FAST-O works well for characterization and monitoring of sheltered housing schizophrenia patients.

OBJECTIVE: The de-institutionalizing process came to an end before the millennium shift by closing mental hospitals. After that some of the most ill patients are cared for in sheltered housing (SH). There is no in-house psychiatric competence and the staff on the floor usually lacks such knowledge and training. Observation instruments may improve this by making it possible to assess and monitor patients. METHOD: FAST-O is a simple twelve-item observation scale. Staff at eight SH units were trained in using the instrument and then assessed a total of 67 patients once, twice or three times at monthly intervals. RESULTS: Ten items formed two highly homogenous subscales reflecting Social skills (Soc) and Excitation/Aggression (E/A). Depression and Clinical Global Impression (CGI) items were considered separately. The correlation pattern suggested that the ratings had construct validity. A cluster analysis identified three patient subgroups, of which one had very high E/A scores. Comparisons with reference data suggested that the average symptom level was on par with acutely admitted in-patients for this subgroup. In all groups, E/A symptoms varied considerably over time, the other symptoms were more stable. There were marked differences among the eight SH units with respect to the level of patient problems. CONCLUSIONS: The SH staff was able to produce valid FAST-O assessments. There are reference data which makes it possible to characterize individual patients as well as SH units with respect to treatment needs and safety aspects (for instance risk of violence).

Psychosis in adulthood is associated with high rates of ADHD and CD problems during childhood.

BACKGROUND: Patients diagnosed with schizophrenia display poor premorbid adjustment (PPA) in half of the cases. Attention deficit/hyperactivity disorder (ADHD) and conduct disorder (CD) are common child psychiatric disorders. These two facts have not previously been linked in the literature. AIMS: To determine the prevalence of ADHD/CD problems retrospectively among patients with psychoses, and whether and to what extent the high frequency of substance abuse problems among such patients may be linked to ADHD/CD problems. METHOD: ADHD and CD problems/diagnoses were retrospectively recorded in one forensic (n = 149) and two non-forensic samples (n = 98 and n = 231) of patients with a psychotic illness: schizophrenia, bipolar or other, excluding drug-induced psychoses. RESULTS: ADHD and CD were much more common among the patients than in the general population-the odds ratio was estimated to be greater than 5. There was no significant difference in this respect between forensic and non-forensic patients. Substance abuse was common, but substantially more common among patients with premorbid ADHD/CD problems. CONCLUSIONS: Previous views regarding PPA among patients with a psychotic illness may reflect an association between childhood ADHD/CD and later psychosis. The nature of this association remains uncertain: two disorders sharing some generative mechanisms or one disorder with two main clinical manifestations. Childhood ADHD and particularly CD problems contribute to the high frequency of substance abuse in such groups.

Is the PANSS cognitive scale measuring cognition?

OBJECTIVE: To investigate the association between the Positive and Negative Syndrome Scale (PANSS) cognitive factors and cognition assessed by neuropsychological tests. METHOD: Ninety patients with a psychotic illness, the majority having a schizophrenia diagnosis, were assessed with PANSS ratings and tested by a comprehensive computerized neuropsychological test battery, EuCog. RESULTS: Test performance was in the normal range for some of the cognitive indices, but substantially reduced for others, compared with norms, particularly speed-based indices. PANSS ratings were non-specifically associated with cognitive indices representing performance (speed and accuracy) and problem solving strategies (executive functions). There was no discriminant validity for the cognitive factor. A regression analysis suggested that the PANSS cognitive factors reflected verbal IQ but no other cognitive domain like memory, attention or speed. CONCLUSION: Cognitive test performance is associated with psychopathology as assessed by PANSS items but in a non-specific way. The PANSS cognitive subscale seems to reflect over-learned verbal skills rather than the cognitive domains, which are known to be specifically affected in schizophrenia and relevant for the prognosis. Consequently, PANSS ratings cannot replace the information inherent in neuropsychological test data. The extensive speed problem of patients with schizophrenia should be studied in more detail using test batteries that focus on that problem.

