A program for relapse prevention in schizophrenia: a controlled study.

BACKGROUND: This study examined whether a program for relapse prevention (PRP) is more effective than treatment as usual (TAU) in reducing relapse and rehospitalization rates among outpatients with schizophrenia. METHODS: Eighty-two outpatients with DSM-III-R schizophrenia or schizoaffective disorder were randomly assigned to receive either PRP (experimental group, n = 41) or TAU (control group, n = 41) and were followed up for an 18-month prospective controlled study. Patients in both groups were prescribed standard doses of maintenance antipsychotic medication. Treatment with PRP consisted of a combination of psychoeducation, active monitoring for prodromal symptoms with clinical intervention when such symptoms occurred, weekly group therapy for patients, and multifamily groups. The TAU consisted of biweekly individual supportive therapy and medication management. RESULTS: Outcome rates over 18 months were 17% for relapse (7 patients) and 22% for rehospitalization (9 patients) in the PRP group, compared with 34% for relapse (14 patients) and 39% for rehospitalization (16 patients) in the TAU group (P = .01 and P = .03, respectively). Addition of age, sex, baseline Global Assessment Scale score, Positive and Negative Syndrome Scale scores (3 measures), and substance abuse to the proportional hazards regression models all yielded nonsignificant effects. The PRP teams were much more likely than the TAU psychiatrists to identify prodromal episodes before patients met objective relapse criteria or needed hospitalization. CONCLUSIONS: The PRP was effective in detecting prodromal symptoms of relapse early in an episode. Crisis intervention including increased antipsychotic medication use during the prodromal phase reduced relapse and rehospitalization rates.

Concurrent assessment of acoustic startle and auditory P50 evoked potential measures of sensory inhibition.

The acoustic startle response (ASR) and midlatency auditory evoked potentials (AEP) have been utilized in the measurement of sensory inhibition. Using these different paradigms, abnormalities suggesting a lack of normal inhibition have been noted in a number of psychiatric syndromes. To date, the most commonly used sensory inhibition paradigms have not been studied in the same individuals, making generalizations across studies tenuous. In this report, reduction of ASR over multiple trials (habituation), prepulse inhibition (PPI) of ASR (decrease in ASR caused by low intensity prepulses) and P50 suppression (P50 AEP amplitude reduction in a paired-click paradigm) were measured in the same individuals. Relationships between these measures of acoustic startle and AEP inhibition were then assessed. Twenty subjects with no personal history of psychiatric disorder were tested and exhibited significant habituation and PPI of ASR as well as P50 suppression. Habituation of ASR was significantly and positively correlated with P50 suppression early, but not late, in AEP testing. Only a modest trend for a positive association between PPI and P50 suppression was noted. Habituation and PPI of startle were both highly correlated (positively) with P50 AEP amplitude. Habituation of startle remained significantly predictive of P50 suppression after controlling for P50 amplitude, whereas the modest association between PPI and P50 suppression was removed when P50 amplitude was factored out. Results indicate that habituation of acoustic startle, but not PPI, is highly associated with P50 suppression in control subjects. An unexpected finding was a robust positive correlation between P50 amplitude and both measures of startle inhibition. These findings and methodologic issues are discussed in terms of possible neural substrates involved in different measures of sensory inhibition.

Visual evoked potential correlates of positive/negative symptoms in schizophrenia.

Previous studies of schizophrenic patients have found evoked potential (EP) correlates of clinical symptomatology, including EP differences between subtypes of schizophrenia. In the current study, 14 medicated male schizophrenics underwent flash visual evoked potentials (VEP) and were clinically rated for positive and negative symptoms. We tested the hypothesis that positive symptoms would be associated with VEP latency reduction and negative symptoms with latency prolongation. Patients were divided into predominantly positive symptom and predominantly negative symptom groups using a combination of positive and negative symptom ratings. Patients with predominantly positive symptoms exhibited reduced latencies when compared with predominantly negative symptom patients. Similarly, significant negative correlations between positive symptom ratings and P200 latency variables were found. Correlations between negative symptom measures and P200 latencies (in the opposite direction) were also noted, but were less significant. These relationships persisted when confounders were statistically controlled for. The results are consistent with previous findings of evoked potential correlates of clinical symptomatology, especially those finding EP latency correlates of psychosis severity and affective blunting. The findings are discussed in relationship to concepts relevant to psychosis, including arousal, sensory gating, and the dopamine hypothesis.

Weight gain among schizophrenic patients treated with clozapine.

A retrospective chart review was used to assess weight changes in 36 chronic schizophrenic inpatients who were treated with clozapine after being treated with standard neuroleptics. The average weight gain during 6 months of clozapine treatment was 16.9 lb; 75.0% of the patients gained at least 10 lb. The results confirm previous findings of clozapine-associated weight gain.

Filgrastim treatment of three patients with clozapine-induced agranulocytosis.

