Schizophrenia In Sweden Research Articles

Antipsychotic use among persons with schizophrenia in Sweden and Finland, trends and differences

Objectives To compare the differences in prevalence of antipsychotic and adjunctive pharmacotherapy use among individuals with schizophrenia between Sweden and Finland during 2006–2016. Methods Nationwide register-based data were utilized for constructing two separate cohorts: all persons in Finland with a diagnosis of schizophrenia treated in inpatient care during 1972–2014, and persons in Sweden aged 16–64 with recorded diagnoses of schizophrenia in inpatient or specialized outpatient care, sickness absence or disability pension during 2005–2013. The prevalence of use was assessed as a point prevalence on 31 October each year 2006–2016, based on drug use periods modelled with the PRE2DUP method. In 2016, the Finnish cohort included 37,780 persons and Swedish cohort 25,433 persons. Results The most commonly used antipsychotic in 2016 was oral olanzapine in both countries (22.7% [95% CI 21.6–22.4] in Finland, 20.9% [20.4–21.4] in Sweden), followed by clozapine which was more frequently used in Finland (22.0%, 21.6–22.4) than in Sweden (14.8%, 14.4–15.3). Long-acting injectable (LAI) use was almost two times more likely in Sweden (21.6%, 95% CI 21.1–22.1) than in Finland (12.8%, 12.5–13.1), a difference which was due to more common use of FG-LAIs in Sweden. A four-fold difference was observed in Z-drugs use (19.9% in Sweden versus 5.0% in Finland). Conclusion Potential explanations for the observed discrepancies include differences in national treatment guidelines, methods of data collection, patient characteristics and/or attitudes towards treatment among both patients and physicians.

P2547Statin and glucose-lowering treatment in individuals with and without schizophrenia

Abstract Background We have recently shown that Cardiovascular (CV) mortality is surprisingly high in patients with schizophrenia in Sweden. Diabetes is 2–3 times more common in patients with schizophrenia. Treatment with Metformin have consistently shown effective to lower CV mortality in patients with diabetes. In addition, recent studies have shown that treatment with Metformin reduces weight and improves lipids even in patients with schizophrenia without diabetes. One reason for the high CV mortality in Swedish patients with schizophrenia may be lack of risk factor treatment, such as glucose-lowering treatment and/or lipid lowering treatment with statins. Objective To determine the prevalence of treatment with glucose-lowering treatment and statins in patients with and without schizophrenia in Stockholm, Sweden. Material and methods Cross-sectional study based on individual-level patient data from the Stockholm regional health-care data warehouse. 6 347 patients with a diagnosis of schizophrenia (International Classification of Diseases, Tenth Revision code F 20.X) were compared with 2 062 112 without schizophrenia from Stockholm County. The prescription of Metformin and insulin were compared in 5-year age groups from 30 to 85 years of age. In addition, the prescription of statins (any statin) were also compared in the same population. Results The prescription of metformin in age groups under 60 years were approximately 2 to 8 times more common in patients with schizophrenia, in patients over 60 the corresponding figures were 0.7 to 3 times. The prescription of statin in age groups under 60 were approximately 0.8–3 times more common in patients with schizophrenia. In contrast, in patients over 60 years statins were less often prescribed in patients with schizophrenia compared to controls. Figure 1 Conclusions Our results indicate that lack of treatment with metformin may not be a reason for the increase cardiovascular mortality in patients with schizophrenia. However, the surprisingly low prescription of statins in older (>60 years) patients with schizophrenia might explain the high CV mortality in this patient group.

F116. CAN INSIGHT LEAD TO REMISSION - FOR PATIENTS WITH SCHIZOPHRENIA?

