The impact of subjective well-being under neuroleptic treatment on compliance and remission

The patients' perspective of antipsychotic treatment was largely neglected for a long period. It has only been during the last 10 years, with the development of atypical antipsychotics, that scientific interest in this issue has markedly increased. Numerous studies have shown that the majority of schizophrenic patients are able to fill out a self-rating scale in a meaningful way, and several self-report scales with sufficient internal consistency and good construct validity have been developed. The effects of antipsychotic treatment on psychopathology and on subjective well-being (SW) are not strongly related; the perspectives of the patient and his/her psychiatrist markedly differ. Recent research indicates that SW/quality of life, much more improved by atypical than by typical antipsychotics, has a strong impact on compliance, as well as on the chance of achieving remission. The data strongly suggest that a systematic evaluation of the patient's perspective of antipsychotic treatment is meaningful and necessary to increase compliance, functional outcome, and long-term prognosis.     

Schizophrenic patients' experiences of neuroleptic medication: a Q-methodological investigation

Day JC, Bentall RP, Warner S. Schizophrenic patients' experiences of neuroleptic medication: a Q-methodological investigation. Acta Psychiatr Scand 1996: 93: 397–402. © Munksgaard 1996. Q-methodology was used to explore the experiences of 50 medicated schizophrenic patients. Four main factors were identified. Participants loading on the first factor agreed with statements suggesting an uncomplaining attitude towards their medication and also with statements indicating a dependent attitude towards the medical profession. Those loading on the second factor endorsed statements indicative of a sceptical attitude towards medication, together with a concern for personal autonomy. Participants loading on the third factor had apparently made a balanced appraisal of the advantages and disadvantages of their medication, whereas those who loaded positively on the final factor reported positive benefits of medication but a sceptical attitude towards medical advice. The study highlights the complexity of psychiatric patients' attitudes to treatment.     

Effect of patients' reasons for refusing treatment on implementing psychiatric advance directives

OBJECTIVE: Clinicians have raised concerns that psychiatric advance directives may be used to refuse all treatment. However, people writing psychiatric advance directives can explicitly state their reasoning underlying treatment decisions. This study examined whether patients' reasons for refusing treatment influenced clinician decision making about implementing psychiatric advance directives. METHODS: A total of 597 mental health professionals completed a questionnaire that presented two scenarios: one in which the patient wrote a psychiatric advance directive refusing all medication because of paranoid delusions and one in which the patient wrote a psychiatric advance directive refusing all medication because of concerns about side effects. RESULTS: Twenty-two percent of clinicians reported that they would respect the former psychiatric advance directive, whereas 72% reported that they would respect the latter. After multivariate regression was used, the reason for treatment refusal remained the single significant predictor of clinicians' decision to honor a patient's psychiatric advance directive. CONCLUSIONS: Results show reasons for treatment refusal in psychiatric advance directives are likely to affect clinicians' decisions to implement the directives.     

Frequent rehospitalization and noncompliance with treatment

The relationship between frequent rehospitalization and compliance with treatment (medication and aftercare) was examined in a retrospective chart review of patients treated at an urban community mental health center over an 18-month period. Twenty-five patients who had been hospitalized three or more times during the study period were compared with a matched group of 25 patients who had been hospitalized less than three times and with the total group of 698 patients active at the center throughout that period. The study found a highly significant correlation between noncompliance with medication and frequent rehospitalization. Compared with the general psychiatric patient population, frequently hospitalized patients tended to be younger and to have a chronic psychiatric illness, particularly one with an affective component, that featured at least intermittent psychosis. The author recommends study of outpatient commitment to treatment as a means of reducing noncompliance.     

A preliminary comparison of guided compliance and high-probability instructional sequences as treatment for noncompliance in children with developmental disabilities.

The efficacy of guided compliance and high-probability instructional sequences was compared with two children referred to an outpatient clinic for treatment of noncompliance. Parents were taught to implement the procedures in their homes, and parent-training outcomes for the two interventions were compared in terms of treatment effectiveness, procedural integrity, and parent satisfaction. Levels of compliance were higher under guided compliance than under high-probability instructional sequences. Nevertheless, parents rapidly learned to implement both treatments with a high degree of accuracy and reported equal satisfaction with the procedures.     

Predicting outcome of neuroleptic treatment on the basis of subjective response and early clinical improvement

The predictive value of the subjective response after 4 hours to an oral test dose of haloperidol and the predictive value of early clinical improvement during a 28-day, fixed-dose regimen with haloperidol were tested in 33 newly admitted schizophrenic patients. A significant (p less than .01) correlation was found between subjective response and therapeutic outcome on Day 28. Five of the 7 patients with dysphoric responses to the test dose had poor therapeutic outcomes. Powerful relationships were found between therapeutic outcome on Day 28 and clinical improvement observed from Day 2 on and between the outcome at discharge and improvement measured on Days 5 and 6.     