BACKGROUND: Agranulocytosis is the most serious side effect of clozapine therapy, occurring in approximately 1% of all treated patients. Despite careful blood monitoring, a significant number of cases of agranulocytosis and resulting fatalities have occurred. Strategies are needed to manage clozapine-induced agranulocytosis more safely. METHOD: This report describes the management of three state hospital inpatients who developed clozapine-induced agranulocytosis. All patients were diagnosed as having chronic paranoid schizophrenia according to DSM-III-R criteria and had previously failed to respond to treatment with standard antipsychotic medications. After onset of agranulocytosis, all patients were transferred to a medical service in a university hospital and treated with recombinant granulocyte colony-stimulating factor (filgrastim). RESULTS: White blood count and absolute neutrophil count returned to within normal limits in each patient after 5 to 8 days of treatment with filgrastim 300 micrograms/day subcutaneously. No side effects were observed during filgrastim treatment. CONCLUSION: Treatment with filgrastim appears to be safe and effective in decreasing the duration of clozapine-induced agranulocytosis. While further studies are necessary to establish the safety and effectiveness of this treatment, filgrastim should presently be considered a treatment of choice for clozapine-induced agranulocytosis.

Prodromal symptoms and relapse prevention in schizophrenia.

The value of monitoring for prodromal symptoms in patients with schizophrenia has been questioned by some investigators who point out that their positive predictive value, sensitivity, and specificity can be low in relation to relapse. This article focuses on methodological and conceptual issues which should be considered in evaluating the usefulness of prodromal symptoms and behaviors as part of the relapse process. The article presents the following conclusions: Many relapses are preceded by the appearance of prodromal symptoms and behaviors which may last from a few days to a few weeks or more. The presence of prodromal symptoms often does not predict impending relapse since the probability of progression to relapse depends on the complex interaction of many personal and environmental factors including the availability of prompt and effective psychiatric intervention. Finally, studies have shown that monitoring for prodromal symptoms and early intervention when they emerge is effective in reducing the likelihood of relapse in individuals with schizophrenia.

Within-session changes in sensory gating assessed by P50 evoked potentials in normal subjects.

1. The authors studied within-session changes in P50 suppression occurring in a group of 28 normal subjects. 2. A conditioning-testing paradigm was used with 120 pairs of 110 Db peak intensity clicks. Clicks were of 0.04 msec duration, 500 msec separation and delivered through headphones at 10 second intervals. 3. Mean P50 suppression ranged from 60.5% during the first 30 click pairs to -19.1% during the last 30 pairs, with an overall mean suppression of 25.4%. 4. The authors concluded that P50 suppression is a dynamic process in normal subjects, and that further work is necessary to elucidate the factors affecting P50 suppression.

Seven keys to relapse prevention in schizophrenia.

Relapse prevention is a primary goal in the treatment of schizophrenia. Relapse can cause significant personal distress, interfere with rehabilitation efforts, and result in psychiatric hospitalization. The emergence of psychotic symptoms and disruptive behaviors can also lead to arrest and incarceration, particularly among patients who are not engaged in treatment. This article focuses on the process of relapse in schizophrenia and theoretical foundations of relapse prevention. The Program for Relapse Prevention is presented, along with the results of a recently completed controlled prospective evaluation. Based upon this study and the current literature, the author presents a series of seven clinical strategies for optimal relapse prevention.

Integrating criminal justice, community healthcare, and support services for adults with severe mental disorders.

Persons with severe mental disorders are overrepresented in our nation's jails and prisons. Factors including cooccurring substance use disorders, homelessness, and lack of access to community services have contributed to this problem, as have gaps between criminal justice, healthcare, and community support systems. In order to address these issues, Project Link was developed by the University of Rochester Department of Psychiatry in collaboration with five local community agencies. Project Link is designed to prevent involvement of individuals with severe mental illness from entering the criminal justice system. While many models of diversion programs exist, they are all dependent on access to appropriate community-based services. This paper will describe the steps that Project Link has taken towards integrating criminal justice, healthcare, and community support services for individuals with severe mental disorders involved in the criminal justice system.

Intensive Psychiatric Rehabilitation Treatment (IPRT): an overview of a new program.

Intensive Psychiatric Rehabilitation Treatment (IPRT) is a new program of out-patient psychiatric rehabilitation which is currently operating in New York State and Iowa. IPRT is based upon a process of psychiatric rehabilitation which was developed at the Boston University Center for Psychiatric Rehabilitation. The purpose of IPRT is to assist individuals with serious and persistent mental illness in identifying and achieving personally meaningful goals within the community. This article will provide an overview of IPRT by examining the program as it operates in New York State, the research foundations of the program, and the preliminary results of a state-wide evaluation of IPRT programs. IPRT is an important new program of outpatient psychiatric rehabilitation. Controlled studies are needed to establish the effectiveness of the program.

The mentally ill in jails and prisons: towards an integrated model of prevention.

Jails and prisons have become a final destination for persons with severe mental illness in America. Addiction, homelessness, and fragmentation of services have contributed to the problem, and have underscored the need for new models of service delivery. Project Link is a university-led consortium of five community agencies in Monroe County, New York that spans healthcare, social service and criminal justice systems. The program features a mobile treatment team with a forensic psychiatrist, a dual diagnosis treatment residence, and culturally competent staff. This paper discusses the importance of service integration in preventing jail and hospital recidivism, and describes steps that Project Link has taken towards integrating healthcare, criminal justice, and social services. Results from a preliminary evaluation suggest that Project Link may be effective in reducing recidivism and in improving community adjustment among severely mentally ill patients with histories of arrest and incarceration.