BackgroundIt is important to have extensive knowledge of the patients with schizophrenia, to provide the right support in outpatient care to create a good situation for the patient and prevent hospitalization. Lack of insight regarding the illness and symptoms might impair the patient’s ability to understand the illness, the treatment and relapses into psychotic episodes. Symptomatic remission is a well-established goal for treatment. If the core-symptoms do not affect their functions and the status is stable for at least six months, the patient is in remission. Previous research has shown an increased remission status from approximately 30% to more than 50% after using standardized remission criteria for patients with schizophrenia in Sweden. This study aims to investigate the relationship between both insight of symptoms and illness insight with cross-sectional remission.MethodsThis is a cross-sectional study and the participants consisted of totally 289 patients with schizophrenia diagnosis. Of the participants 111 were women and 178 were men, with a mean age of 47 years (19–83 years old). Using semi-structured interviews and evidence-based assessment scales Remission Scale - Symptom (RS-S) and Psychosis Evaluation Tool for Common use by Caregivers (PECC) the data is collected. Cross tabulations were used to compare the distribution of the variables and the Pearson Chi-Square Tests for examine significant association.ResultsInsight of symptom: The results show that from the patients who are not in remission, 69.5% are missing insight to symptoms, while 30.5% are having insight of symptoms. When it comes to the patients within remission, 59.0% have an insight of symptoms, while 41.0% are missing this sort of insight. The findings in the analysis with Chi-Square Tests examine independence indicated significant association between insight of symptoms and remission status (1, x2 = 22.17), p = <0,001, phi = -0.28.Insight of illness: During the analysis of insight of illness, the results show that from the patients who are in remission, 61.9% possess insight of illness, compared to 38.1% of the patients lacking insight of illness. Concerning the insight of illness for the patients who are not in remission, 68.2% lack insight of illness, while 31.8% possess insight of illness. The Chi-Square Tests examine independence indicated significant association between insight of illness and remission status (1, x2 = 24.28), p = <0.001, phi = -0.29.DiscussionThe results show that there is a relationship between insight of symptoms and illness with the cross-sectional symptomatic remission. However, the question is still open if remission is a consequence of insight or if the insight changes over time according to the activity of the illness. By following patients over time and monitoring the activity of symptoms including the state of remission and insight, it will probably be visualized if changes occur related to each other or independently. Also, whether the main focus for success is pharmaceutical treatment aiming for maximal symptom reduction or psychoeducational treatment to develop patients’ ability to understand their illness. Finally, whether insight after being established is a state or a treatment phenomenon? Further research to explore this issue is needed.

Antipsychotics and mortality in a nationwide cohort of 29,823 patients with schizophrenia

IntroductionIt has remained controversial if antipsychotic treatment is associated with increased or decreased mortality among patients with schizophrenia, and if there are any clinically meaningful differences between specific agents and routes of administration. MethodsWe linked prospectively gathered nationwide register-based data during 2006–2013 to study all-cause mortality among all patients aged 16–64years with schizophrenia in Sweden (N=29,823 in total; N=4603 in the incident cohort). Multivariate Cox regression models were adjusted for clinical and sociodemographic covariates. Sensitivity analyses with the incident cohort were conducted to control for survival bias. ResultsDuring the mean follow-up of 5.7years, 2515 patients (8.4%) died. During the maximum follow-up (7.5years), the lowest cumulative mortality was observed for second generation (SG) long-acting injection (LAI) use (7.5%). Adjusted hazard ratios (aHRs) compared to SG LAI use were 1.37 (95%CI 1.01–1.86) for first generation (FG) LAIs, 1.52 (1.13–2.05) for SG orals, 1.83 (1.33–2.50) for FG orals, and 3.39 (2.53–4.56) for nonuse of antipsychotics. Concerning specific agents, the lowest mortality was observed for once-monthly paliperidone LAI (0.11, 0.03–0.43), oral aripiprazole (0.22, 0.15–0.34), and risperidone LAI (0.31, 0.23–0.43). In pairwise comparison, LAIs were associated with 33% lower mortality than equivalent orals (0.67, 0.56–0.80). The results with incident cohort were consistent with the primary analyses. ConclusionsAmong patients with schizophrenia, LAI use is associated with an approximately 30% lower risk of death compared with oral agents. SG LAIs and oral aripiprazole are associated with the lowest mortality.