'Speedy action over goal orientation': cognitive impulsivity in male forensic patients with dyslexia.

Previous neuropsychiatric studies suggest a relationship between reading disability and cognitive impulsivity. This relationship is not entirely explained by the high comorbidity between reading disability and attention deficit hyperactivity disorder (ADHD), as children with a co-occurrence of these disorders tend to be more impulsive than those with ADHD only. Other research has demonstrated that poor verbal skill (irrespective of the presence of dyslexia) deficits in executive functions and impulsivity are important risk factors for criminal behaviour. The present study bridges these two research traditions by examining whether patients undergoing forensic psychiatric investigation who also have dyslexia, have a cognitive style characterized by impulsivity. Male forensic patients (mean age 27 years, range 16-35) with (n = 9) and without (n = 13) dyslexia were evaluated on the computerized EuroCog test battery. The findings suggest that patients with dyslexia tend to use a cognitive impulsive style and suggest a more direct link between dyslexia and cognitive impulsivity that is not mediated by the presence of ADHD. In order to identify treatment needs and tailor treatment accordingly, forensic patients should be assessed with respect to poor verbal skill, dyslexia and impulsivity.

Suicides during 7 years among a catchment area cohort of patients with psychoses.

OBJECTIVE: To investigate a series of consecutive suicides at a psychosis clinic by using a psychological autopsy technique. METHOD: The clinic serves an adult population of 225,000 individuals, of whom 0.5% have regular contact with the clinic. During a 7½-year period, 23 men and nine women committed suicide, which corresponds to an odds ratio of 14. RESULTS: Most patients were schizophrenic, and 24 were outpatients. Suicide methods were violent in all but two cases. Nineteen had a history of at least one suicide attempt, and 24 were known to have had suicidal ideation. More than half had no social contacts over the last year except with psychiatric staff. The median time between the last contact with the psychiatric services and the suicide was 4 days. No warning signs were noted. At the time of death, 3 of the 24 who were prescribed antipsychotics, and none of the 10 who were prescribed antidepressants had plasma levels of the corresponding drug. CONCLUSION: Findings of special interest are the lack of forewarnings and the poor drug compliance. Patients appear to have played "business as usual" with the care-givers, and did it well. Is it a sign of health and despair, or illness?

PECC--factor structure and findings in three longitudinal cohorts of patients with schizophrenia.

BACKGROUND: Symptom control by drug treatment is the most important task in routine clinical care of patients with schizophrenia. Structured assessment methods are needed in this task but not used much. The US-developed Positive and Negative Syndrome Scale (PANSS) is a standard tool for symptom assessment. The Psychosis Evaluation tool for Common use by Caregivers (PECC) was constructed in Europe some years ago, with the intent to overcome some of the PANSS drawbacks. AIMS AND METHODS: To validate PECC on three longitudinal cohorts of schizophrenic patients representative of Swedish outpatients (n = 225, six assessments over 5 years), international forensic patients (n = 186) and matched non-forensic controls (n = 116), five assessments over 2 years for both. RESULTS: The factor structure of PECC appears to be highly robust. Norm values (in percentiles) were calculated on the materials. Such data provides for analyses of symptom profiles and improvement over time measured in absolute numbers. Forensic patients appear to have a much lower symptom load (except for cognitive symptoms) than the other groups. Forensic controls had much shorter inpatient times than any other group and never caught up with respect to symptom control, even after 2 years. These differences suggest that the scale is clinically valid. CONCLUSION: PECC has a more robust factor structure than PANSS and is simpler to use. Percentile norms have been constructed for outpatients with schizophrenia in general and forensic psychiatry. Percentile scores are accessed readily by the net. PECC is available in many languages. Its separate self-harm item may improve assessments of suicide risk among patients with schizophrenia.

Flunitrazepam intake in male offenders.

