Integrated care in schizophrenia: a 2-year randomized controlled study of two community-based treatment programs.

OBJECTIVE: To evaluate the efficacy of two community-based programs that combined antipsychotic medication, family interventions and social skills training. METHOD: A randomized controlled trial with 2 years follow-up. The study included 84 patients with schizophrenic disorders, continuously managed in terms of care and treatment, and regularly assessed. Analysis was by intention-to-treat. RESULTS: Between-program comparisons showed significantly improved social function and consumer satisfaction in favour of the program 'Integrated Care' (IC) at the 2-year follow-up. The main clinically important differences between the two treatment programs studied were the procedures for shared decision making and patient empowerment in IC. CONCLUSION: The implementation of IC in clinical practice can improve social recovery and increase consumer satisfaction for patients with schizophrenic disorders. We identified specific procedures that might be added to improve the effectiveness of any program for severely mental ill people.

Case management and assertive community treatment in Europe.

OBJECTIVE: Case management studies from Europe and the United States continue to yield conflicting results. At a symposium at the World Psychiatric Conference in Hamburg in 1999, researchers from four European countries explored the possible reasons for differences in outcome. They also examined reasons for the differing foci of case management studies across the different cultures. The authors summarize the symposium's findings. METHODS: Individual case presentations were given of studies and services from the United Kingdom (three studies), Sweden (two studies), Germany, and Italy (one each). Outcomes, methodologies, and national service context were examined. RESULTS AND CONCLUSIONS: A significant influence of national culture is evident both in the acceptability of case management and in approaches to researching it. Case management is perceived as an "Anglophone import" in Italy but is now national policy for persons with severe mental illness in the other three countries. Studies from the United Kingdom emphasized methodological rigor, with little attention to treatment content, whereas those from Sweden accepted a less disruptive research approach but with a more prescriptive stipulation of treatment content. Studies from Italy and Germany emphasized the importance of differing descriptive methodologies. Marked differences in the range of social care provision were noted across Europe. Overall, European researchers are less concerned than U.S. researchers with studying the impact of case management on hospital use.

Event recording in psychiatric care: development of an instrument and 1-year results.

Methods for regular monitoring of care and services are needed for psychiatrists to act on, to refine practice. We developed a computer-based instrument to be used by staff working with schizophrenic patients. The instrument was tested in a group of patients randomly assigned to an integrated-care program. Data on time, place, direct/indirect contacts, and the main elements of the content of care were regularly recorded on a pocket computer and later transferred to a desktop computer for analysis. One-year data on 24 subjects are presented on three levels: individual, case load, and total patient population. Of the encounters 66% were individual patient contacts. Staff spent 59% of the time at patients' homes. A computer-aided system with built-in information on care delivery, program fidelity, and outcome can be the basis of decision-making on different health-management levels.

Patient-rated versus clinician-rated side effects of drug treatment in schizophrenia. Clinical validation of a self-rating version of the UKU Side Effect Rating Scale (UKU-SERS-Pat).

A self-rating version of the UKU Side Effect Rating Scale has been developed. The present study examines the agreement between patients' self-assessment of side effects and the attending clinicians' ratings. The patient sample consisted of 63 patients with schizophrenia under maintenance treatment with risperidone, clozapine or classical antipsychotics. Approximately two thirds of the patients used concomitant medication with e.g. benzodiazepines, SSRIs, anticholinergics. Most inter-correlations between scores for single, corresponding items, subscores of Psychic, Neurological, Autonomic and Other side effects, as well as the Total Score from the patient version of the UKU Side Effect Self Rating Scale (UKU-SERS-Pat) and the clinician version (UKU-SERS-Clin) were found to be statistically significant. Patients reported side effects more frequently and or rated symptoms more severe than the clinicians. The results support the validity of the SERS-Pat and suggest that patient rated side effects may provide important clinical information not detected by clinician rated interviews. Such information can be utilised both in clinical investigations, in development of treatment programs and for individual patients in clinical practice.

Assessment of patient satisfaction with psychiatric care. Development and clinical evaluation of a brief consumer satisfaction rating scale (UKU-ConSat).

Quality management and quality control of health services has become increasingly important. Central to the concept of quality of care is the patient's (the health care consumer's) own view of the care provided and the treatment outcome. UKU (Udvalg for Kliniske Undersøgelser; that is, Committee for Clinical Trials), a working group within the Scandinavian Society for Psychopharmacology (SSP), has designed a brief consumer satisfaction rating scale, the UKU-ConSat. Based on an extensive literature review, a number of principles related to content, assessment, interview techniques, documentation and standardisation steered the design of the rating scale. UKU-ConSat consists of six items related to the structure and process of treatment care, and two items related to outcome and well-being. A manual accompanies the rating scale with guidelines for how to solicit information from the patient and how to rate each item. A first field trial of the rating scale in 135 inpatients at multiple clinical sites in Finland and Sweden showed that it could be applied to several relevant patient categories (psychotic, affective, neurotic, organic and alcohol and substance abuse disorders). According to both patients and staff the rating scale promises to become useful both for research and for improvement of routine psychiatric services.

