Olanzapine and haloperidol in first episode psychosis: two-year data.

Few studies have assessed the comparative efficacy and safety of atypical and typical antipsychotic medications in patients within their first episode of psychosis. This study examined the effectiveness of the atypical antipsychotic olanzapine and the typical antipsychotic haloperidol in patients experiencing their first episode of a schizophrenia-related psychotic disorder over a 2-year treatment period. Two hundred and sixty-three patients were randomized to olanzapine or haloperidol in a doubleblind, multisite, international 2-year study. Clinical symptoms and side effects were assessed at baseline and longitudinally following randomization for the duration of the study. Olanzapine and haloperidol treatment were both associated with substantial and comparable reductions in symptom severity (the primary outcome measure) over the course of the study. However, the treatment groups differed on two secondary efficacy measures. Patients were less likely to discontinue treatment with olanzapine than with haloperidol: mean time (in days) in the study was significantly greater for those treated with olanzapine compared to haloperidol (322.09 vs. 230.38, p<0.0085). Moreover, remission rates were greater in patients treated with olanzapine as compared to those treated with haloperidol (57.25% vs. 43.94%, p<0.036). While extrapyramidal side effects were greater in those treated with haloperidol, weight gain, cholesterol level and liver function values were greater in patients treated with olanzapine. The data from this study suggest some clinical benefits for olanzapine as compared to haloperidol in first episode patients, which must be weighed against those adverse effects that are more likely with olanzapine.

The therapeutic community as a research ward: myths and facts.

The clinical research ward run as a therapeutic community has been criticized as inefficient and scientifically unsound. This article discusses the therapeutic community as a research ward and identifies certain misconceptions which underlie many criticisms. The following myths are discussed and refuted: (1) There is an insurmountable community-research chasm. (2) The therapeutic community induces stress that interferes with research. (3) Patient passivity is engendered by research and this is destructive to the therapeutic community. (4) Symptoms are exacerbated by a research ward that is disruptive to the community. (5) Normal research subjects cannot live in a therapeutic community without pathologic psychic changes. These inaccurate myths are seen as a reflection of attempts to oversimplify very complex clinical and research issues. The use of mythology to simplify experiments, to artificially "clarify" complex issues, or to "protect" patients is seen as a disservice. The therapeutic community and research are syntonic when both receive appropriate support.

Short vs long hospitalization. A controlled study: III. Inpatient results for nonschizophrenics.

A controlled, prospective, two-year follow-up study examined the relative effectiveness of short-term vs long-term psychiatric hospitalization. Results of the inpatient phase for a sample of 74 nonschizophrenic patients are reported here. About four weeks after admission the patients hospitalized for a short stay were discharged, and at that time were functioning better than the patients in the long-stay group. When the patients hospitalized for a long stay were discharged, three to fur months after admission, they were then functioning as well as, but not noticeably better than, the patients in the short-stay group had been at their earlier time of discharge. Patients with affective disorders were more impaired at admission and improved more than patients with other diagnoses, regardless of length of stay.

Short vs long hospitalization: a prospective controlled study. VII. Two-year follow-up results for nonschizophrenics.

A controlled, prospective study examined the relative effectiveness of short-term versus long-term psychiatric hospitalization. Results of a two-year follow-up of a sample of 74 nonschizophrenic subjects are reported here. Two years after admission there were no statistically reliable differences in functioning between short-term and long-term subjects with diagnoses of either affective disorders, or neurosis and personality disorders (including hysterical personality disorder). The findings reported do not support extended hospitalization for patients with these diagnoses. Caution regarding these findings is suggested by an anecdotal impression that short-term hospitalization may not have allowed for proper diagnosis and treatment for some persons in the affective disorder group.

Short vs long hospitalization: a prospective controlled study. VI Two-year follow-up results for schizophrenics.

