Top ten concerns burdening people with cancer: Perceptions of patients with cancer and the nurses caring for them.

PURPOSE: We examined the concerns that nurses perceive patients to have, whether these are congruent with patients' concerns and whether they vary according to cancer site. We also examined Distress Thermometer scores according to cancer site. METHOD: A cross-sectional survey design: (i) secondary analysis of an existing Holistic Needs Assessment (HNA) and Distress Thermometer (DT) dataset was used, (ii) a survey of specialist nurse teams to identify their perceptions of patient concerns. Data collected between January 2015 and June 2016 from the HNA database from one NHS Trust in England (n = 1233 patients). Specialist nurse teams for breast, colorectal, gynaecology, skin and urology cancers identified the concerns that they perceived their patients would report. RESULTS: The HNA showed high internal consistency (Cronbach's alpha 0.86). Across the five cancer sites, nurses identified between 3 and 6 of the top ten concerns (TTC) expressed by patients, with wide variation across cancer sites. Nine of the TTC were significantly associated (p < 0.05) with a specific cancer site. The breast and gynaecological cancer groups both recorded significantly higher median Distress Thermometer scores than the urology, skin and colorectal cancer groups (Kruskall-Wallis χ2 (4, n = 1228) 186.695, p=<.01). CONCLUSIONS: One of the aims of the eHNA is to enable service delivery appropriate to patient needs. Our findings suggest that this will only be achieved if eHNA is examined, and services developed, by individual cancer site. The misconception of patient needs by specialist nurses underscores the importance of review of information provided by patients during consultations.

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 critical review of research on psychosocial treatment of schizophrenia.

In the following review, the evidence for the effectiveness of the psychosocial treatments of schizophrenia are evaluated. Although most studies focus on relapse and hospitalization, when available, we present information on other domains of outcome (e.g., social adjustment and employment). We begin with family treatments for schizophrenia, then intensive case management, followed by social skills training, supported employment programs, and finally, individual psychotherapy. The topics have been chosen in descending order of available critical supportive studies. Recommendations for specific psychosocial interventions (including target populations) are discussed. Overall psychosocial treatments have been shown to reduce schizophrenic relapses but have not convincingly generalized to improving other facets of the illness. Despite this, psychosocial treatments should be supported and further research to improve them is necessary.

Placebos and paradoxes in psychiatric research: an ethics perspective.

The use of placebos in clinical trials, particularly in research with mentally ill people, has emerged as a subject of considerable controversy. We first outline ethical aspects of the primary scientific arguments for and against placebo use in research. Three examples of paradoxical aspects of the ethical use of placebos are discussed: involvement of relatively more vulnerable populations, use of apparently "less than standard" therapy, and the omission of information in placebo comparisons. In the current scientific and regulatory context, placebo use in psychiatric research may be necessary for scientific reasons, and when certain conditions are present, it may be justified on ethical grounds. Four key recommendations to facilitate the ethical use of placebos in research trials are presented. We conclude that placebo trials should be undertaken only after careful evaluation of alternative scientific strategies and, as with all human research, with great respect and genuine consideration for the individuals who choose to participate in these protocols.

Consideration of the relevance of ethological animal models for human repetitive behavioral spectrum disorders.

Treatment successes of various stereotyped behaviors in animals and humans has renewed interest in ethologic animal models for the study of psychiatric disorders. This report presents another such behavior occurring in horses to weaving. This anomalous, repetitive, and purposeless behavior draws analogies to human compulsive spectrum behaviors. A "weaver" provided an opportunity to evaluate serotonin, dopamine, and opioid neurotransmitter system contributions by probing each with a selective agent in A-B-A-C-A-D design. The horse was treated in sequential 1-month periods separated by 1-month washouts with a serotonin transport inhibitor (SRI), opiate antagonist (OA), and neuroleptic (DA). Videotape was taken weekly and analyzed by two blind raters. Frequency of head swings, latency to onset, and severity were recorded. The SRI showed > 95% symptom reduction, the DA 40%, and OA 30%. The findings suggest that neurochemical explanations of disturbance based on single drug vs. placebo trials may be oversimplified. Multiple-system probes are needed to dissect complex interactive biological systems. Animal model research can have an important role in such investigations.