The abuse of flunitrazepam (FZ) compounds is worldwide, and several studies have reflected on the consequences with regard to violence, aggression and criminal lifestyle of FZ users. Criminals take high doses of FZ or some other benzodiazepines to "calm down" before the planned crime. There is support from earlier studies that most likely, all benzodiazepines may increase aggression in vulnerable males. Chronic intake of high doses of FZ increases aggression in male rats. Because psychopathy involves aggression, we have examined whether psychopathy as well as any of the four facets of the Psychopathy Checklist-Revised (PCL-R) (Interpersonal, Affective, Lifestyle and Antisocial) are related to different substance use disorders, with the focus on FZ. We have also examined the relationship between each PCL-R item and FZ use. Participants were 114 male offenders aged 14-35 years, all of whom were convicted for severe, predominantly violent, offences. Substance use, including FZ, was not more common in those who scored high in psychopathy. Use of FZ was more common in offenders who scored high in Facet 4 (Antisocial) of the PCL-R (odds ratio = 4.30, 95% CI 1.86-9.94). Only one of the PCL-R items, "Criminal versatility", was significantly associated with FZ use (odds ratio = 3.7). It may be concluded that intake of FZ has a specific relationship to only one of the facets and not to psychopathy per se. The findings have also important theoretical implications because Facet 4 is not a key factor of the construct of psychopathy. Clinical implications of the article: We have used the new two-factor and four-facet theoretical model of psychopathy in the young offender population, many of them with one or more substance use disorders. The present results suggest that antisocial behavior defined by Facet 4 (poor behavioral control, early behavior problems, juvenile delinquency, revocation of conditional release and criminal versatility) in the studied subjects is more typical for FZ users than it is for non-FZ users. This may have implications for assessment and treatment. Clinicians should be aware that criminals with high scores on Facet 4 have a more than fourfold odds of being a FZ user. This conclusion has an important clinical implication because FZ abuse is very common and is not always the focus of a forensic psychiatric assessment.

Sex differences in offending trajectories in a Swedish cohort.

BACKGROUND: Despite the increased interest in female offending trajectories over the last decades, knowledge is still limited. AIM: To meet the need for more knowledge on female offending trajectories by studying sex differences in criminal career patterns. METHOD: Data on 518 female and 2567 male offenders up to age 30 from the Swedish longitudinal Project Metropolitan study were analysed using latent class analysis. RESULTS: The female offenders were much less predisposed to offend than the males, but when they did, they tended to follow a similar set of trajectories to males in their criminal development over time. Four criminal career patterns were identified for each sex. Two patterns were the same between the sexes, and two were gender unique. All career patterns had meaningful and distinct associations with crime characteristics. CONCLUSIONS: Our study presents indicators relating both to gender differences and to heterogeneity within the group of female offenders. One important finding was the identification of an adult-onset offender group unique to females. This group was characterised by high criminal activity over the years following their late onset. Further research will focus on the childhood origins, pathways and outcomes of different female antisocial and criminal careers.

Use of antipsychotics - an analysis of lifetime treatment in 66 patients with psychoses.

Only a minority of patients treated with antipsychotics in clinical studies continue their treatments throughout a longer study period. Few studies address this issue from a lifetime perspective. In this naturalistic study, we aimed at analysing the prescription pattern of antipsychotic drugs among a sample of Swedish patients with a diagnosis of psychotic illness, from the first contact with psychiatry (typically between 1973 and 1997) until the last written note in the case history documents. A retrospective descriptive analysis was performed of all case history data of 66 patients diagnosed with schizophrenia or related psychotic disorders. Patients with schizophrenia were prescribed antipsychotic medication more than 90% of the time. Each patient generally had been prescribed several (up to 16) different antipsychotic drugs and a quarter of the patients had been prescribed two or more antipsychotics for a third of their prescription time. Patients with psychosis were exposed to a cumulatively growing number of antipsychotics. Various factors, including clinician and patient expectations, and specific strengths and limitations of available antipsychotics may account for frequent medication changes over time.

