Treatment patterns of schizophrenia based on the data from seven Central and Eastern European Countries.

OBJECTIVE: The aim is to analyze how schizophrenia is pharmacologically treated in seven CEE countries: Croatia, Estonia, Hungary, Poland, Serbia, Slovakia and Slovenia. METHODS: Psychiatrists from selected centers in each of participating countries were asked to complete a pre-defined questionnaire on their current clinical practice. Information on protocols and resource utilization in schizophrenia treatment was included and derived from randomly selected patient medical records. Expert opinions on country-wide treatment patterns were additionally sought. This sub-analysis focuses on pharmacological treatment patterns in the last six months and over the course of the disease. RESULTS: 961 patients' data show that during last six months the most commonly prescribed medications were oral atypical antipsychotics: olanzapine (n=268), clozapine (n=234) and risperidone (n=160). The most frequently prescribed atypical antipsychotics over course of disease were: risperidone (54.5%), olanzapine (52.4%) and clozapine (35.1%), along with haloperidol (39.3%). Experts reported risperidone (four countries) and olanzapine (three countries) as first-line treatment, with the same two medications prescribed as second-line treatment. Clozapine was the most reported medication for refractory patients. Approximately 22% of patients received polypharmacy with antipsychotics in at least one period over the disease course. Mean time since diagnosis was 13.1 years and on average 4.8 treatment courses received during that period. Anxiolytics (70%), antidepressants (42%), mood-stabilizers (27%) were also prescribed, with diazepam (35.4%), sertraline (10.5%), valproic acid (17.5%) the most commonly reported, respectively, in each group. The most frequently reported treatment change was switch from one oral atypical antipsychotic to another (51%). CONCLUSION: Oral atypical antipsychotics, mostly older drugs (risperidone, olanzapine, clozapine), were most commonly prescribed for schizophrenia treatment in participating countries. Given that results are from the first large-scale analysis of RWD, we believe these findings can be a benchmark for future real-world studies, which could contribute to the optimization of treatment for this debilitating disease.

Schizophrenia causes significant burden to patients' and caregivers' lives.

BACKGROUND: Schizophrenia is a serious public health problem and is ranked among the most disabling diseases in the world. The sub-study presented here was part of a larger project to characterize the burden of schizophrenia on healthcare systems and on individuals living with the disease in Central and Eastern Europe (CEE). AIMS: This sub-study aimed to assess and analyze the impact of schizophrenia on many aspects of the lives of patients and caregivers. METHODS: Psychiatrists from selected centers in seven Central and Eastern European countries were asked to complete a questionnaire in order to collect information about the disease history, characteristics, treatment protocols and resources used for each randomly selected patient. All data were statistically analyzed and compared between countries. RESULTS: Data from 961 patients with schizophrenia (mean age 40.7 years, 45.1% female) were included in the analysis. The mean number of days spent in hospital per patient per year across all seven countries was 25.3 days. Hospitalization occurred on average once per year, with psychiatrist visits 9.4 times per year. Of the patients in the study, 61% were single, 12% divorced and 22% married or cohabiting. Almost 84% were living with relatives or a partner; only 17% lived alone and, on average, 25% of patients received support from social workers. Relatives provided care for approximately 60% of patients and 4% of them had to stop working in order to do so. Twenty-nine percent of the patients were unemployed, and 56% received a disability pension or were retired, with only 19% in full-time employment or education. CONCLUSION: Schizophrenia has a significant effect on the lives of patients and caregivers and impacts their social integration.

Electroconvulsive therapy in a Hungarian academic centre (1999-2010).

BACKGROUND: Since the 1930s, the Department of Psychiatry and Psychotherapy at Semmelweis University (DPPSU) in Budapest has played a leading role in convulsive therapy in Hungary. The aim of this study was to describe the pattern of ECT use at the DPPSU over an 11-year period. SUBJECTS AND METHODS: Analysis of the medical notes of all patients treated with ECT in this academic centre between 1999 and 2009. RESULTS: During the study period, 28,230 patients were admitted to the DPPSU, of whom 457 (1.6%) received ECT. More than 50% of patients receiving ECT were diagnosed with schizophrenia. The percentage of female patients receiving ECT significantly exceeded that of the male patients, above what was expected in view of the diagnostic mix. CONCLUSION: The data indicate that in the first decade of the 21(th) century, ECT use shows a declining tendency in this Hungarian academic centre. The mean number of treatment sessions was relatively low and nearly the same across diagnostic groups. ECT was mainly used as a last resort for treatment-resistant patients. In the majority of cases, bifronto-temporal brief pulse stimulation was applied. Seizures were monitored with EEG and EMG.