Clozapine, long‐acting injectables show greatest effectiveness in relapse prevention

A nationwide cohort study of patients with schizophrenia in Sweden has found significant variability among antipsychotic medications in their effectiveness in preventing rehospitalization. Results in relapse prevention were particularly strong for clozapine and for long‐acting injectable antipsychotics. Study results were published online June 7 in JAMA Psychiatry

No exposure to antipsychotics yields greatest mortality risk in schizophrenia

A study of individuals diagnosed with schizophrenia in Sweden has found the highest overall mortality among patients who received no exposure to antipsychotic treatment. The results, which also showed higher mortality among individuals with high exposure to antipsychotics than among those who had low or moderate exposure, indicate that antipsychotic treatment in adequate doses does not lead to excess mortality risk. Study results were published online Nov. 24, 2014, in Schizophrenia Bulletin.

Copy number variation in schizophrenia in Sweden.

Schizophrenia (SCZ) is a highly heritable neuropsychiatric disorder of complex genetic etiology. Previous genome-wide surveys have revealed a greater burden of large, rare copy number variations (CNVs) in SCZ cases and identified multiple rare recurrent CNVs that increase risk of SCZ although with incomplete penetrance and pleiotropic effects. Identification of additional recurrent CNVs and biological pathways enriched for SCZ CNVs requires greater sample sizes. We conducted a genome-wide survey for CNVs associated with SCZ using a Swedish national sample (4719 cases and 5917 controls). High-confidence CNV calls were generated using genotyping array intensity data, and their effect on risk of SCZ was measured. Our data confirm increased burden of large, rare CNVs in SCZ cases as well as significant associations for recurrent 16p11.2 duplications, 22q11.2 deletions and 3q29 deletions. We report a novel association for 17q12 duplications (odds ratio=4.16, P=0.018), previously associated with autism and mental retardation but not SCZ. Intriguingly, gene set association analyses implicate biological pathways previously associated with SCZ through common variation and exome sequencing (calcium channel signaling and binding partners of the fragile X mental retardation protein). We found significantly increased burden of the largest CNVs (>500 kb) in genes present in the postsynaptic density, in genomic regions implicated via SCZ genome-wide association studies and in gene products localized to mitochondria and cytoplasm. Our findings suggest that multiple lines of genomic inquiry--genome-wide screens for CNVs, common variation and exonic variation--are converging on similar sets of pathways and/or genes.

Copy number variation in schizophrenia in Sweden

Copy number variation in schizophrenia in Sweden

Pharmacoeconomics of depot antipsychotics for treating chronic schizophrenia in Sweden

Aims: To determine the cost-effectiveness of long-acting injectable (LAI) antipsychotics for chronic schizophrenia in Sweden. Methods: A 1-year decision tree was developed for Sweden using published data and expert opinion. Five treatment strategies lasting 1 year were compared: paliperidone palmitate (PP-LAI), olanzapine pamoate (OLZ-LAI), risperidone (RIS-LAI), haloperidol decanoate (HAL-LAI) and olanzapine tablets (oral-OLZ). Patients intolerant/failing drugs switched to another depot; subsequent failures received clozapine. Resources and employment time lost (indirect costs) were costed in 2011 Swedish kroner (SEK), from standard government lists. The model calculated the average cost/patient and quality-adjusted life-years (QALYs), which were combined into incremental cost-effectiveness ratios. Multivariate and 1-way sensitivity analyses tested model stability. Results: PP-LAI followed by OLZ-LAI had the lowest cost/patient (189,696 SEK) and highest QALYs (0.817), dominating in the base case. OLZ-LAI followed by PP-LAI cost 229,775 SEK (0.812 QALY), RIS-LAI followed by HAL-LAI cost 221,062 SEK (0.804 QALY), HAL-LAI followed by oral-OLZ cost 243,411 SEK (0.776 QALY), and oral-OLZ followed by HAL-LAI cost 249,422 SEK (0.773 QALY). The greatest proportions of costs (52.5–83.8%) were for institutional care; indirect costs were minor (2.4–3.8%). Results were sensitive to adherence and hospitalization rates, but not drug cost. PP-LAI followed by OLZ-LAI dominated OLZ-LAI followed by PP-LAI in 59.4% of simulations, RIS-LAI followed by HAL-LAI in 65.8%, HAL-LAI followed by oral-OLZ in 94.0% and oral-OLZ followed by HAL-LAI in 95.9%; PP-LAI followed by OLZ-LAI was dominated in 1.1% of the 40,000 iterations. Conclusion: PP-LAI followed by OLZ-LAI was cost-effective in Sweden for chronic schizophrenia and cost-saving overall to the healthcare system.

