Pathways to aggression in schizophrenia affect results of treatment

Schizophrenia elevates the risk for aggressive behavior and violent crime, and different approaches have been used to manage this problem. The results of such treatments vary. One reason for this variation is that aggressive behavior in schizophrenia is heterogeneous in origin. This heterogeneity has usually not been accounted for in treatment trials nor is it adequately appreciated in routine clinical treatment planning. Here, we review pathways that may lead to the development of aggressive behavior in patients with schizophrenia and discuss their impact on treatment. Elements in these pathways include predisposing factors such as genotype and prenatal toxic effects, development of psychotic symptoms and neurocognitive impairments, substance abuse, nonadherence to treatment, childhood maltreatment, conduct disorder, comorbid antisocial personality disorder/psychopathy, and stressful experiences in adult life. Clinicians' knowledge of the patient's historical trajectory along these pathways may inform the choice of optimal treatment of aggressive behavior. Clozapine has superior antiaggressive activity in comparison with other antipsychotics and with all other pharmacological treatments. It is usually effective when aggressive behavior is related to psychotic symptoms. However, in many patients, aggression is at least partly based on other factors such as comorbid substance use disorder, comorbid antisocial personality disorder/psychopathy, or current stress. These conditions which are sometimes underdiagnosed in clinical practice must be addressed by appropriate adjunctive psychosocial approaches or other treatments. Treatment adherence has a crucial role in the prevention of aggressive behavior in schizophrenia patients.     

The treatment of schizophrenia

Summary The object of the present communication is to present a summary of the principal attitudes in the treatment of schizophrenia. The views in general are three-fold. It appears from the works of others that the broadpsychobiological approach has rendered better service in the general management of schizophrenic problems than have other forms of treatment.Pharmacotherapeutic investigations have likewise been reported as yielding favorable results under the circumstances particular to the nature of the drug employed. A third plan comprises acombination of the first two methods. In some cases combined treatment is the method of choice, either the psychical or the pharmaceutic measures being emphasized, depending upon the special circumstances surrounding the case. Ordinarily drug therapy appears to be useful as a means by which the patient may be rendered accessible to psychotherapy. Occupational therapy occupies a somewhat similar position, in that it affords the patient an opportunity to express his needs and his interests and by the expression the way is open for more profound investigation and treatment of the psychological issues peculiar to the case at hand.On the whole one may feel that, though there are yet many unsolved problems in schizophrenia, there are also some palpable therapeutic aids that should encourage us in the handling of this form of mental disease.     

Acupuncture treatment of schizophrenia: report on three cases.

The authors conducted a 9-week blind controlled study of the effects of acupuncture on schizophrenic illness in three patients on an inpatient ward of a psychiatric hospital. This paitents were used as their own controls. The authors compared the effects of acupuncture, pseudo-acupuncture (random needling), and no treatment control periods. Two patients who had had florid schizophrenic symptoms responded positively to true acupuncture treatment and negatively to pseudo-acupuncture. The third patient, whose symptoms were primarily affective-depressive, showed no significant response to treatment. The authors explore the mechanisms thought to be involved in the etiology of schizophrenia, focusing on the cortical arousal hypothesis.     

The ESSEN study of childhood-onset schizophrenia: Selected results

Introduction: We present the results of a 42 year long-term follow-up of 44 patients (19 males, 25 females) with childhood-onset schizophrenia (COS, age at onset: 7-14 years) who could be traced for a second follow-up examination 27 years after the first follow-up. Methods: Data from interviews, clinical records, premorbid and social disability assessments were evaluated for statistical analyses. The symptomatology observed during the whole course of illness was rediagnosed by DSM-IV criteria. Results: The paranoid, catatonic, and schizoaffectives subtypes appeared most frequently. There have been no gender differences in age of first psychiatric symptoms (AFS), AFPS, and age of first hospitalization. Kaplan-Meier's survival-analysis carried out for AFPS with sex as the grouping factor revealed that the cumulative prevalence appears to be earlier in females (between 7 and 15 years) than in males (between 10 and 18 years). Of the 44 patients 50 % had a continuing severe course. Patients with onset before 12 years of age were characterized by a chronic/insidious onset, marked premorbid abnormalities, and by a poorer remission. Premorbid features of social withdrawal and reluctance indicated a risk for social disability within the later course. Conclusion: COS, as a rare but severe variant of schizophrenia, frequently develops from premorbid social maladaptation to an insidious onset but is subsequently followed by a transition to a course and outcome not distinguishable from that of adult-onset schizophrenia.     