[Antipsychotic drug combinations in the treatment of schizophrenia. A review of the literature]. / Antipszichotikumok kombinációjának használata szkizofrénia kezelésében. Irodalmi áttekintés.

Main indication for antipsychotic medication is the treatment of schizophrenia and other psychotic disorders. Influential protocols in the treatment of schizophrenia recommend the use of antipsychotics in monotherapy. In case of therapy resistance, combination of antipsychotics is a feasible option. Applying antipsychotics in combination is common in clinical practice, although existing efficacy and safety data concerning antipsychotic combinations are scarce. Authors, after reviewing existing scientific data, make attempt to give recommendations for combined antipsychotic therapy in everyday clinical practice.

[Adulthood -- childhood -- adulthood: long-term therapy in child and adolescent psychiatry]. / Felnottkor -- gyermekkor -- felnottkor: Hosszútávú kezelés a gyermek és felnott pszichiátriában.

The aggregation of psychiatric disorders within families is well-known. The relative role of biological, psychogenic and socialization-related factors varies with the individual case. Another well-known fact is that parents play a very important role in influencing whether their child gets the right treatment when it is necessary. In this paper we highlight the complex links between childhood and adulthood through the presentation of three psychiatric cases. The first story starts with a lactation psychosis of a mother and ends when the daughter who became psychotic at the age of 15 enters adulthood. During these 18 years several psychiatrically relevant episodes happened in the family. During our care, step by step, in relation to emerging psychological problems, the family revealed more and more secrets, explaining past events, and offering a possibility for psychoeducation and psychotherapy. Knowledge concerning the life and psychiatric history of parents, in spite of the fears of the family, largely contributed to evaluating the symptoms of the daughter, reaching a diagnosis, initiating and maintaining therapy and achieving the present balanced state. The next two cases present the stories of two boys with Attention-Deficit/Hyperactivity Disorder (ADHD). One of the children was 6 years old when the family sought professional help, and now he is 11, the other child was 8 years old when the parents sought help and he is 15 now. The two families reacted differently to the offered treatment, but in both cases the family stayed continuously in touch with their child psychiatrists. With these two different stories on ADHD we would like to present several issues and successes which may surface during the long-term treatment of ADHD.

[Classification of endogenous psychoses. Predictive validity of initial diagnosis based on 5 and 21-33-years of follow-up in a long-term prospective study (Budapest 2000)]. / Az endogén pszichózisok osztályozása. A kiindulási diagnózisok prediktív validitása egy hosszú távú prospektív kutatás egymást követö 5 éves és 21-23 éves utávizsgálata alapján (Budapest 2000).

As regards the clinical psychopathological diagnostics, Leonhard's classification of endogenous psychoses published in 1957 contained description of a detailed nosology with claims that the diagnostic categories included in this classification system involve differentiated predictions of course and outcome of the illness. The principal investigator (BP) chose Leonhard's classification system to test these nosological hypotheses via a prospective study of psychotic patients based on their clinical and life history in 1966-67. Validity of the categorial diagnoses given at baseline (female patients n=222; healthy control persons n=54; 1968-1976) was proven by combination of assessments of psychopathological symptoms and personality types at the 5-year follow-up. Moreover, "pure defect" also proved to be valid (84,6%). At the time of the long-term follow-up in 1997-2002 (patients: n=125; healthy control persons: n=38) predictive validity of the nine categories was measured empirically and by using a stochastic (Markovian) model, thus combining validity and reliability. Hebephrenias, group of normal persons and of schizophrenias proved to be valid, with diagnostic stabilities of 0,93, 0,89, and 0,93, for the three groups, respectively. In addition, bipolar manic-depressive psychoses and cycloid psychoses were also valid (diagnostic stability of 0,76 in both cases). Unipolar depression was valid (diagnostic stability=0,84) only by forming a "nosological family" based on diagnostic stability and on current status and clinical presentation during the period preceeding the follow-up with regard to other moodcongruent disorders and outcome-diagnosis "healthy control". Validity of systematic paraphrenias (diagnostic stability =0,68) was also in the moderate range. Division of schizophrenias in "systematic vs. non-systematic" nosological categories was inconclusive; the categories of affect-laden paraphrenia, periodic catatonia and systematic catatonias could not be confirmed reliably in this study.

