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.

A multisite investigation of the reliability of the Scale for the Assessment of Negative Symptoms.

OBJECTIVE: The Scale for the Assessment of Negative Symptoms is a widely used instrument for measuring negative symptoms in schizophrenia, but few studies have examined its reliability. This study examined the interrater, internal, and test-retest reliabilities of the scale and its factor structure in the context of a multisite study. METHOD: Two hundred seven patients with schizophrenia who were participating in the Treatment Strategies in Schizophrenia study were assessed with the Scale for the Assessment of Negative Symptoms following a symptom exacerbation and again 3-6 months later. All assessments were performed by trained psychiatrists who were treating the patients. RESULTS: Interrater reliabilities ranged from low to high for the items on the Scale for the Assessment of Negative Symptoms but were statistically significant in most cases. Most correlations between individual items and subscale total scores were moderate to high, as were coefficient alphas for each subscale, indicating adequate internal consistency. Test-retest correlations were of moderate magnitude. Few differences in reliability statistics between sites were found, although differences in mean scale ratings between sites were present. A factor analysis indicated three factors corresponding to the Affective Flattening or Blunting subscale, the Avolition-Apathy and Anhedonia-Asociality subscales, and the Alogia and Inattention subscales. CONCLUSIONS: The results suggest that the Scale for the Assessment of Negative Symptoms has good reliability and is a useful instrument for the measurement of negative symptoms in multisite clinical studies. The internal reliability of the Alogia, Avolition-Apathy, and Inattention subscales could be improved by replacing some items and including additional items.

Double jeopardy: schizophrenia and substance use.

OBJECTIVE: Although the clinical reality of substance dependence and/or abuse among schizophrenia patients is widely acknowledged, the interaction of these diagnoses is not well understood. Perhaps the largest study documenting the comorbidity of substance abuse is the Epidemiologic Catchment Area (ECA) study, which found the rate to be 47% in schizophrenia patients (1). The present study examined substance use and compared the broad categories of substance users versus nonusers vis-à-vis schizophrenic symptomatology, hospitalizations, compliance, and demographic variables. We further examined the two subcategories of alcohol versus other substances of abuse (hereafter called "drugs") to determine differences. METHODS: Data were collected by the same person retrospectively from the charts of schizophrenia outpatients in a public inner city mental health center. Patients must have had at least 10 outpatient visits within a 2-year period for data to be used. RESULTS: Data were compiled from 262 charts. Of the schizophrenia patients, 55% had a history of past or current substance use. Consistent with previous reports, substance-using schizophrenia patients were more likely to be younger and male than nonusers. Substance users had significantly more hospitalizations and more outpatient visits with positive symptoms. There was also a higher rate of missed appointments in the substance-using patients, and there was a correlation between missed appointments and hospitalizations. As for the differences in the two subcategories of alcohol versus drugs, drug users had notably more negative symptoms, except in those cases for which the alcohol user required treatment for alcoholism. Current drug use also correlated with higher tardive dyskinesia scores, higher incidence of cognitive deficiency, less education, and higher average neuroleptic dose than with nonuse or alcohol use. CONCLUSION: These results extend the previous findings to a large inner city group of subjects and to a population that is at high risk for relapse. Our findings further emphasize the impact of substance use on outcome in schizophrenia and the need for more research on the nature and treatment of the patient with a dual diagnosis.

Dichotic listening in psychotic patients.

Patients recently recovered from schizophrenic or manid-depressive psychoses showed larger ear difference scores than normal controls on a dichotic listening test, i.e. when asked to identify dissimilar words fed synchronously to the two ears. The possible significance of the finding is discussed, in relation both to hemispheric organization and to other aspects of cognitive activity which may underlie performance on the task.