Validation of an economic model of paliperidone palmitate for chronic schizophrenia

Objective:Model validation is important, but seldom applied in chronic schizophrenia. Validation consists of verifying the model itself for face validity (i.e., structure and inputs), cross-validation with other models assessing the same issue, and comparison with real-life outcomes. The primary purpose was to cross-validate a recent pharmacoeconomic model comparing long-acting injectable (LAI) antipsychotics for treating chronic schizophrenia in Sweden. The secondary purpose was to provide external validation.Methods:The model of interest was a decision tree analysis with a 1-year time horizon with costs in 2011 Swedish kroner. Drugs analyzed included paliperidone palmitate (PP-LAI), olanzapine pamoate (OLZ-LAI), risperidone (RIS-LAI), haloperidol (HAL-LAI), and oral olanzapine (oral-OLZ). Embase and Medline were searched from 1990–2012 for models examining LAIs. Articles were retrieved, with data extracted for all drugs compared including: expected costs, rates of hospitalization, proportion of time not in relapse, and associated QALYs. Outcomes from the model of interest were compared with those from other articles; costs were projected to 2012 using the consumer price index.Results:Twenty-six studies were used for validation; 14 of them provided evidence for cross-validation, 13 for external validation, and four for cost. In cross-validation, cost estimates varied −1.8% (range: −12.4–20.1%), hospitalizations 5.2% (−12.1–3.1%), stable disease 2.5% (−5.6–1.5%), QALYs 9.0% (4.3% after removing outliers). All estimates of clinical outcomes were within 15%. In external validation, hospitalization rates varied by 6.3% (−0.7–11.3%). The research was limited by data availability and validity of the original results.Conclusion:Other models validated the outputs of our model very well.

Cost effectiveness of paliperidone palmitate versus risperidone long-acting injectable and olanzapine pamoate for the treatment of patients with schizophrenia in Sweden

Objective:To model the cost effectiveness of paliperidone palmitate (paliperidone long-acting injectable; PLAI), a new once-monthly long-acting antipsychotic therapy, compared with risperidone long-acting injectable (RLAI) and olanzapine pamoate (OLAI), in multi-episode patients (two or more relapses) with schizophrenia in Sweden.Methods:A Markov decision analytic model was developed to simulate the history of a cohort of multi-episode patients transitioning through different health states on a monthly basis over a 5-year time horizon from the perspective of the Swedish healthcare system. Therapeutic strategies consisted of starting treatment with RLAI (mean dose 37.5 mg every 2 weeks), PLAI (mean dose 75 mg equivalent (eq.) every month) or OLAI (150 mg every 2 weeks or 300 mg every 4 weeks). Probability of relapse, level of adherence, side-effects (extrapyramidal symptoms, tardive dyskinesia, weight gain and diabetes) and treatment discontinuation (switch) were derived from long-term observational data when feasible. Incremental cost-effectiveness outcomes, discounted at 3% annually, included cost per quality-adjusted life-year (QALY) and cost per relapse avoided (expressed in 2009 Swedish Krona SEK).Results:Relative to RLAI and OLAI, PLAI is economically dominant: more effective (additional QALYs, less relapses) and less costly treatment option over a 5-year time horizon. The results were robust when tested in sensitivity analysis.Limitations:The impact of once-monthly treatment on adherence levels is not yet known, and not all variables that could impact on real-world outcomes and costs were included in this model.Conclusion:PLAI was cost saving from a Swedish payer perspective compared with RLAI and OLAI in the long-term treatment of multi-episode (two or more relapses) schizophrenia patients.

