previously used this drug (type 2), have an unfulfilled indication for this drug, by type of indication (type 3), or were at least markedly psychotic, but had not yet received two adequate treatments with other antipsychotic drugs (type 4). We expected to find major differences between teams. To rule out that these differences are caused by differences in severity of psychopathology, we also calculated the proportions of patients who use clozapine given an indication at any time (number of type 1 patients divided by the sum of type 1, 2, and 3 patients).Materials and methods: The nurse practitioner of each team identified the patients already on clozapine. Next, using a highly-structured decision tree, the nurse practitioner and psychiatrist assessed whether the remaining patients had an indication for this drug. Indications were treatment-resistant positive symptoms, tardive dyskinesia, aggression and suicidality. The severity of positive symptoms was determined using the Clinical Global Impression-Schizophrenia Scale (CGI-SCH).Results: In the participating FACT-teams 2,286 NAPD patients were assessed. The range among teams in proportions was: type 1: 8.8–34.7% (mean: 23.0%), type 2: 0–8.2% (mean: 3.5%), type 3: 1.7–15.6% (mean: 6.9%), type 4: 1.8–16.3% (mean: 8.6%). The range in proportions of patients using this drug given an indication was 49.0–90.9% (mean: 68.8%). These figures were lower in early intervention teams.Conclusions: The proportion of patients in FACT-teams who have an unfulfilled indication for clozapine is 6.9%. There were considerable differences between teams with respect to this proportion. Almost a third of the outpatients had at any time an indication for clozapine. If one takes type 4 patients into account, this proportion may be higher.Registration number: NTR5135 http://www.trialregister.nl/trialreg/index.asp

S69. A CASE STUDY OF CLOZAPINE AND COGNITION: FRIEND OR FOE?

BackgroundCognitive dysfunction is as a hallmark feature of schizophrenia. Antipsychotic medication is effective for treating the positive symptoms of psychosis, but their potential for therapeutic effects on cognition continues to divide researchers.Improvements in clinical symptoms can occur independently of cognitive functioning, whereby typical antipsychotics improve different clinical domains, but have little or no efficacy for improving primary cognitive functions. However, it has been suggested that the second-generation antipsychotic clozapine can improve cognition in schizophrenia. Unusual cases, such as remitted patients who decide to stop taking clozapine, thus represent a unique opportunity to understand the effect of antipsychotic medication on cognition, as described in the case study below.MethodsA 38-year old man suffered severe psychotic episodes at age 19, leading to a diagnosis of treatment-resistant schizophrenia. Clozapine was initiated at age 21, with excellent treatment response and complete remission of positive, negative and depressive symptoms. For the following 16 years, he had a full-time paid job, lived independently and had an ample social circle. For the last five years, he was stable and compliant taking 175 mg of clozapine, with clozapine levels in sub-therapeutic range (between 0.17 and 0.26 mg/L). He had no metabolic syndrome and no oversedation, but complained of hypersalivation and persistent memory problems. He decided, against advice, that medication was no longer needed and requested support for waning off clozapine.A five-month program was subsequently implemented, with 25 mg reductions of clozapine every six weeks. Four enhanced assessments were scheduled after two weeks on stable doses of 125, 75, 25 and 0 mg, respectively, which included the Brief Assessment of Cognition in Schizophrenia (BACS) and the Clinical Global Impression-Schizophrenia scale (CGI-SCH).ResultsAt each level of clozapine dose, the patient continued to be stable. However, the patient showed impaired cognitive performance at the highest dose of clozapine titration (see T-scores from Table and figure), with improvements then shown at each level of dose reduction (75 and 25 mg). The final assessment was done after 6 weeks of not taking medication. At this time, he was admitted to hospital for psychotic relapse. Unfortunately, the patient refused to re-initiate clozapine and has remained floridly psychotic for 18 months.Our case suggests that cognitive impairment is dose-dependent with clozapine. As presented, the t-score of the patient at 125 mg was worse than normative data reported for healthy controls (z-score=0.50) and patients with schizophrenia treated with other first-or second generation antipsychotics (z-score=-1.42). However, cognitive performance of the patient was most notably impaired when medication-free.DiscussionThe longterm effects of high-dose antipsychotic medication on cognition in patients with schizophrenia are largely unknown. It is also possible that changes in cognitive states are either domain-specific with clozapine. Nonetheless, daily antipsychotic dose and polypharmacy have been shown to predict poor cognitive functioning.The present case is also a reminder that the appropriate long-term maintenance dose of clozapine is poorly understood. As this case suggests, the current recommended therapeutic levels of clozapine (0.35 to 0.50 mg/L) might be unnecessarily high for patients in full remission. Controlled studies are therefore needed to evaluate the potential for cognitive improvements in schizophrenia as a function of reduced clozapine dose, to ensure the optimal delivery needed not just for good clinical but also good cognitive outcome.