A controlled, prospective study examined the relative effectiveness of short-term versus long-term psychiatric hospitalization. The results of a two-year follow-up of a sample of 141 schizophrenic patients are reported here. The differences favoring long-term subjects that were apparent at one year postadmission had decreased by two years postadmission. However, there appears to be an interaction between prehospital functioning and length of hospital stay, with subjects who had good prehospital functioning doing better at two years when assigned to long-term hospitalization. Subjects with poor prehospital functioning did about equally well, regardless of length of stay, and may even have showed some tendency to do better with a shorter hospital stay. This reversal of effect was more prominent for women, although this sex difference was not statistically significant.

Inpatient family intervention: a randomized clinical trial. II. Results at hospital discharge.

Although family intervention is practiced in most psychiatric hospitals, to our knowledge, no adequately controlled studies of its efficacy exist. This study was designed to answer, in part, the question of the relative efficacy of hospitalization with family intervention as compared with hospitalization without family intervention for patients (1) with major psychiatric disorders, (2) in need of hospital treatment, and (3) for whom both treatments are judged clinically feasible. This article compares treatment results at the time of hospital discharge for 169 patients randomly assigned to the inpatient Family Intervention or comparison conditions. Inpatient Family Intervention had greater efficacy than the comparison treatment, mostly attributable to its effect on female patients, especially those patients (and their families) with affective disorder.

A controlled evaluation of inpatient family intervention. I. Preliminary results of the six-month follow-up.

Although family intervention is practiced in most psychiatric hospitals, there are no adequately controlled studies of its efficacy. This study was designed to answer, in part, the following question: What is the relative efficacy of hospitalization with family intervention as compared with hospitalization without family intervention for patients with major psychiatric disorders who are in need of hospital treatment and for whom both treatments are judged clinically feasible? This is our first report, presenting preliminary data on six-month follow-up for the first three quarters of the total sample of 144 patients (80 with schizophrenic disorder and 64 with major affective disorder).

Relapse and rehospitalization during maintenance treatment of schizophrenia. The effects of dose reduction and family treatment.

BACKGROUND: Previous studies have examined dose reduction and family treatment in schizophrenia, but none has examined their interaction. This study assessed the impact of dose reduction of antipsychotic medication and family treatment on relapse and rehospitalization during maintenance treatment. METHODS: Subjects were 313 male and female outpatients at 5 centers with a DSM-III-R diagnosis of schizophrenia or schizoaffective disorder. In a 3 x 2 design, subjects were randomized to 1 of 3 medication strategies using fluphenazine decanoate under double-blind conditions: continuous moderate dose (standard) (12.5-50 mg every 2 weeks); continuous low dose (2.5-10 mg every 2 weeks); or targeted, early intervention (fluphenazine only when symptomatic). Subjects also were randomized to 1 of 2 family treatment strategies (supportive or applied). Supportive family management involved monthly group meetings. The more intensive applied family management involved monthly group meetings and home visits where communication and problem-solving skills were taught. Patients and families were treated and assessed for 2 years. RESULTS: Both continuous low-dose and targeted treatment increased use of rescue medication and relapse; only targeted treatment increased rehospitalization. This pattern was consistent across both family treatments; there were no differences between family treatments. CONCLUSIONS: These findings reaffirm the value of antipsychotic medication in preventing relapse and rehospitalization. The absence of family treatment differences may be because both conditions engaged families.

Use of joint consultations in inpatient psychiatry.

The coexistence of medical and psychiatric problems in psychiatric inpatients often causes compliance difficulties, based on either irrational and distorted fears of medical treatment or more rational concerns that proposed psychiatric treatment could adversely affect a preexisting medical condition. The authors propose the use of joint consultations, in which both the psychiatrist and the other medical specialist meet together with the patient, as a way of ameliorating such distortions and conflicts and thereby improving compliance with both medical and psychiatric treatment.

Short versus long hospitalization: a prospective controlled study. II. Results for schizophrenic inpatients.