Change of medical student attitudes toward psychiatry: the impact of the psychiatric clerkship.

UNLABELLED: Psychiatry - as a profession - is getting less and less popular among medical students resulting in a dramatic decrease in number of those choosing this field as a future career. AIMS: This study set out to investigate how undergraduate psychiatric training influenced the attitudes toward psychiatry and the career choices of fifth-year Hungarian medical students. METHODS: Students' attitudes toward psychiatry were measured by the ATP-30 and their preference for a career in medicine was also inquired about. RESULTS: The mean total ATP-30 score of the 71 participants only moderately increased (109.28 +/- 11.82 vs. 111.08 +/- 11.94; p=0.186). However, in some respects participants' views about psychiatry and psychiatric patients turned significantly positive, and a few misconceptions abated. Yet, the mean score on the item "I would like to be a psychiatrist" dropped significantly (1.94 +/- 0.89 vs. 1.68 +/- 0.79; p=0.023). CONCLUSION: The mean ATP-30 scores indicate that the attitude of Hungarian medical students toward psychiatry is rather positive compared to students from other countries. Our findings suggest that undergraduate exposure to psychiatry does not have a major impact on student attitudes toward the profession; in fact, psychiatry became less attractive following the clinical clerkship. On the whole, the number of students willing to enter the psychiatric workforce is critically low in relation to the growing demand in Hungary.

[Strategies for optimizing stimulus dosage during electroconvulsive therapy]. / Az optimális stimulus-intenzitás beállításának stratégiái elektrokonvulzív kezelés során.

UNLABELLED: Core element of electroconvulsive therapy (ECT) is the induction of a generalized seizure. Stimulus intensity must be above patient's seizure threshold for seizure induction. As individual seizure thresholds vary in a wide range, determining optimal initial stimulus intensity is a challenge to the clinician. In the literature four different methods are recommended for this purpose: 1) dose-titration 2) half-age method 3) age method 4) fix dose method. AIM: to determine the most optimal method out of these four for selecting initial stimulus dose for bilateral electroconvulsive therapy of patients with schizophrenia. METHODS: 40 patients with schizophrenia were treated with ECT during the studied period. Data of these treatments were analyzed retrospectively. Seizure threshold was determined with dose-titration in each case at the beginning of the treatment. Relationship between seizure threshold and age was investigated with the Pearson's correlation test. RESULTS: Mean age of the studied population was 38.07+/-16.66 years. To eliciting a seizure duration of at least 20 sec, a mean stimulus intensity of 18.37% (92.61 mC)+/-8.35(42.08 mC) was required. The patient's age showed significant positive correlation (p less than 0,001) with stimulus intensity. EEG registered mean seizure duration was 39.65+/-17.78 s, and mean motoric seizure lasted for 32.45+/-17.24 s. DISCUSSION: Variation between the lowest and the highest seizure threshold in our study was 6-fold. Having analyzed the different initial dosing strategies on the basis of the seizure thresholds observed in our study, we concluded that the age method seems to be the most optimal one for bilateral ECT of patients with schizophrenia.

[Changes of hallucination and delusion: the results of the 21-33 year follow-up of "Budapest 2000"]. / A téveszme és a hallucináció változásai: a "Budapest 2000" 21-33 éves follow-up eredményei.