The reliability of compliance assessments performed by doctors and patients during neuroleptic treatment: a comparison of compliance ratings.

OBJECTIVE: To compare compliance assessments made by doctors and patients during neuroleptic drug treatment and to detect any variables explaining the discrepancies between their ratings. METHOD: Compliance reports regarding neuroleptic medication were collected from 100 in-patients and out-patients and from their doctors. Re-ratings were performed after 1-2 weeks. Compliance ratings were compared with demographic, treatment and symptom-related variables and with the Attitudes to Neuroleptic Treatment (ANT) questionnaire using logistic regression analysis. RESULTS: The doctors' and patients' compliance ratings showed good test-retest reliability (r=0.80, doctors; r=0.81, patients) and concordance (79% of the cases within the limits of +/-25%-units deviation). Variables explaining discrepancies between the ratings included female gender, a low level of education, the diagnosis of mania, a high neuroleptic dose and several items from the ANT scale. CONCLUSION: Manic episodes, negative attitudes to neuroleptic medication and a high-dose treatment increase the risk for deviating views of compliance in the doctor-patient relationship.     

Movement disorders with neuroleptic drug treatment

Antipsychotic drugs produce several neurologic complications including acute dyskinesia, parkinsonism, neuroleptic malignant syndrome, akathisia, and tardive dyskinesia. Despite increased awareness of these syndromes, they continue to be underdiagnosed among patients receiving antipsychotic drugs. The clinical features, possible pathophysiologic mechanisms, and treatment of these conditions are discussed in this review.     

Meige's syndrome associated with neuroleptic treatment

Meige's syndrome is characterized by blepharospasm and oromandibular dystonia. Three cases are presented; two were associated with long-term neuroleptic administration. This drug-induced syndrome may be a variant of tardive dystonia, and prompt discontinuation of neuroleptic treatment may be therapeutic.     

Schizophrenic patients' perceptions of stress, expressed emotion, and sensitivity to criticism

This study was designed to get an "insider's view" of expressed emotion (EE) from the perspective of schizophrenic patients. Thirty-two patient and "influential other" pairs participated in the study. Patients' perceptions of EE attitudes in influential others were examined to determine whether they corresponded with actual EE ratings. Patients also rated how "stressed" they felt when interacting with their influential others, and patients' general sensitivity to criticism (STC) was assessed. As predicted, patients' perceptions of critical attitudes were related to actual EE ratings of criticism, although patients' perceptions of emotional overinvolvement (EOI) were not related to EOI ratings. Patients reported feeling more stressed when interacting with high-EE influential others, supporting an "EE as stressor" hypothesis. Finally, patients' STC influenced the level of stress they reported.     

Clinical factors associated with treatment noncompliance in euthymic bipolar patients

BACKGROUND: Noncompliance with medication is a very common feature among bipolar patients. Rates of poor compliance may reach 64% for bipolar disorders, and noncompliance is the most frequent cause of recurrence. Knowledge of the clinical factors associated with noncompliance would enhance clinical management and the design of strategies to achieve a better outcome for bipolar patients. Although most patients withdraw from medication during maintenance treatment, compliance studies in euthymic bipolar samples are scarce. METHOD: Compliance treatment and its clinical correlates were assessed at the end of 2-year follow-up in 200 patients meeting Research Diagnostic Criteria for bipolar I or bipolar II disorder by means of compliance-focused interviews, measurements of plasma concentrations of mood stabilizers, and 2 structured interviews: the Schedule for Affective Disorders and Schizophrenia and the Structured Clinical Interview for DSM-III-R Axis II disorders. Well-compliant patients and poorly compliant patients were compared with respect to several clinical and treatment variables. RESULTS: The rate of mildly and poorly compliant patients was close to 40%. Comorbidity with personality disorders was strongly associated with poor compliance. Poorly compliant patients had a higher number of previous hospitalizations, but reported fewer previous episodes. The type of treatment was not associated with compliance. CONCLUSION: Clinical factors, especially comorbidity with personality disorders, are more relevant for treatment compliance than other issues such as the nature of pharmacologic treatment. Compliant patients may have a better outcome in terms of number of hospitalizations, but not necessarily with respect to the number of episodes. Bipolar patients, especially those with personality disorders, should be monitored for treatment compliance.     

Reinstitution of neuroleptic treatment with molindone in a patient with a history of neuroleptic malignant syndrome

The decision to reinstitute neuroleptic treatment in patients with a history of neuroleptic treatment is fraught with hazards. A case is reported in which neuroleptic treatment was successfully reintroduced with molindone after previous bouts of neuroleptic malignant syndrome (NMS) with trifluoperazine and thioridazine. Molindone may represent an alternative neuroleptic to consider in patients with a history of NMS, although all neuroleptics including clozapine and molindone may potentially precipitate this syndrome.