Occupational functioning, symptoms and neurocognition in patients with psychotic disorders: investigating subgroups based on social security status

Purpose

Reported employment rates for patients with psychosis are low, but vary partly depending on illness phase. Illness-related factors such as neurocognition and negative symptoms are associated with occupational functioning, while external factors may also act as barriers for employment. The current study investigated the relationship between neurocognition, symptoms and employment using a threefold division of employment status: employed, receiving temporary benefits and receiving disability benefits. The latter group was divided into two based on level of social functioning.

Methods

A total of 155 patients with broad DSM-IV schizophrenia spectrum disorder were assessed with clinical, neurocognitive and social and occupational functioning measures. Group differences were analyzed with ANOVAs and hierarchical regression analysis.

Results

Thirteen percent were employed, 52 % received temporary benefits and 35 % received disability benefits. There were no differences in symptom level and neurocognitive functioning between groups. Among patients on disability benefits, the subgroup with higher social functioning had fewer negative and general symptoms and a trend for better neurocognition compared with those with lower social functioning, thus being more similar to employed patients. Negative symptoms and executive functioning explained 26 % of the variance in social functioning for patients receiving disability benefits.

Conclusions

The association between neurocognition and employment may not be as strong as previously assumed, due to external factors that may influence this relationship. Patients on disability benefits rated high on social functioning showed similarities with employed patients. This could imply that these patients have some work capacity. This issue needs further investigation.     

Stress response symptoms in relatives of acutely admitted psychotic patients: A pilot study

Objective: The aim of this study is to identify specific stress response symptoms in relatives of acutely admitted psychotic patients, and to compare these responses with those of relatives of chronic inpatients. Method: Twenty-five relatives of acutely hospitalized, psychotic patients and 21 relatives of chronic inpatients were assessed within days of the acute patient's admission and 6 weeks later. The Impact Event Scale assessed intrusion and avoidance; items from the General Health Questionnaire (GHQ) and the Spielberger State Anxiety Inventory (STAI) assessed arousal. Results: At the first assessment, relatives of the acutely admitted psychotic patients reported higher intensity of intrusive symptoms, and more often a high arousal level compared to the relatives of chronic inpatients. Six weeks later, relatives of acutely admitted psychotic patients revealed both higher intensity and higher number of intrusive and avoidance symptoms, and higher level of arousal symptoms. Seven relatives of acutely admitted psychotic patients and no relatives of the chronic inpatients reported moderate to high level of intrusion, avoidance and arousal at both assessments. Conclusion: Relatives of acutely admitted psychotic patients revealed strong acute and persistent stress responses, similar to those described in subjects exposed to severe or life threatening illness. Even relatives of the chronic inpatients revealed stress-specific symptoms, but at a lower level. Specific stress response symptoms may impair the relatives' well-being, care-giving abilities, and their co-operation with the mental health system. Our results suggest that stress response symptoms in relatives should be given more attention.     

Effectiveness of psychoeducation for relapse, symptoms, knowledge, adherence and functioning in psychotic disorders: a meta-analysis

Psychoeducation (PE) for schizophrenia and other psychotic disorders is widely adopted but insufficiently evaluated. So far, meta-analytic data has demonstrated efficacy for PE when interventions include family members. Whether PE directed solely at patients is also effective remains unclear. The current meta-analysis evaluates short- and long-term efficacy of PE with and without inclusion of families with regard to relapse, symptom-reduction, knowledge, medication adherence, and functioning. Randomized controlled trials comparing PE to standard care or non-specific interventions were included. A literature search in the Cochrane Library, PsycINFO and Medline retrieved 199 studies for closer examination, of which 18 studies, reporting on 19 comparisons, met the inclusion criteria. These studies were coded with regard to methodology, participants, interventions and validity. Effect sizes were integrated using the fixed effects model for homogeneous effects and the random effects model for heterogeneous effects. Independent of treatment modality, PE produced a medium effect at post-treatment for relapse and a small effect size for knowledge. PE had no effect on symptoms, functioning and medication adherence. Effect sizes for relapse and rehospitalization remained significant for 12 months after treatment but failed significance for longer follow-up periods. Interventions that included families were more effective in reducing symptoms by the end of treatment and preventing relapse at 7-12 month follow-up. Effects achieved for PE directed at patients alone were not significant. It is concluded that the additional effort of integrating families in PE is worthwhile, while patient-focused interventions alone need further improvement and research.     