UNLABELLED: In view of the fact that there are only a few longitudinal follow-up examinations in patients with major mental illness, data on the changes of hallucination and delusion over the lifetime of the patient are extremely limited. AIM: The purpose of this study was to investigate the long-term course of delusions and hallucinations in patients with psychotic disorders. METHOD: 221 patients were evaluated in this study. The subjects were classified according to Leonhardian nosological system into affective, cycloid and schizophrenic groups and were assessed at three different times (index, and 5- and 21-33 year follow-up). All subjects received pharmacotherapy during the study. The psychopathological assessment of patients was performed by two trained raters. The Rockland Pollin Rating Scale was obtained at each time-point in the study. RESULTS: The initially low severity of hallucinations and delusions showed a tendency for full recovery across the course of the illness in the affective group. The high initial severity of both symptoms displayed a full resolution in the cycloid group. By contrast, at each follow-up time-point in all groups with schizophrenia, persistence of both symptoms was observable with some fluctuation, i.e., with the worsening of hallucination between the second and third follow-up time-points. Certain schizophrenia subgroups were distinguishable based on the correlation of the two symptoms. The severity of these symptoms did not show a significant association with the severity of psychosis observed at a particular time. DISCUSSION: The main productive symptoms with some fluctuations persist through course of the illness.

The augmentation of clozapine treatment with electroconvulsive therapy.

OBJECTIVES: The assessment, in terms of safety and efficacy, of augmenting clozapine monotherapy, as well as combined psychopharmacotherapy involving clozapine, with electroconvulsive therapy (ECT). METHOD: Reviewed were the charts of patients who received clozapine-ECT treatment in the Department of Psychiatry and Psychotherapy of Semmelweis University between November 1999 and December 2003. RESULTS: During the studied period there were altogether 43 patients treated with the combination of clozapine and electroconvulsive therapy. In the schizoaffective group, the values for post-electroconvulsive therapy CGI were significantly lower than either in the catatonic (Z=-3.72, p<0.01) or in the hebephrenic (Z=-3.17, p<0.01) group. Among the groups created on the basis of the number of augmentation strategies utilized, the clozapine+3 group consisted of patients significantly older than the clozapine+ 1 group (Z=2.45, p=0.01). In the clozapine monotherapy group, the values for post-electroconvulsive therapy CGI were significantly lower than in any of the groups that had received a combination of augmentations (monotherapy-1 augmentation: Z=-3.01, p<0.01; monotherapy-2 augmentation: Z=-2.89, p<0.01; monotherapy-3 augmentation: Z=-2.41, p=0.01). CONCLUSIONS: According to our examinations, the augmentation of clozapine treatment with electroconvulsive therapy should be tried primarily on schizoaffective patients, in case the clozapine monotherapy is ineffective. The simultaneous use of different augmentation strategies is expected to increase only the side effects not the efficacy of the treatment.

[Neuropsychiatric symptoms caused by mefloquine (report of several cases)]. / A mefloquin okozta neuropszichiátriai tünetegyüttesek (néhány eset alapján).

INTRODUCTION: The number of Hungarian citizens travelling to countries infected with malaria is increasing year by year. Mefloquine is the most effective medicine in the prophylaxis and treatment of malaria. However, neuropsychiatric side-effects can more often be seen with the use of mefloquine compared to other anti-malaria drugs. AIMS: To assess the neuropsychiatric side-effects with mefloquine prophylaxis; to screen those patients who are possibly affected by the side-effects and to explore factors that forecast the possible side-effects. METHOD: The retrospective analysis of patients, who in the past 2 years, have had mefloquine prophylaxis and then turned up at Semmelweis University, Department of Psychiatry and Psychotherapy and at Szent László Hospital, Outpatient Department of Psychiatry and Addictology because of neuropsychiatric symptoms. RESULTS: Out of the 6 cases presented, whose neuropsychiatric symptoms ranged from slight dizziness, malaise through panic attacks and depression to psychosis, the preceeding psychiatric condition was positive in 4 cases. Even the most serious psychiatric symptoms disappeared within a few days using temporary drug-treatment. In those cases in whom the side-effects were more serious, a positive psychiatric history or a more sensitive personality differing from the average was established. CONCLUSIONS: Because of the low number of cases it is not possible to draw a general conclusion. After analysis of the data the authors assume, that besides the psychiatric history, the premorbid personality can also be a factor that forecasts the possible neuropsychiatric side-effects caused by mefloquine prophylaxis.

The impact of neuroleptic medication on seizure threshold and duration in electroconvulsive therapy.