Consumer satisfaction in schizophrenia. A 2-year randomized controlled study of two community-based treatment programs.

Quality management and quality control of health services have become increasingly important. Central to the concept of quality of care is the consumer's (the patient's) own view of the care provided. UKU (Udvalg for Kliniske Undersøgelser), a task force within the Scandinavian Society for Psychopharmacology, has designed a brief consumer satisfaction rating scale, the UKU-ConSat. The UKU-ConSat rating scale was applied in a randomised comparative two-year study of two community-based treatment programs. The study included 84 patients with schizophrenic disorders according to DSM-IV. The major finding was a significantly increased consumer satisfaction with the new community-based program "Integrated Care" in comparison with best-established practice, called "Rational Rehabilitation." Thus, the new UKU-ConSat rating scale can detect differences, not only for in-patients as has previously been shown, but also between programs in community care settings. By per item analysis it was possible to discriminate between various elements of consumer satisfaction. There were significant correlations between the UKU-ConSat total scores and other clinical outcome domains, viz. symptoms, social function, and patient as well as carer's distress. To conclude, the UKU-ConSat rating scale is suitable for quality management and monitoring of treatment programs in mental health services.

Violence and its prediction at a psychiatric hospital.

Aggressive behaviour in psychiatric inpatients was assessed before and after a training course for staff members. The Social Dysfunction Aggression Scale (SDAS) was used to report and assess aggressive behaviour over time, and the Staff Observation Aggression Scale (SOAS) to report and assess single aggressive incidents. In addition, the numbers of nursing staff members who were on sick leave because of injuries in the periods before and after the course were recorded and compared. No statistically significant reduction was found in the number of aggressive patients or in the number of staff members on sick leave. One interesting finding was a lower reporting on the SOAS of perceived aggressive incidents after the training course in comparison with the SDAS reports. Directed verbal aggressiveness and violence towards things were found to be predictors of violence.

Comparison of quality of life with standard of living in schizophrenic out-patients.

Standard of living reflects the objective dimension of how well the basic needs of life are met, while quality of life is the patient's own subjective view of well-being and satisfaction with her/his life. Sixty-one schizophrenic out-patients completed self-report inventories and participated in interviews about quality of life and standard of living. When living standards were met by a well functioning social service system, patients' perceptions of their quality of life and their standard of living appeared to be independent. Subsequent analyses revealed that 'inner experiences' was one quality-of-life domain frequently reported as unsatisfactory. Moreover, differences in quality of life were found across patients' age, education, and work status.

The development of an observer-scale for measuring social dysfunction and aggression.

Scales for measuring aggressive cognitions and behaviour have mainly been administered by nursing-staff or been self-ratings. During recent years we have made an attempt to construct an observer-scale for aggression analogous to the Hamilton scale for depression. The Social Dysfunction and Aggression Scale (SDAS) consists of 9 items (SDAS-9) covering outward aggression and 2 items (SDAS-2) covering inward aggression. The inter-observer reliability of the SDAS has been found adequate in terms of intra-class coefficients. In a pilot study on 82 inpatients from different centres in Denmark and Sweden the SDAS was compared to three-item scales for outward and inward aggression and to a global scale for outward aggression. The results showed that the SDAS-9 correlated positively with the other outward observer-scales, and the SDAS-2 with the other inward scale. A divergent validity was seen between the outward and inward scales, indicating that it is necessary to measure both dimensions. Preliminary ranks-according-to-frequency scores showed the following order of the nine outward items: irritability, dysphoric mood, social disturbances, nondirected verbal aggressiveness, negativism, directed verbal aggressiveness, physical violence towards staff, physical violence towards things, and physical violence towards persons other than staff.

Defining treatment refractoriness in schizophrenia.

Addressing the need for research on the nature of refractoriness to antipsychotic drug therapy exhibited by a substantial minority of schizophrenic patients, Philip R.A. May and Sven Jonas Dencker instigated an international study group to discuss this problem, beginning with the International Congress of Neuropsychopharmacology in Göteborg, Sweden, in 1980. The study group subsequently met in Haar, Federal Republic of Germany, in 1985; in Banff, Canada, in 1986; and again in Telfs, Austria, in 1988. The study group set three objectives: (1) to clarify the concept of treatment resistance or refractoriness; (2) to suggest criteria for defining or rating the degree of treatment refractoriness; and (3) to explore the role of psychosocial and drug therapies in increasing the responsiveness of the treatment refractory patient. This position article represents a distillation of the study group's efforts to define treatment refractoriness in schizophrenia.