A pharmacoeconomic analysis of sertindole in the treatment of schizophrenia in Sweden

Background: Atypical antipsychotics have similar clinical efficacy in the treatment of schizophrenia; variability in their tolerability represents the discerning factor in treatment choices. Sertindole has a relatively good tolerability profile that favours long-term patient adherence and, therefore, is associated with lower rates of relapse and rehospitalization. Aim: A model was developed to compare the cost-effectiveness of a 5-year treatment strategy starting with sertindole versus olanzapine, risperidone, aripiprazole or the typical antipsychotic agent, haloperidol. Methods: The model was based on published trials and local clinical practice, and considered costs from the perspective of the Swedish National Health Insurance Board. Results: All atypical agents were clinically superior and more cost-effective than haloperidol with a cost per quality-adjusted life year gained of approximately 490,000 Swedish kroner. Sertindole was associated with the lowest direct and indirect medical costs, driven by its tolerability profile. Conclusions: Sertindole represents a useful alternative to the current treatment options available in Sweden. Clinical implications: The relatively good tolerability profile of sertindole translates into lower costs of schizophrenia management, primarily driven by substantially lower direct and indirect costs. Sertindole appears to be a clinically and cost-effective alternative in the management of patients with schizophrenia in Sweden.

Alcohol Use Disorders in Schizophrenia

Comorbid alcohol use disorders (AUDs) in schizophrenia are associated with increased morbidity, more inpatient treatment, and violent offending. It is of clinical importance to identify those with schizophrenia who may go on to develop an alcohol use disorder; however, the risk factors are not well understood. The aim of this study was to identify risk factors for the development of an AUD in patients after they had been diagnosed with schizophrenia. We conducted a retrospective case-control study of 12,653 individuals diagnosed with ICD-defined schizophrenia in Sweden in 1973-2004, using data from national registers. We tested the associations between individual factors (marital status, immigrant status, and previous violent offending), sociodemographic factors (income and education), and parental risk factors (AUDs, psychosis, and violent offending) ICD-defined and AUD development using logistic regression modeling. Over a median follow-up of 17.3 years, 7.6% of patients had at least 1 hospital diagnosis of AUD. After adjustment for gender and age at diagnosis in a multivariate regression model, previous violent offending (OR = 2.1; 95% CI, 1.8-2.5), low education (OR = 1.3; 95% CI, 1.1-1.5), maternal AUD (OR = 1.9; 95% CI, 1.4-2.7), and paternal AUD (OR = 1.9; 95% CI, 1.5-2.3) remained independently associated with increased risk of patient AUD. AUDs are a common sequela of schizophrenia. Risk factors that could be identified at the time of first presentation include low educational attainment, previous violent offending, and parental history of AUDs and may inform clinical treatment and follow-up of those most at risk.