Research on the psychosocial treatment of schizophrenia: a summary report.

The authors present an overview of research on psychosocial treatments for schizophrenia. Findings from studies of five therapeutic approaches--individual psychotherapy, group psychotherapy, family therapy, milieu therapy, and community support systems--are discussed in detail. The usefulness of each type of therapy is critically assessed on the basis of available data from controlled outcome studies. The authors make recommendations regarding high-priority areas to be addressed in future studies of psychosocial treatment.

Evaluating characteristics of patient selection and dropout rates.

Patient selection and dropout rates can affect the results of a clinical trial. Long lists of exclusions in the selection of patients for clinical trials reduce the possibility of examining treatment responses for heterogeneity and make recruitment difficult. In many cases, a pool of 100 potential subjects may yield only 2 or 3 qualified participants, a fact that raises the issue of generalizability of results. Dropouts should be carefully defined in advance and can be used as dependent variables for the comparison of different treatments. This article discusses some of the sampling characteristics (gender, age, diagnosis, inpatient/ outpatient status, prior neuroleptic use, and symptom severity) and dropout rates in 5 recent comparative clinical trials of atypical antipsychotics.

Sildenafil for iatrogenic serotonergic antidepressant medication-induced sexual dysfunction in 4 patients.

OBJECTIVE: To evaluate the effect of sildenafil on iatrogenic serotonergic antidepressant-induced sexual dysfunction. METHOD: Four outpatients (2 men, 2 women) who developed sexual dysfunction (erectile impotence, anorgasmia) during treatment with a serotonin reuptake inhibitor antidepressant for psychiatric disorder were selected. Each subject was initially prescribed sildenafil 50 mg to be taken approximately 1 hour before sexual activity. The dose was increased to 100 mg for a partial or failed response. RESULTS: Four cases are detailed in case report fashion. All 4 had rapid reversal of their sexual dysfunction, usually with the first dose. Reversal equates to 1 successful use of sildenafil in each of 2 patients and 3 uses in 2 patients. CONCLUSION: Sildenafil may be an effective treatment for serotonergic antidepressant-induced sexual dysfunction and deserves further evaluation in randomized placebo-controlled studies.

Psychosocial treatment: individual, group, family, and community support approaches.

The authors present an overview of research on psychosocial treatments for schizophrenia. Findings from studies of four therapeutic approaches--individual psychotherapy, group psychotherapy, family therapy, and community support systems--are discussed in detail. The usefulness of each type of therapy is critically assessed on the basis of available data from controlled outcome studies. The authors make recommendations regarding high-priority areas to be addressed in future studies of psychosocial treatments.

The diagnosis of schizophrenia: a review of onset and duration issues.

The diagnosis of schizophrenia remains a topic of continuing dialogue both within the United States and internationally, as witnessed by the numerous revisions to the Diagnostic and Statistical Manual (i.e., DSM-I, DSM-II, DSM-III, and DSM-III-R) and the International Classification of Diseases (i.e., ICD-9, and ICD-10). At issue is how best to characterize patients suffering the debilitating symptoms and chronicity associated with the disease and, at the same time, arrive at a diagnosis that has specific clinical utility and can be reliably assessed. The purpose of the following report is to review three issues associated with the diagnosis of schizophrenia: the role of prodromal and residual symptoms, the duration of psychotic symptoms, and the 6-month versus 1-month time criterion. Our general recommendation, based on extant studies providing data related to various facets of the issues under debate, is to use diagnostic criteria that are consistent with the international diagnostic system. However, final decisions will depend on the outcome of the ongoing DSM-IV field trials.

U.S. and Soviet perspectives on the diagnosis of schizophrenia and associated dangerousness.

During a visit of U.S. senior mental health and forensic experts to the Soviet Union to assess recent changes in Soviet psychiatry, a symposium was held to discuss the U.S. and Soviet concepts of the diagnosis of schizophrenia and dangerousness associated with psychiatric illness. The basic conclusion from this exchange was that significant differences exist between the countries in both areas, as the U.S. conceptualization of schizophrenia and associated dangerousness is considerably narrower than that of Soviet practice. Clearly, future scientific exchange is warranted to examine these conceptual differences in an effort to establish a better empirical basis for assessing the most appropriate medical treatment and legal disposition for patients.