T106. IMPROVING PSYCHIATRIC DIAGNOSIS BY ADDING MOTOR FUNCTION NEXT TO MENTAL HEALTH FUNCTION: A NETWORK APPROACH

BackgroundCurrently, the predictive value of psychiatric diagnosis is inadequate compared to other medical fields. It has been suggested that the use of a network model might aid in acquiring new insights into the underlying connections between symptoms (Bringmann et al., 2013). In addition, previous research (Bakker et al., 2012) has revealed associations between dysregulated mental- and motor function. As such, the network graphs might be enhanced by adding non-mental factors.MethodsBaseline data from a 4-year prospective naturalistic study (Bakker et al., 2012) was used to obtain data about 207 psychiatric long-stay patients. (i) Drug-induced movement disorders: tardive dystonia (TD), akathisia, parkinsonism, and dyskinesia. (ii) ratings of the clinical global impression-schizophrenia (CGI) scale, and (iii) age and total defined daily dose to account for potential confounders. Statistical programming environment R (Epskamsp, Cramer, Waldorp & Borsboom, 2012) was used to visualise several psychopathology-severity networks.ResultsInterpretation of the graphs is based on the “centrality” of the symptoms. Centrality indicates the influence of a symptom on the network. Parkinsonism scored a low centrality score in graphs depicting high psychopathology in contrast with the other levels. Dyskinesia scored a low centrality score in medium psychopathology contrary to the other levels. The network graphs show a consistent positive correlation between age and parkinsonism (0.25, 0.53, and 0.19 for low, medium, and high psychopathology, respectively.), and a negative correlation between age and akathisia (-0.32, -0.47, and -0.21, respectively). High severities of psychopathology negatively correlated with parkinsonism (-0.16) and positively correlated with high levels of TD (0.33).DiscussionThe usage of a network model including motor factors has provided useful information to take into consideration when examining psychopathology of a patient. TD and parkinsonism draw the most attention. More research with the dataset, combined with further developing the network architecture technique is needed to accurately map motor- and mental factors.

S4. ASYMMETRIC DRUG-INDUCED PARKINSONISM IS RELATED TO PSYCHOPATHOLOGY

BackgroundDrug-Induced Parkinsonism (DIP) is the most common movement disorder induced by antipsychotics. The prevalence of DIP in chronic psychiatric populations ranges between 17 and 72% (1–3). Although, DIP is mostly symmetric, asymmetric DIP is reported in 18 to 54% of the patients. (4). There are no studies to the clinical relevance of asymmetric DIP. We investigated the prevalence of motor asymmetry in DIP and its relationship to the severity of psychopathology in a prospective study.MethodsIn a cohort study of 207 long-stay psychiatric inpatients the prevalence of DIP was assessed at least two times (mean follow-up 1.1 year) in each patient (5). DIP was assessed with the Unified Parkinson Disease Rating Scale (UPDRS) and the prevalence of persistent DIP was 56.2%. Patients with at least one time parkinsonism in the upper/lower limb(s) were included for analyses. Asymmetry of parkinsonism was calculated with the symmetry index (Figure 1). A cut-off value of ≥ 0,20 was used for the definition of asymmetric DIP. Multilevel mixed models were built to explore the relationship between asymmetry in DIP and the severity of psychopathology, measured on the Clinical Global Impression-Schizophrenia scale severity index (CGI-SCH SI).ResultsIn a cohort study of 207 long-stay psychiatric inpatients the prevalence of DIP was assessed at least two times (mean follow-up 1.1 year) in each patient (5). DIP was assessed with the Unified Parkinson Disease Rating Scale (UPDRS) and the prevalence of persistent DIP was 56.2%. Patients with at least one time parkinsonism in the upper/lower limb(s) were included for analyses. Asymmetry of parkinsonism was calculated with the symmetry index (Figure 1). A cut-off value of ≥ 0,20 was used for the definition of asymmetric DIP. Multilevel mixed models were built to explore the relationship between asymmetry in DIP and the severity of psychopathology, measured on the Clinical Global Impression-Schizophrenia scale severity index (CGI-SCH SI).DiscussionDIP is asymmetric in 1 of 5 patients. Therefore, the clinical rule that Parkinson’s disease always starts asymmetrically and such may be helpful to differentiate between Parkinson’s disease and DIP is not valid. Asymmetric presentation of DIP is of clinical relevance as it is related to the severity of psychopathology. Asymmetric DIP may alert the clinician of more severe psychopathology. Replication is indicated to examine the robustness of the relationship.