Cost Effectiveness of Long-Acting Risperidone in Sweden

In Sweden, risperidone long-acting injectable (RLAI) is generally used in a population of schizophrenia patients who are at a high risk of being non-compliant. However, RLAI might also be suitable for use in the general schizophrenia population. To analyse the clinical and economic effects of RLAI in the Swedish treatment practice using a discrete-event simulation (DES) model. Treatment outcomes and direct costs were analysed for both the high-risk non-compliant patient population and the general schizophrenia population. An existing DES model was adapted to simulate the treatment of schizophrenia in Sweden. Model inputs were based on literature research and supplemented with expert opinion. In the high-risk non-compliant schizophrenia population, RLAI was compared with haloperidol LAI. The analysis was built upon differences in symptom reduction, time between relapses, compliance and adverse effect profile between the two drugs. Main outcomes were the predicted incremental (discounted) costs (€) and effects (QALYs). In the general schizophrenia population, RLAI was compared with oral olanzapine. This analysis was built upon differences in compliance and adverse effects between the drugs. Multivariate probabilistic sensitivity analyses (PSA) were carried out to assess the sensitivity of the results of the two analyses. In the high-risk non-compliant patient population, RLAI was predicted to generate 0.103 QALYs per patient over 3 years while realizing cost savings of €5013 (year 2007 values) compared with haloperidol LAI. The main driver of the cost effectiveness of RLAI was the difference in Positive and Negative Syndrome Scale (PANSS) reduction between the two drugs, followed by the difference in adverse effects. The PSA showed that, in this setting, RLAI had a probability of 100% of being cost effective at a willingness-to-pay (WTP) threshold of €43,300 per QALY gained, compared with haloperidol LAI. The probability that RLAI combines additional effectiveness with cost savings compared with haloperidol LAI was estimated at 94%. When analysing RLAI in the general schizophrenia population, it was predicted to generate 0.043 QALYs and save €239 per patient over 5 years compared with olanzapine. Compliance was the main driver of the cost effectiveness of RLAI in this scenario. In the PSA it was shown that RLAI had a probability of 78% of being cost effective at a WTP threshold of €43,300 per QALY gained, compared with olanzapine. The estimated probability that RLAI combines additional effectiveness with cost savings was 50% and the probability that RLAI is less effective and more costly than olanzapine was negligible (0.2%). Treatment with RLAI is suggested to result in improved QALYs combined with cost savings compared with haloperidol LAI among the Swedish, high-risk non-compliant schizophrenia patient population. In the general schizophrenia population, RLAI also resulted in positive incremental QALYs and cost savings, when compared with olanzapine. However, the estimates used in the model for compliance and symptom reduction need further validation through naturalistic-based studies with reasonable follow-up to more definitely establish the real-life differences between RLAI and the comparators in the considered patient populations and to further reduce the uncertainty of these parameters.

Increasing cardiovascular mortality trends in schizophrenia in Sweden

Background:Several studies from different countries demonstrate that cardiovascular mortality is the main cause of death for schizophrenia patients as well as for the population although patients with schizophrenia have a doubled cardiovascular mortality risk. The general population of Sweden has during recent years experienced remarkable declines in mortality from cardiovascular disease resulting in increased overall life expectancy. It is unclear whether patients with schizophrenia have experienced these benefits.Methods:Standardized mortality ratios (SMR) for schizophrenia patients in Sweden during 1970 through 2003 were analyzed, using data from national registers on diagnosis and causes of death. Secular trends for SMR were calculated in Poisson regression models.Results:SMR was for schizophrenia patients for all causes of death 2.33 for men and 2.35 for women, cardiovascular death 2.08 for men and 2.15 for women, coronary heart disease 1.91 for men and 2.06 for women, and for myocardial infarction 1.75 for men and 1.86 for women. Age-standardized mortality ratios for schizophrenia patients increased significantly (p<0.001) for both men and women for all causes of death, cardiovascular disease, coronary heart disease and acute myocardial infarction. Among schizophrenia patients, there were 3,410 excess deaths from cardiovascular causes.Conclusion:The substantial improvements in recent years in mortality from cardiovascular disorders in the general population were not observed among patients with schizophrenia. For the medical care system and for psychiatry the increasing differences in mortality from cardiovascular disease between the general population and patients with schizophrenia are a major clinical and public health concern.

The Risk for Schizophrenia From Childhood and Adult Infections

The Risk for Schizophrenia From Childhood and Adult Infections

Mortality among persons with schizophrenia in Sweden: An epidemiological study

The objective of the study was to analyse 10-year mortality among persons with schizophrenia from an epidemiological perspective. This cohort study included all persons with schizophrenia (n=255) living in the northern catchment area in Uppsala in 1991, and 1275 subjects from the national population register matched for sex, age and living area. The prevalence of schizophrenia was 0.37% and the mortality rate for individuals with schizophrenia was higher than for referents: 23.0% vs. 11.2%. The higher mortality among those with schizophrenia was mainly the result of unnatural causes and cardiovascular disease, especially in men. Excess mortality from cardiovascular disease was more pronounced in middle age, irrespective of gender. Multivariate analysis revealed higher mortality among individuals with schizophrenia living in the city than among those living in less urbanized areas. People with schizophrenia die more often than those without schizophrenia from unnatural causes or circulatory diseases. Individuals with schizophrenia die sooner from circulatory diseases than those without schizophrenia. Having schizophrenia and living in the city also results in higher mortality than having schizophrenia and living in other areas. The risk of early death from circulatory disease needs to be studied in more detail to reveal the potential respective contributions of intrinsic patient vulnerability, lifestyle factors and side-effects from psychotropic drugs.