Research on first-episode psychosis: report on a National Institute of Mental Health Workshop.

The need to focus increased research on patients experiencing their first episode of psychosis was emphasized in A National Plan for Schizophrenia Research. To develop strategies for enhancing research in this area, a National Institute of Mental Health Workshop on First-Episode Psychosis was held in 1991. The topics discussed at that workshop are summarized, with key issues including the following: (1) the need for better operational definitions of onset, end of an episode, and relapse of psychosis; (2) careful consideration of inclusion and exclusion criteria related to age, gender, prior treatment, comorbid substance abuse, and similar issues; (3) the challenge of finding patients never exposed to neuroleptics and the value of entering first-episode patients into standardized treatment protocols; (4) the design of followup studies; (5) strategies to increase the pool of applicants; and (6) approaches for increasing power through data sharing and collaboration between groups.

What is schizophrenia?

One of the main questions related to schizophrenia is, naturally enough, what is it? Such a question may seem obvious, naive, impossible, or any combination of these. And certainly it is a bit demanding to expect that anyone could say what schizophrenia is in 1,000 words. On the other hand, we felt that it was worth the effort. We hope that presenting these brief discussions on "what is schizophrenia" by persons who have worked extensively in the field will allow the reader to note areas of overlap and disagreement as well as variations in emphasis. Although no one may yet be able to provide the definitive answer, at least this collection of informed opinions may help clarify the major questions. The group of essays by Solomon H. Snyder, Seymour S. Kety, and Michael J. Goldstein is the second in this series. Further collections of these statements will be presented in subsequent issues. Readers' responses and comments are cordially invited.

Family treatment and medication dosage reduction in schizophrenia: effects on patient social functioning, family attitudes, and burden.

The effects of 2 family intervention programs (supportive family management [SFM], including monthly support groups for 2 years; or applied family management [AFM], including 1 year of behavioral family therapy plus support groups for 2 years), and 3 different neuroleptic dosage strategies (standard, low, targeted) on social functioning of patients with schizophrenia. their relatives' attitudes, and family burden were examined. AFM was associated with lower rejecting attitudes by relatives toward patients and less friction in the family perceived by patients. Patients in both AFM and SFM improved in social functioning but did not differ, whereas family burden was unchanged. Medication strategy had few effects, nor did it interact with family intervention. The addition of time-limited behavioral family therapy to monthly support groups improved family atmosphere, but did not influence patient social functioning or family burden.

Integrating treatments in schizophrenia.

Schizophrenia is a common and severe illness found throughout the world. Onset is usually in adolescence and young adulthood, and many individuals have illness-related impairments for life. Schizophrenia assaults the very essence of what is distinctly human. The personality is devastated, subjective experience and thought distorted, and the psychological building blocks of everyday life torn asunder. This article discusses diagnostic and conceptual considerations, pharmacotherapy, and interpersonal strategies of integrating therapeutics for schizophrenics.

The costs of schizophrenia. Assessing the burden.

Much has been learned about the costs of schizophrenia during the last three decades. Assessing the costs is a challenging task given the complexity of the disease. Much can be done to refine the methodologies of cost of schizophrenia studies based on the human capital approach and to develop the conceptual framework for a consistent account of the income distribution effects of the disease. The knowledge base, however, is quite extensive and data presented here indicate that although people with schizophrenia account only for about 1% of the adult population, they consume about 2.5% of total annual health care expenditures, they constitute about 10% of the totally and permanently disabled population, and comprise as high as about 14% of the homeless population in some large urban areas. These data clearly indicate the negative economic consequences of the disease: People with schizophrenia tend to be high users of medical care and tend to concentrate in subpopulations that are highly dependent on public assistance funds as a result of the disabling nature of the disease. These negative economic consequences of schizophrenia provide a powerful economic case for developing strategies to improve treatment effectiveness through biomedical and services research.

Transition from acute to maintenance treatment: prediction of stabilization.