Concomitant medication of psychoses in a lifetime perspective.

OBJECTIVE: Patients treated with antipsychotic drugs often receive concomitant psychotropic compounds. Few studies address this issue from a lifetime perspective. Here, an analysis is presented of the prescription pattern of such concomitant medication from the first contact with psychiatry until the last written note in the case history documents, in patients with a diagnosis of psychotic illness. METHODS: A retrospective descriptive analysis of all case history data of 66 patients diagnosed with schizophrenia or schizophrenia-like psychotic disorders. RESULTS: Benzodiazepines and benzodiazepine-related anxiolytic drugs had been prescribed to 95% of the patients, other anxiolytics, sedatives or hypnotic drugs to 61%, anti-parkinsonism drugs to 86%, and antidepressants to 56% of the patients. However, lifetime doses were small and most of the time patients had no concomitant medication. The prescribed lifetime dose of anti-parkinsonism drugs was associated with that of prescribed first-generation but not second-generation antipsychotics. CONCLUSIONS: Most psychosis patients are sometimes treated with concomitant drugs but mainly over short periods. Lifetime concomitant add-on medication at the individual patient level is variable and complex but not extensive.

Development and validation of the Fast Assessment in Acute Treatment of Psychosis-Observation Rating Scale (FAST-O).

OBJECTIVES: There is a need for an observation scale for assessment and monitoring of acutely psychotic patients. Milestones based on such ratings should be defined, similar to the PANSS-based Remission criteria. FAST-O is such an instrument (11 items and a CGI rating). METHODS: Reliability, validity and factor structure were analyzed in four separate studies--most importantly in one study of 33 chronic forensic in-patients rated concurrently by three independent raters, and another study of 91 Psychiatric Intensive Care Units patients and 20 newly admitted forensic patients, rated twice, each time by two independent raters. RESULTS: The factor structure was simple, two factors and an orphan item (Depression). Reliability was adequate on item (>0.75) as well as scale (>0.85) level. There was no bias related to the rater's professional background. The instrument was sensitive to change. Percentile-based algorithms allow characterization of patients and groups. Tentative treatment milestones are defined; a clinical state "half-way" between the acute state and remission. CONCLUSIONS: FAST-O is a reliable, valid and easy to implement observation scale for patients with a psychotic illness, which can be used without bias by all staff.

Changes in cognitive domains during three years in patients with Alzheimer's disease treated with donepezil.

BACKGROUND: The objective was to identify separate cognitive domains in the standard assessment tools (MMSE, ADAS-Cog) and analyze the process of decline within domains during three years in Alzheimer's disease (AD) patients with donepezil treatment. METHOD: AD patients (n = 421) were recruited from a clinical multi-centre study program in Sweden. Patients were assessed every six months during three years. All patients received donepezil starting directly after study entry. After dropouts, 158 patients remained for analyses over three years. Data for the other patients were analysed until they dropped out (4 groups based on length in study). RESULTS: Factor analyses of all items suggested that there were three intercorrelated factors: a General, a Memory and a Spatial factor for which we constructed corresponding domains. Overall there was a cognitive improvement at six months followed by a linear drop over time for the three domains. Some group and domain differences were identified. Patients who remained longer in the study had better initial performance and a slower deterioration rate. The early dropouts showed no improvement at six months and many dropped out due to side effects. The other groups displayed a performance improvement at six months that was less pronounced in the Memory domain. Before dropping out, deterioration accelerated, particularly in the Spatial domain. CONCLUSION: The course of illness in the three domains was heterogeneous among the patients. We were not able to identify any clinically relevant correlates of this heterogeneity. As an aid we constructed three algorithms corresponding to the cognitive domains, which can be used to characterize patients initially, identify rapid decliners and follow the course of the disease.

Remission in schizophrenia: analysis in a naturalistic setting.