INTRODUCTION: In most patients diagnosed with psychotic depression or schizophrenia and treated with electroconvulsive therapy, parallelly administered antipsychotic medication cannot be stopped. Antipsychotic drugs can influence both seizure threshold and seizure activity in different ways. PATIENTS AND METHOD: The present study processes the data of 77 patients treated parallelly with electroconvulsive therapy and antipsychotic drugs. Oral doses of the antipsychotic medication administered the day before the electroconvulsive therapy, stimulus intensity, seizure durations, and impedance were analysed from session to session. RESULTS: One group of antipsychotics (haloperidol, fluphenazine, risperidone, sulpirid) was not found to influence seizure activity: there was no significant difference in EEG and EMG registered seizure duration or in stimulus intensity between the treated and non-treated group. However, significant difference was found between the next treated and non-treated groups in 40% of the sessions in case of olanzapine, in 50% of the sessions in case of clozapine and in 57% of the sessions in case of zuclopenthixol in EEG or EMG registered seizure duration as well as in stimulus intensity. In the third group (quetiapine) there was a significant difference in each session (2nd session: EMG, p=0.02; 5th session: EEG, p=0.05, EMG, p=0.04). Most of the antipsychotics (olanzapine, clozapine, zuclopenthixol) have been shown to possess epileptogenic properties; only quetiapine reduces seizure activity. CONCLUSION: In the clinical use of olanzapine, clozopine and zuclopenthixol seems epileptogenic, whereas in the case of quetiapine seizure reducing properties must be taken into account. Together with the consideration of the accompanying somatic and neurologic disturbances and with the concomitant medications this can influence the treatment of choice.

Impact on psychiatric interns of watching live electroconvulsive treatment.

OBJECTIVE: Watching a live electroconvulsive treatment (ECT) has both positive and negative effects on spectators. The authors aim to survey the attitude change towards ECT in interns after watching a live ECT session. METHODS: A 23-item questionnaire was administered to 66 interns before and after watching ECT. RESULTS: In five statements, the number of answers indicating negative attitudes decreased significantly after viewing ECT. A general change in attitude towards ECT depended on the interns' knowledge about the treatment. In the group of interns claiming minimal knowledge about ECT, a positive attitude change toward ECT and an increase in the acceptance of ECT were found, while in the group with moderate self-rated knowledge no significant attitude change, but a decrease in acceptance, were detected. CONCLUSION: The visual information on ECT reduced the interns' negative attitudes, in general; however, acceptance of the treatment decreased in a subgroup of interns.

Survey of referrals to electroconvulsive therapy in Hungary.

BACKGROUND: The diagnostic distribution of patients treated with electroconvulsive therapy (ECT) in Hungary is significantly different from that in Western Europe or the USA. In Hungary most of the treated patients are diagnosed with schizophrenia. AIM: To analyze the practice of referring patients for ECT in Hungary. METHODS: Questionnaires containing socio-demographic data were mailed to all Hungarian psychiatric units where ECT was used (n=34), and all of the psychiatrists working there were invited to participate. Respondents were asked to rate how often they considered ECT for various symptoms/syndromes on a five-point Likert Scale. RESULTS: A total of 78 questionnaires were returned. Altogether, 89% of the respondents have referred patients to ECT, and 54.8% had done so in the last year. The respondents had most frequently recommended ECT for antipsychotic and antidepressant-resistant patients, catatonic symptoms, or patients with previous good treatment response to ECT. CONCLUSION: Considering the very high Hungarian suicide rate, the low referral rate in cases of severe suicidal intent and threat is surprising. The respondents also rarely considered ECT for NMS or severe depression. The discrepancy between current referral practices and standard recommendations could be decreased with more ECT training courses.

The predictive validity of the Leonhardean classification of endogenous psychoses: a 21-33-year follow-up of a prospective study ("BUDAPEST 2000").