The stabilization period that follows the exacerbation of a schizophrenic illness represents a critical point in the course of the illness. Successful stabilization is a prerequisite to long-term tenure in the community and the possibility of improvement in functional outcome. In this paper we present an operational definition of stabilization, developed in the context of a study of long-term maintenance treatment that incorporates time, symptomatic equilibrium and consistency of medication dosage. Patients were identified at the time of hospitalization and followed prospectively to determine whether or not they met stabilization criteria. Characteristics that predicted successful stabilization included measures drawn from the domains of patient personal characteristics and psychiatric history, symptoms of psychopathology and side effects in response to initial treatment and family judgments. These patients were treated primarily with fluphenazine decanoate, and five distinct dosing strategies with this agent were identified retrospectively. The dosing strategies distinguished the length of time to subsequent stabilization. The implications of these findings for clinical management of schizophrenia are discussed.

Effects of chronic haloperidol and clozapine treatments on frontal and caudate neurochemistry in schizophrenia.

N-Acetyl-aspartate (NAA), a marker of neuronal integrity, has been found to be reduced in frontal regions in schizophrenia. However, the impact of antipsychotic drug type on NAA has not been carefully evaluated. We studied outpatients with schizophrenia/schizoaffective disorders chronically treated with haloperidol or clozapine and normal controls with single-voxel 1H-MRS of the caudate nuclei and the left frontal lobe. Concentrations of NAA, choline containing compounds (Cho) and creatine plus phosphocreatine (Cre) were determined and corrected for the proportion of cerebrospinal fluid (CSF) in each voxel. The haloperidol-treated group had significantly lower CSF-uncorrected and CSF-corrected left frontal NAA than the normal controls, with the clozapine group having intermediate concentrations. The haloperidol-treated group had significantly lower CSF-uncorrected caudate NAA than the normal controls, but the three groups did not differ after correcting for CSF fraction. Performance times in the Grooved Pegboard, a measure of motor dexterity and proxy for parkinsonism, were correlated with CSF-uncorrected and CSF-corrected left frontal NAA. Demographic and illness-related variables were not related to NAA. Exposure to haloperidol-like drugs may in part account for the frontal NAA reductions previously reported in schizophrenia. Adjustment for proportion of voxel CSF should be considered in 1H-MRS studies.

Schizophrenia: improving outcome.

Therapeutic advances over the last four decades have enabled most persons with schizophrenia to live in the community. Nevertheless, the majority will continue to experience various symptoms and to have social and cognitive disabilities. With the development of new medications and psychosocial interventions, outpatient status can no longer be viewed as a satisfactory final outcome. This article presents the current state of schizophrenia therapeutics in a variety of clinically relevant situations: first-episode psychosis, treatment-resistant psychosis, chronic, relapsing psychosis, continuous poor functioning, and chronic psychosis not responsive to pharmacotherapy. The first-line atypical antipsychotics should generally be used, mainly because of their comparatively benign side-effect profiles, and they should be given as early as possible in the illness. The clinician should not be quick to accept persistent psychosis; the second-line atypical clozapine should be tried early in the course of the disease in patients showing treatment resistance. For patients residing with their families, educational and supportive family interventions have an important effect on relapse prevention; for those who live on their own and suffer frequent relapses, Assertive Community Treatment may be helpful. Patients with psychosis that is not responsive to pharmacotherapy may benefit from specific modalities of cognitive-behavioral therapy currently being developed, while persons with persistent negative symptoms and limited social competence may find social-skills training useful. In addition, new programs of supported employment may enable some patients to maintain competitive employment.

Mental disorders in primary care services: an update.

Frank mental disorders, such as depression and panic disorder, are prevalent in primary care; they cause people substantial suffering and interfere with daily functioning. Even subthreshold or "subsyndromal" conditions, with fewer symptoms than necessary for making a diagnosis, cause substantial morbidity. Recent literature on mental disorders in primary care, where many, if not most, people with mental health problems are seen, is reviewed with focus on recognition and diagnosis issues, management of these problems in primary care, obstacles to accurate diagnosis and appropriate treatment, and prevention issues. In addition to a review of recent research, there is an effort to place these topics in the context of various directives, including research and Federal documents, that have direct implications for better treatment in primary care of people with mental disorders (for example, practice guidelines). Mental health problems and disorders seen in primary care are a public health problem meriting immediate attention and substantial work at many levels--clinical, educational, organizational, and budgetary.