Successful use of donepezil for the treatment of psychotic symptoms in patients with Parkinson's disease

The risk of psychosis among patients with Parkinson's disease (PD) is high, and the management of these patients remains a substantial problem for physicians. Atypical antipsychotics, despite their advantages over conventional antipsychotics, can cause different side effects and deterioration of PD. Several reports have suggested that donepezil can be helpful in the treatment of psychotic conditions in patients with dementia with Lewy bodies and Alzheimer's disease. This report presents the results of preliminary study of six patients (four women, two men; age range, 60-75 years) with PD (range of duration, 3-7 years) and dementia complicated by psychosis. All patients were treated with antiparkinsonian therapy, and donepezil was added to their regular treatment. The severity of the psychotic symptoms was assessed using the Scale for the Assessment of Positive Symptoms, and extrapyramidal symptoms were assessed using the Simpson-Angus Scale. With the addition of donepezil (as much as 10 mg/day) to their constant antiparkinsonian treatment, five patients had clinically significant (more than 53%) improvement on the assessment scale, and one patient had minimal (24%) improvement after 6 weeks of the treatment. None of the patients had side effects or deterioration of parkinsonian symptoms. The results suggest that donepezil may ameliorate psychotic symptoms in patients with PD, but this will need to be tested further in controlled, double-blind trials.     

Vigabatrin use in psychotic epileptic patients: report of a prospective pilot study

OBJECTIVES: Evaluation of any possible behavioural reactions in epileptic patients during vigabatrin treatment. MATERIAL AND METHODS: Ten patients with refractory partial epilepsy, previous mental retardation and psychosis or other significant psychiatric morbidity treated with vigabatrin were submitted periodically to specific tests (to quantify any possible change in behavioural parameters) and also to EEG recordings. RESULTS: After 1 year of treatment 5/10 patients became seizure-free, 3/10 of them presented reduction of seizures by over 75%. None of the subjects presented episodes that could be interpreted as psychotic reactions and, moreover, some patients showed a reduction in stereotypies, instability and aggressiveness. In 66% of these patients an improvement in cognitive functions was observed. CONCLUSION: The onset of side effects can be prevented by a gradual introduction of vigabatrin and by the use of the drug in moderate doses. These data do not confirm the contraindication to treat with vigabatrin patients with a history of psychiatric disturbances.     

Medication supervision and adherence of persons with psychotic disorders in residential treatment settings: a pilot study.

BACKGROUND: Little is known about risk factors for and predictors of medication nonadherence within residential facilities. This pilot study examined the association between medication adherence and level of supervision and other environmental and clinical variables among patients with schizophrenia and related psychotic disorders living in supported housing. METHOD: A convenience sample of 74 adult residents with schizophrenia and related psychotic disorders (DSM-IV criteria) living in 4 supported housing facilities in New York City were assessed by their treating psychiatrist for medication cessation during the previous month. Demographic characteristics, medications, supervision, global function as measured by the Global Assessment of Functioning (GAF), and substance abuse were also assessed. A priori hypotheses were that regimen complexity would be directly and medication supervision would be inversely related to medication nonadherence. RESULTS: In multivariate models, lack of direct medication supervision, negative medication attitude, and lower GAF score were associated with increased medication nonadherence in the recent past. CONCLUSION: This pilot study suggests that direct supervision of medication is associated with better adherence in residential treatment settings. This finding is relevant for mental health service planners and clinicians working in these settings.     

Functional adaptation skills training (FAST): a pilot psychosocial intervention study in middle-aged and older patients with chronic psychotic disorders.