The authors compared treatment results for 141 schizophrenic patients randomly assigned to short-term or long-term hospitalization. The patients received intensive treatment and were on partially fixed drug dosage schedules. Test results indicated that the short-term group was functioning better at four weeks. However, at discharge (21 to 28 days for short-term patients; 90 to 120 days for long-term) the long-term group showed significantly better functioning. There were no significant differences between the groups on symptomatology at discharge. The authors discuss the implications of these findings for decisions regarding length and type of hospitalization for schizophrenic patients.

Outcome of irregularly discharged psychiatric patients.

Clinicians' attitudes about the posthospitalization outcome of patients who are irregularly discharged from the hospital (i.e., against medical advice or AWOL) have been pessimistic, but unsystematic follow-up data of such patients compared with regularly discharged patients suggest that outcomes for the two groups are similar. Because of this discrepancy, the authors used data from a controlled, systematic study of a large sample of voluntary inpatients that measured global outcome over 2 years. Their findings suggest that 1 year and 2 years after admission, most patients who were irregularly discharged had outcomes similar to those of patients with regular discharges. There was, however, a subgroup of irregularly discharged patients who had worse outcomes.

Short versus long hospitalization: a propspective controlled study. IV. One-year follow-up results for schizophrenie patients.

The authors compared treatment results for 141 schizophrenic patients randomly assigned to short-term or long-term hospitalization. Test results indicated that the long-term group was functioning significantly better one year after admission according to global measures only. The authors caution that the differences between the two groups, although statistically reliable, were modest and may have been confounded by the amount of psychotherapy the patients received after hospitalization. Although there appears to be a general advantage to the long-term approach, further work will be needed to identify patient subgroups for whom this more expensive treatment is cost effective.

Short versus long hospitalization: a prospective controlled study. V. One-year follow-up results for nonschizophrenie patients.

The authors studied the effect of long-term versus short-term hospitalization on a group of 74 patients with the diagnoses of affective disorder, neurosis and personality disorder, and hysterical personality one year after their admission to the hospital. Although they had found in an earlier study that short-term patients seemed to integrate more rapidly in the hospital, the results reported in this study showed no statistically reliable differences between the long-term and short-term groups. In contrast to the author's results for schizophrenic patients, their findings for nonschizophrenic patients do not support extended hospitalization.

A controlled study of transitional day care for non-chronically-ill patients.

The authors randomly assigned 79 inpatients with nonchronic schizophrenia or affective disorder to either an intensive experimental day program called "transitional treatment" or a control treatment--weekly clinically believed to require intensive posthospital treatment to make the transition to the community. Although initially there was a significantly higher dropout rate from the control condition, at the point of discharge from the two programs as well as at 6- and 12-month follow-up there was no difference in outcome. Direct costs for the transitional treatment, however, were much higher.

A randomized clinical trial of inpatient family intervention, III: Effects at 6-month and 18-month follow-ups.

This paper focuses on the follow-up results of a randomized clinical trial of inpatient family intervention (IFI) that emphasized psychoeducation. Results for the sample of 169 psychiatric patients suggested that adding family treatment to standard hospital treatment was effective; however, the statistical interactions indicated that this therapeutic effect was restricted to female patients with schizophrenia or major affective disorder. The effect of family treatment on male patients with these diagnoses was minimal or slightly negative. In a group of patients with other diagnoses, the Treatment by Sex effect was reversed: male patients did better with the family treatment.

Lithium augmentation fails to reduce symptoms in poorly responsive schizophrenic outpatients.

BACKGROUND: Nearly one third of patients suffering from schizophrenia do not fully respond to antipsychotic medication. Safe, effective, and cost-efficient methods to reduce symptoms are clearly needed; therefore, lithium as an adjunct to fluphenazine decanoate was tested in a placebo-controlled trial in outpatients who were part of the Treatment Strategies of Schizophrenia (TSS) study. METHOD: Forty-one patients with DSM-III schizophrenia or schizoaffective disorder were assigned to either adjunctive lithium or placebo after at least 6 months of fluphenazine decanoate treatment to stabilize symptoms had failed. The trial was designed for 8 weeks of treatment, and patients assigned to placebo could afterward be administered lithium in an 8-week, open-label study. RESULTS: Assessment of the intent-to-treat analysis revealed no significant differences in demographic variables between the lithium and placebo groups. Although both groups showed significant (p = .00135) improvement as measured by total scores on the Brief Psychiatric Rating Scale (BPRS), there were no significant differences in response between the lithium and placebo groups. Patients originally treated with placebo added to neuroleptic did not have significantly greater improvement when receiving open-label adjunctive lithium. CONCLUSION: Although success with lithium augmentation therapy for persistent psychosis has been reported in the past, this study of well-characterized patients showed no benefit for this common strategy, thus indicating that care be used in utilizing lithium augmentation.