OBJECTIVE: To investigate the recently defined Positive and Negative Syndrome Scale for Schizophrenia remission criteria in a naturalistic setting of psychotic patients; to identify causal factors that change remission status; and to validate the criteria against global indices of illness, cognitive functions, and social outcome. METHODS: This was a longitudinal naturalistic study of 162 patients, diagnosed with schizophrenia or schizophrenia-related psychotic disorders (mean illness duration, 11 years) and treated with risperidone at study entry. Symptoms, drug treatment, cognitive function, and social outcome were measured at baseline and annually for 5 years. Remission was constructed retrospectively with only indirect data on stability over time. RESULTS: At study entry, 40% of the patients with schizophrenia were in symptomatic remission, stabilizing between 55% and 60% after a few years. The need for hospitalization became less frequent over time; initially 31%, dropping to 7% by years 4 and 5. Many patients went in and out of remission. Remission was strongly associated with global indices of illness, with intact insight and with social outcome (except work/studies) but not with cognition or medication. CONCLUSIONS: In spite of certain weaknesses of the study, we may conclude that current definition of remission is primarily a symptomatic measure, covering a subset of symptoms, some of which are not schizophrenia-specific. Although the definition may be clinically relevant, we must be aware of the risk that the connotation of the word could induce too much focus on symptom control.

Untreated ADHD in adults: are there sex differences in symptoms, comorbidity, and impairment?

OBJECTIVE: To analyze sex differences among adult, never-treated patients referred for central stimulant treatment of ADHD. METHOD: Data for 600 consecutive patients from northern Norway referred for evaluation by an expert team during 7 years were analyzed. General background information, diagnostic and social history, and symptom profiles were compared between previously never-treated men and women. RESULTS: The sex ratio was skewed. Of the previously untreated patients, more than 20% fell outside society's ordinary vocational activities or social benefit system. Most patients had the combined form, one third the inattentive type, and only 2% the hyperactive/impulsive subtype. Abuse and criminality were more common among men, and affective, eating, and somatization disorders were more common among women. Otherwise few sex differences were found. CONCLUSION: AD/HD symptom intensity and subtypes did not differ between the sexes and was unrelated to age. Symptom intensity was linked with criminality, abuse, and other psychiatric problems, differentially for the two sexes.

A symptom self-rating scale for schizophrenia (4S): psychometric properties, reliability and validity.

The objective of the study was to validate a self-administrated symptom rating scale for use in patients with schizophrenia spectrum disorders by item analysis, exploration of factor structure, and analyses of reliability and validity. Data on 151 patients, initially treated by risperidone, obtained within the framework of a naturalistic Phase IV longitudinal study, were analysed by comparing patient and clinician ratings of symptoms, side-effects and global indices of illness. The Symptom Self-rating Scale for Schizophrenia (4S) is psychometrically adequate (item analysis, internal consistency, factor structure). Side-effect ratings were reliable. Symptom ratings displayed consistent associations with clinicians' ratings of corresponding symptom dimensions, suggesting construct validity. Patients had most difficulties assessing negative symptom items. Patients were well able to assess their own symptoms and drug side-effects. The factor structure of symptom ratings differs between patients and clinicians as well as how they construe global indices of illness. Clinicians focus on psychotic, patients on affective symptoms. Use of symptom self-ratings is one way to improve communication and thereby strengthen the therapeutic alliance and increase treatment adherence.

Differences in Psychiatric Problems and Criminality Between Individuals Treated With Central Stimulants Before and After Adulthood.