Asymmetric Drug-Induced Parkinsonism and Psychopathology: A Prospective Naturalistic Study in Long-Stay Psychiatric Patients.

Drug-induced parkinsonism (DIP) is the most common movement disorder induced by antipsychotics. Although DIP is mostly symmetric, asymmetric DIP is reported in a substantial part of the patients. We investigated the frequency of motor asymmetry in DIP and its relationship to the severity of psychopathology in long-stay psychiatric patients. We obtained data from a cohort study of 207 long-stay psychiatric patients on the frequency and risk factors of tardive dyskinesia, akathisia, tardive dystonia, and DIP. From July 2003 to May 2007 (mean follow-up, 1.1 year) drug-induced movement disorders were assessed at least two times in each patient, with a frequency of persistent DIP of 56.2%. All patients who had at least one time parkinsonism in the upper/lower limb(s) were included for analyses (190 patients, 79 women; mean age, 48.0 ± 12.9 years). The Unified Parkinson Disease Rating Scale motor scale was used to calculate the frequency of asymmetric parkinsonism. Multilevel mixed models were built to explore the relationship between asymmetry in parkinsonism and the severity of psychopathology, measured on the Clinical Global Impression-Schizophrenia scale severity index (CGI-SCH SI). The frequency of asymmetric parkinsonism was 20.8%. Asymmetry in parkinsonism was associated with symptom severity on all CGI-SCH SI scales (β range, 0.37-3.74) and significantly associated with the positive symptom scale (β, 3.74; 95% CI, 0.35-7.31). DIP is asymmetric in a substantial part of patients. Asymmetric presentation of DIP is of clinical relevance as it is related to the severity of psychopathology and may alert the clinician of more severe psychopathology. Future research is recommended to provide insight into the neuropsychopathology and clinical value of asymmetric parkinsonism for psychiatric patients.

The Korean Version of the University of California San Diego Performance-based Skills Assessment: Reliability and Validity.

ObjectiveThe study’s aim was to develop and standardize a Korean version of the University of California San Diego Performance-based Skills Assessment (K-UPSA), which is used to evaluate the daily living function of patients with schizophrenia.MethodsStudy participants were 78 patients with schizophrenia and 27 demographically matched healthy controls. We evaluated the clinical states and cognitive functions to verify K-UPSA’s reliability and validity. For clinical states, the Positive and Negative Syndrome Scale, Clinical Global Impression-Schizophrenia scale, and Social and Occupational Functioning Assessment Scale and Schizophrenia Quality of Life Scale-fourth revision were used. The Schizophrenia Cognition Rating Scale, Short-form of Korean-Wechsler Adult Intelligence Scale, and Wisconsin Card Sorting Test were used to assess cognitive function.ResultsThe K-UPSA had statistically significant reliability and validity. The K-UPSA has high internal consistency (Cronbach’s alpha, 0.837) and test-retest reliability (intra-class correlation coefficient, 0.381–0.792; p<0.001). The K-UPSA had significant discriminant validity (p<0.001). Significant correlations between the K-UPSA’s scores and most of the scales and tests listed above demonstrated K-UPSA’s concurrent validity (p<0.001).ConclusionThe K-UPSA is useful to evaluate the daily living function in Korean patients with schizophrenia.