Pharmacokinetic and pharmacodynamic studies on high doses of fluphenazine.

Six chronic schizophrenics--earlier refractory to recommended doses of neuroleptic drugs but eventually responding to 250 mg fluphenazine heptanoate weekly--participated in a pharmacokinetic study. Five out of the six patients showed rather constant steady state plasma fluphenazine values on a 250 mg depot weekly. After depot drug withdrawal, the single oral dose pharmacokinetics on 400 mg fluphenazine showed the same variations in Cmax, tmax, t 1/2 and AUC as are observed when recommended doses of fluphenazine are used. We thus could not demonstrate any dose-dependent pharmacokinetics on high oral fluphenazine doses. In half the patients, a biphasic decay in the plasma concentration curve indicated at least two compartments. The patients were then studied for up to 2 years on 200-500 mg fluphenazine as a single daily dose. The fluphenazine plasma levels were rather constant in the individual patients during this period. The plasma prolactin values were related to the fluphenazine values even in the high value area, thus showing a persistent pharmacodynamic variation capacity. The clinical part of the study did not show any relevant findings.

Schizophrenic relapse after drug withdrawal is predictable.

Thirty-two patients in remission were followed by regular ratings during a prospective neuroleptic withdrawal study. They were outpatients who fulfilled the DSM-III criteria of schizophrenia and who were motivated for drug withdrawal. The relapse rate was 81%. The results from the rating scales confirm the hypothesis that a symptom increase occurs before psychotic relapse. In the order statistical differences occurred, the factors predicting relapse were those concerned with positive psychopathology, motor dysfunction, impaired affects and sleep disturbances. The corresponding symptoms and signs were mainly concerned with thought disorders, paranoid ideation, overactivity, depression and insomnia middle, all of nonpsychotic degree of severity. If prodromes appear, the patient should resume his neuroleptic treatment, or other preventive measures should be taken. By such therapeutic interactions, psychotic relapse may be prevented, or can be dealt with in an outpatient setting.

Patients admitted for compulsory treatment to selected psychiatric units in Italy and in Sweden.

Eighty-five Italian and forty-nine Swedish patients consecutively admitted for compulsory treatment to either an Italian or a Swedish psychiatric unit in selected areas of the two countries have participated in an exploratory study aimed at assessing the main characteristics of compulsory admitted patients, and in particular, the immediate reason for admission. The two series proved to be quite similar as concerns most sociodemographic variables, and as concerns clinical diagnosis and severity of the morbid condition at admission as measured by means of a rating scale. More Swedish than Italian patients lived alone when admitted to hospital, and for more of them the request for admission was made by other people than relatives, and a larger proportion of them was accompanied to the hospital by medical or social welfare personnel. In both series the largest proportion had a low educational level and belonged to the lower social groups. The same proportion in the two series had previous admissions. The most common reason for admission was "odd or improper behaviour" for the Swedish patients, and "feared or manifest dangerousness" for the Italian patients. The Italian patients remained at hospital on average half the time than the Swedish patients.

Serum concentrations of cis(Z)-flupentixol and prolactin in chronic schizophrenic patients treated with flupentixol and cis(Z)-flupentixol decanoate.

Nine chronic schizophrenic patients selected from three hospital departments were treated with flupentixol (orally and IV) and cis(Z)-flupentixol decanoate in Viscoleo (IM) in a three-phase pharmacokinetic study. Oral administration (single and repeated dosage) showed a relatively slow absorption with maximum serum concentration around 4 h after administration. Intravenous injection indicated multicompartment kinetics for cis(Z)-flupentixol. The biological half-lives calculated after the different doses were the same, indicating that the pharmacokinetics of cis(Z)-flupentixol does not differ between single and repeated administration and does not change when moderately higher doses are given. The bioavailability of orally administered cis(Z)-flupentixol was calculated to be about 40% with IV injection as reference. After IM administration maximum serum concentration was seen between 4 and 10 days in most patients. Calculation of a disappearance half-life gave very variable results, indicating that the release of the drug from the oil depot is not a monoexponential process. The intramuscular depot had a much lower bioavailability than IV injection, which means that steady state has not been obtained after 8 weeks of depot treatment. Serum prolactin concentrations were elevated during neuroleptic treatment, but no correlation was found between prolactin concentrations and the serum concentrations of cis(Z)-flupentixol. A correlation between the changes in clinical ratings and concentrations of cis(Z)-flupentixol or prolactin was not found.