OBJECTIVE: The evidence for central stimulant (CS) treatment in ADHD is strong in some respects but not with respect to unselected clinical material and long-term effects over the life course cycle. The objective of this study was to explore differences in vocational, psychiatric, and social impairment, including crime and substance abuse, among adults with ADHD, treated or not, with CS drugs before age 18. METHOD: A clinical population of men ( N = 343) and women ( N = 129) seeking CS treatment as adults was assessed within a specific program for such treatment. Clinical information and data collected by structured instruments were available. RESULTS: Previously CS-treated persons had a lower frequency of problems (alcohol/substance abuse, criminality), and of certain psychiatric disorders (depressive, anxiety and personality ones). Most differences were substantial. CONCLUSION: The study supports the assumption that CS treatment during childhood/adolescence offers some protection against the development of a range of problems known to characterize adult ADHD patients.

Tardive dyskinesia and antipsychotics: a 5-year longitudinal study of frequency, correlates and course.

The present study comprised a naturalistic, multicentre, 5-year study of course and correlates of tardive dyskinesia (TD). One hundred and sixty-six patients treated with risperidone were included during 1995/96 and followed once a year for 5 years. Mean age at inclusion was 38 years, and mean illness duration was 12 years. Tardive dyskinesia was assessed by the Abnormal Involuntary Movement Scale, and each patient's cognitive function was tested with a comprehensive computerised test battery. At study entry, 14% had TD according to a criterion index. Fifty percent were aware of it, but few reported distress. Age and sex did not correlate with TD, but schizophrenia and bipolar diagnoses did. The presence and intensity of TD correlated with all Positive and Negative Syndrome Scale for Schizophrenia symptom dimensions except the affective factor, but not with type of medication or chlorpromazine-equivalent levels. Tardive dyskinesia patients were cognitively impaired in tests reflecting mental speed, but not in other cognitive modalities. Over the 453 patient years of exposure, five patients developed TD and 14 became free of it. Our findings support the view that TD: (i) is a dynamic phenomenon; (ii) is only partly drug-induced; (iii) has a mild course during treatment with modern neuroleptics; and (iv) appears to have some correlation with mental slowness.

Current therapy issues and unmet clinical needs in the treatment of schizophrenia: a review of the new generation antipsychotics.

This review discusses the atypical antipsychotics, focusing on the possibility of symptom reduction with a minimum of side-effects. A selective review of clinically relevant reports, studies and meta-analyses is presented. The results from clinical trials suggest that atypical agents improve negative and affective symptoms, and cognitive functioning more than typical antipsychotics, but that the pattern of effects on these domains, as well as on suicidality, appears to differ. In clinical trials, the newer drugs generally have less extrapyramidal side-effects (EPS) than typical antipsychotics. However, amisulpride, risperidone, olanzapine and ziprasidone still show evidence of a dose-related increase in EPS, whereas clozapine, quetiapine, sertindole and aripiprazole do not. Weight gain, increased blood lipids/cholesterol, and insulin resistance/type 2 diabetes are emerging as significant treatment-associated concerns, particularly for clozapine and olanzapine. Sedation has been reported for all the newer compounds except sertindole. The considerable variation in benefit/risk profiles of the atypical compounds can help the clinician to select the most appropriate treatment for individual patients.

Reliability and Validity Evaluation of the Psychopathy Checklist: Screening Version (PCL:SV) in Swedish correctional and forensic psychiatric samples.

This study evaluated the structural reliability, construct-related validity, and cultural validity generalization of the Hare Psychopathy Checklist: Screening Version (PCL:SV) in a sample of more than 560 male and female Swedish forensic psychiatric treatment patients, forensic evaluation patients, and criminal offenders. Structural reliability was excellent for most indices. PCL:SV scores were higher for males than females for total and Part 1 scores (interpersonal/affective features) but not for Part 2 (behavioral features). With some exceptions, PCL:SV scores were meaningfully related to aggression to others, a measure of risk for violence, substance use problems, personality disorder (positive), and psychosis (negative). Correlations between PCL:SV and aggression were larger for females than males, although the difference was smaller when personality disorder was held constant. The structural reliability and pattern of validity coefficients were comparable in these Swedish samples to other non-North American samples. Implications for the cross-cultural manifestation and correlates of psychopathy are discussed.