A randomized clinical trial of inpatient family intervention. IV. Followup results for subjects with schizophrenia.

This is the last of a series of four papers, here focussing on schizophrenia, which report followup data up to 18 months from a randomized clinical trial of a psychoeducational family intervention (IFI), which was added to medication and limited to the inpatient phase of treatment, after which post-hospital care was not controlled. Our data suggested that patients with poor prehospital functioning (i.e., the chronic patients) may benefit from inpatient family intervention, but this therapeutic effect appears to be limited to females and does not appear until 18 months postadmission. Families of patients with schizophrenia also show benefit from having received IFI, the effect is seen earlier than with the patients, and is associated with achieving the goals of IFI. The results in the IFI group could not be accounted for by improved post-hospital medication compliance, but they may be related to this group's greater tendency to obtain further family treatment after discharge.

Treatment with atypical antipsychotics: new indications and new populations.

Atypical antipsychotics have revolutionized the treatment of schizophrenia, becoming the treatment of choice for patients not only during their first episode, but also throughout their life course. Of note, as of 1999 more than 70% of prescriptions for these drugs are being prescribed for conditions other than schizophrenia, such as bipolar disorder and geriatric agitation. While there have been very few controlled trials that have established the efficacy of the atypical antipsychotics for these "off-label" uses, there have been a large number of open trials and case reports. The few controlled trials suggest that the atypical antipsychotics may be useful for affective disorders (both mania and depression), geriatric conditions such as senile dementia and aggression, as well as a variety of other disorders. Atypical agents may be particularly helpful for elderly, child, or adolescent patients who are especially susceptible to the side effects of medications and whose risk of tardive dyskinesia is high but further controlled studies are necessary.

The inpatient care of the chronically mentally ill.

The inpatient treatment of the chronically mentally ill as it has been practiced in the past, is practiced at the present, and may be practiced in the future is discussed. The reasons for admitting the chronically ill to inpatient services; the steps of such treatment and treatment modalities employed; and considerations for discharge are presented. In addition, the indications as well as pros and cons for long-term inpatient hospitalization are included.

Gender and schizophrenia outcome: a clinical trial of an inpatient family intervention.

Several studies document sex differences in premorbid and intermorbid role functioning, showing less functional deficit among females. The specific nature of sex differences in role functioning is still poorly understood. The purpose of the present study was to investigate sex differences in symptomatology and role functioning in a sample of 92 inpatients hospitalized for an episode of DSM-III-diagnosed schizophrenic disorder. Patients were randomized at hospital admission to either of two treatment conditions: (1) multimodal hospital treatment with the addition of an inpatient family intervention (IFI) or (2) multimodal hospital treatment without IFI. Results indicated (1) sex differences in levels of substance abuse and antisocial behavior (worse for males both at admission and followup)--dimensions of psychopathology unrelated to the core features of schizophrenia; (2) superior family and occupational functioning in females at followup; and (3) superior clinical response of females to IFI. Data on family response to IFI suggest some ameliorative effects of IFI on critical family attitudes toward female patients as well as greater family compliance with IFI treatment among the families of females. Sex differences in intermorbid family and occupational functioning and response to a family-based psychosocial intervention are discussed in light of data on rejecting family attitudes toward the patient and sex differences in symptomatology. The possible influence of sex-differentiated social role demands on response to IFI is also discussed.