To our knowledge, no previous long-term studies of the Leonhardean classification in the whole spectrum of endogenous psychoses have been conducted. This prospective study (n = 276; female patients n = 222; normal control persons n = 54) started in 1967-1976. The same population was followed-up by participation of a "blinded control" psychiatrist in 1997-2002 [patients available at follow-up = 125 (56.3%); available controls = 38 (70.4%)]. Patients for this investigation were selected by two independent diagnosticians from eight nosological groups based on full diagnostic agreement. Diagnostic agreement at follow-up (weighted-kappa) was 0.87. Predictive validity of the diagnostic categories was measured empirically and using a stochastic (Markovian) model, thus combining validity and reliability. Hebephrenias, group of normal persons and of schizophrenias proved to be valid categories, with diagnostic stabilities of 0.94, 0.91, and 0.93, for the three groups, respectively. In addition, bipolar manic-depressive psychoses and cycloid psychoses were also valid (diagnostic stability of 0.77 and 0.76, respectively). Unipolar depression was valid (diagnostic stability = 0.84) only by forming a "nosological family" based on diagnostic stability and on current status and clinical presentation during the period preceding the follow-up with regard to other mood-congruent disorders and outcome-diagnosis "normal control". Validity of systematic paraphrenias (diagnostic stability = 0.69) was in the moderate range. Division of schizophrenias in "systematic versus non-systematic" nosological categories was inconclusive; the categories of affect-laden paraphrenia, periodic catatonia and systematic catatonias could not be confirmed reliably in this study.

Validity of reliability: comparison of interrater reliabilities of psychopathological symptoms.

We have tested the stability of interrater reliability of psychiatric symptoms over a quarter of century using 2 rating scales. Interrater reliabilities of items of 2 psychiatric rating scales employed by 2 consecutive follow-ups were compared. Interrater reliabilites proved to be by and large stable. Interrater reliability depends on the standard deviation of the items scores. In addition to the traditional approach, a new statistical method for unifying the assessments from multiple raters is also presented. Using this method, we demonstrated that probabilities of correct ratings are higher in the absence of manifest symptoms, or in the presence of symptoms, as compared with cases characterized by middle scores. To interpret the relationships revealed in the setting of the experiment, we introduce for its theoretical designation the term "validity of reliability." It is recommended for evaluation of results of rating scales in the context of psychiatric nosology.

Hungarian medical students' knowledge about and attitudes toward electroconvulsive therapy.

A survey using self-administered questionnaires was conducted among fifth-year medical students beginning their psychiatry clerkships to assess their attitude toward and their basic knowledge of electroconvulsive therapy (ECT). The questionnaire, consisting of 28 questions, was completed by 127 students. Ten rated their own knowledge on ECT as mediocre, the rest of them as minimal. A total of 67% of the students would not consent to undergoing ECT themselves, not even if they had severe depression with psychotic features. ECT was believed to be used to bring violent patients under control by 35% of the students, was believed to be painful by 54%, and to be even dangerous by 50%. A total of 61% of the participants believed that ECT should only be used as a last resort, 35% found ECT outmoded, 32% thought that ECT causes permanent brain damage, and 14% would ban its use. Among the students refusing to be treated with ECT, the proportion of women was higher, and their attitude toward ECT was significantly more negative (P = 0.031) than that of those who would consent to ECT. The answers that psychiatrists often misuse ECT, that ECT is an outmoded therapy causing brain damage, and that the use of which should be forbidden were given more frequently by those who refused to be treated with ECT. Also, the attitude of those describing themselves as more knowledgeable about psychiatry was found to be significantly (P = 0.005) more negative than the attitude of those with minimal psychiatric knowledge. The frequent occurrence of incorrect beliefs about and negative attitudes toward ECT support the necessity of covering ECT in the medical school curriculum more thoroughly and in more detail.

Attitudes towards electroconvulsive therapy among Hungarian psychiatrists.

Participants of a postgraduate biologic psychiatric course were surveyed about their attitudes toward electroconvulsive therapy (ECT) with a self-administered questionnaire. Among the respondents, 65 persons were specialists in psychiatry, 32% of whom would not consider using ECT even if they were in a psychotic depressive state. According to the bias factor, which has been calculated based on the answers to the 11 questions regarding attitudes, those psychiatrists who worked in inpatient care showed a less negative attitude. Among the items concerning knowledge of ECT, incorrect answers were most frequent to questions about myocardial infarction as a contraindication, and about the identity of the person who had pioneered this treatment. The negative attitude of Hungarian psychiatrists, especially of those who work in outpatient care, may have an important role in the decrease of the application of ECT in the past decade in Hungary.