Evaluation of diagnostic procedures in Swedish patients with schizophrenia and related psychoses

We aimed to estimate the value of structured interviews, medical records and Swedish register diagnoses for assessing lifetime diagnosis of patients with schizophrenia. Psychiatric records and diagnostic interviews of 143 Swedish patients diagnosed by their treating physician with schizophrenia and related disorders were scrutinized. Based on record analysis only, or a combined record and interview analysis, DSM-IV diagnoses were obtained by the OPCRIT algorithm. Independent of the OPCRIT algorithm, a standard research DSM-IV diagnosis, based on both record and interview analysis, was given by the research psychiatrist. Concordance rates for the different psychosis diagnoses were calculated. DSM-IV diagnoses based on records only, showed a good to excellent agreement with diagnoses based on records and interviews. Swedish register diagnoses displayed generally poor agreement with the research diagnoses. Nevertheless, 94% of subjects sometimes registered with a diagnosis of schizophrenic psychoses (i.e. schizophrenia, schizoaffective psychosis or schizophreniform disorder) displayed a standard research DSM-IV diagnosis of these disorders. For patients in long-term treatment for schizophrenia in Sweden, psychiatric record reviews should be optimal, cost effective and sufficient for assessment of lifetime research diagnoses of schizophrenia. For these patients a research interview adds little new information. The results further indicate that a Swedish register diagnosis of schizophrenic psychoses has a high positive predictive power to a standard research DSM-IV diagnosis of the disorders. It is concluded that for future Swedish large-scale genetic studies focusing on a broad definition of schizophrenia, it would be sufficient to rely on the Swedish register diagnoses of schizophrenic psychosis.

Men with Schizophrenia Who Behave Violently: The Usefulness of an Early- Versus Late-Start Offender Typology

Persons who develop schizophrenia are more likely than nondisordered persons to commit crimes. It is important to investigate those who offend, in order to develop treatment programs that effectively prevent recidivism, and eventually, early childhood violence prevention programs. Recent studies have shown that among offenders with major mental disorders, there are two groups: early starters, who begin their criminal careers in adolescence; and late starters, who first offend as adults. The present study examined 272 violent male offenders with schizophrenia in Sweden who underwent a pretrial psychiatric assessment between 1988 and 1995. Early- and late-start offenders were found to present differences in behavior, comorbid disorders, personality traits, and referrals for treatment in childhood, adolescence, and adulthood. Their parents also differed. The findings have implications for treatment and management of offenders with schizophrenia, for risk assessment, and for prevention.

Metric Determination of Schizophrenic Dementia

In the diagnosis of schizophrenia the psychologist may refer to Rorschach who believed his test permitted often, perhaps in the future always, a differential diagnosis between neurosis and latent or manifest schizophrenia. Piorrowski (3) provided a statistical index for diagnosing by means of the Rorschach intelligent, over-controlled, and cautious schizophrenic patients. Agreement between clinical diagnosis and his test index was 91 % in an initial study but dropped for other groups (2) to 83%. I have found significantly lower agreement, perhaps due to the more narrow definition of schizophrenia in Sweden which restricts this grave diagnosis to patients with primary symptoms such as hallucinatory Gedankenlautwerden. As a first approximation to a meaningful parameter for the Rorschach differential diagnosis, the factor loadings of Davies' 1954 study on Cattell and Scheier's Anxiety Factor F(Q) I1 (cf. 1, Table 4-6) were rounded and the following weighted Y formula obtained,