The cost of schizophrenia treatment in Taiwan

The costs associated with mental illness in Taiwan have been the subject of discussion and concern in Taiwan's Bureau of National Health Insurance. The authors report the first estimates of these costs on the basis of national data for 52,432 patients treated in 1999. Total schizophrenia-related health care expenditure was estimated at 112.4 million dollars, which constituted 1.2 percent of national health care expenditures that year. The cost per outpatient visit was 57 dollars, the cost per admission was 1,123 dollars, and the annual average direct cost of treating a person with schizophrenia was 2,144 dollars.     

利培酮治疗难治性精神分裂症临床分析

目的：评价对利培酮对难治性精神分裂症的疗效与副作用。方法：对我住院的难治性精神分裂症３０例换用利培酮治疗２４周。用阳性与阴性症状量表（ＰＡＮＳＳ）评定疗效,用副反应量表（ＴＥＳＳ）及锥体外系副反应量表（ＥＳＲＳ）评定副作用。结果：ＰＡＮＳＳ部分、ＰＡＮＳＳ－Ｇ（一般精神病理）分、ＰＡＮＳＳ－Ｐ（阳性症状）分治疗前后有显著差异。ＰＡＮＳＳ总分及各分量表分均自治疗１２周末起有显著下降,说明自第１２周末开始显效。ＰＡＮＳＳ部分减分率≥２０％者１８例,≥５０％者５例,有效率为６０％。最常见的副作用是ＥＰＳ（６／３０）,但症状多较轻。结论：利培酮对难治精神分裂症有肯定的疗效,副反应轻微。     

The CATIE schizophrenia trial: results, impact, controversy

The CATIE (Clinical Antipsychotic Trials for Intervention Effectiveness) Schizophrenia Trial was designed to examine fundamental issues about second-generation antipsychotic (SGA) medications (olanzapine, risperidone, quetiapine, and ziprasidone) - their relative effectiveness and their effectiveness compared to a first-generation antipsychotic (FGA), perphenazine. This article reviews these and other findings from this important trial and offers a perspective regarding their meaning for practice and their significance for the advancement of research in psychiatry. The primary outcome measure, time to discontinuation, served as an index of effectiveness and was remarkably short; only 26% of subjects completed the 18-month trial on the medicine to which they were initially randomized. Subjects receiving olanzapine experienced a slightly longer time to discontinuation. Based on this single criterion, olanzapine showed greater effectiveness than the other agents despite its association with significant metabolic disturbance, especially weight gain. Perphenazine unexpectedly showed comparable levels of effectiveness and produced no more extrapyramidal side effects than the other agents. Despite modest prolactin elevation, risperidone was the best-tolerated medication. Ziprasidone was associated with weight loss and with positive impact on lipids and blood glucose. In Phase 2, clozapine demonstrated better effectiveness compared to other SGAs for subjects who discontinued their Phase 1 medication because of efficacy. Olanzapine and risperidone showed greater effectiveness in the tolerability pathway. CATIE secondary outcomes are currently being examined. Improvements in cognition were modest among all the agents in Phase 1, and perphenazine was no less effective in improving cognitive performance than the SGAs. Cost-effectiveness analysis revealed a significant advantage for perphenazine, due to the impact of the high-priced, brand-name SGAs on overall health care costs.     

The Texas medication algorithm project: clinical results for schizophrenia

In the Texas Medication Algorithm Project (TMAP), patients were given algorithm-guided treatment (ALGO) or treatment as usual (TAU). The ALGO intervention included a clinical coordinator to assist the physicians and administer a patient and family education program. The primary comparison in the schizophrenia module of TMAP was between patients seen in clinics in which ALGO was used (n = 165) and patients seen in clinics in which no algorithms were used (n = 144). A third group of patients, seen in clinics using an algorithm for bipolar or major depressive disorder but not for schizophrenia, was also studied (n = 156). The ALGO group had modestly greater improvement in symptoms (Brief Psychiatric Rating Scale) during the first quarter of treatment. The TAU group caught up by the end of 12 months. Cognitive functions were more improved in ALGO than in TAU at 3 months, and this difference was greater at 9 months (the final cognitive assessment). In secondary comparisons of ALGO with the second TAU group, the greater improvement in cognitive functioning was again noted, but the initial symptom difference was not significant.