OBJECTIVE: Developing behavioral interventions to improve functioning of older patients with schizophrenia and other chronic psychoses has the potential to significantly increase the patients' independence and quality of life. METHODS: The authors evaluated a psychosocial intervention designed to improve everyday living skills of middle-aged and older outpatients with very chronic psychotic disorders (mean duration of illness: 21 years). Forty patients who resided in board-and-care facilities were randomly assigned to either a 24-session functional adaptation skills training (FAST) group therapy program targeting problem areas identified in previous work as being problematic for this population (e.g., using public transportation) or treatment-as-usual. Almost all the participants also received antipsychotics. RESULTS: Compared with the patients randomized to the treatment-as-usual condition, FAST-treated patients' performance on everyday living skills improved significantly immediately post-intervention and was still significantly better at a 3-month maintenance follow-up period. There was no significant change in psychopathology. CONCLUSION: Results suggest that older patients with longstanding psychotic disorders may benefit from participation in this skills-training program.     

Anxiety symptoms in patients with hypertension: a community-based study

OBJECTIVES: To investigate incidence and severity of anxiety symptoms in patients with hypertension. METHODS: A cross-sectional survey in 891 (432 females) hypertensive patients was conducted in a regional community. All patients were interviewed and detailed physical examination was performed. Zung self-rating anxiety scale (SAS) was used to evaluate the severity of anxiety symptoms. RESULTS: Anxiety was diagnosed on clinical grounds in 103 patients (11.6%) who also had a raw SAS score of more than 40. In all subjects surveyed, the average SAS score in females was higher than males (32.9+/- 7.1 vs 31.2+/-6.4, p < 0.001). The average SAS score was also higher in patients with hypertension of more than 3 years (32.4+/-7.0 vs 31.2+/-6.1, p = 0.01), in patients with severe hypertension (39.8+/-6.9 vs 29.6 4+/-4.5, p < 0.001), and in patients with a history of hospitalization for cardiovascular disorders (35.7+/-7.7 vs 31.7+/-6.6, p < 0.001). Multivariate regression analysis showed that female gender, duration of hypertension, and hospitalization history were independent predictors of anxiety symptoms (p < 0.05). CONCLUSIONS: Almost 12% of hypertensive patients have anxiety symptoms. Female gender, the duration of hypertension, and the history of hospitalization are associated with the occurrence and severity of anxiety symptoms in patients with hypertension.     

Associations between diurnal cortisol patterns and lifestyle factors,psychotic symptoms,and neurological deficits: A longitudinal study on patients with chronic schizophrenia

The present study examined the relationships between diurnal cortisol patterns and perceived stress, lifestyle factors, psychotic symptoms, neurological deficits, and daily functioning in patients with chronic schizophrenia. The participants were 149 Chinese patients with chronic schizophrenia, who provided salivary cortisol measures upon waking, before lunchtime, and before bedtime at baseline (Time 1). Self-report measures on perceived stress and lifestyle factors such as body-mass index and daily exercise span were recorded at Time 1. Diagnostic assessments on psychotic symptoms, neurological deficits, and daily functioning were made at Time 1 and Time 2 (3 months later). Latent growth modeling and path modeling analysis were performed to investigate the diurnal cortisol patterns and the relationships with the study variables, respectively. Greater perceived stress and body-mass index and less physical activity were significantly linked to reduced cortisol decline. Reduced cortisol decline at Time 1 significantly predicted greater psychotic (positive and negative) symptoms and more severe neurological deficits in motor coordination and sequencing of complex motor acts at Time 2. The present results contribute to a better understanding of the diurnal cortisol patterns among chronic schizophrenia patients and the associations with lifestyle factors, psychotic symptoms, and neurological deficits. The findings lend support to the neural diathesis–stress model and suggest that hypothalamic–pituitary–adrenal axis may potentially mediate the effects of lifestyle factors on psychotic symptoms and neurological deficits.     

Patterns of symptoms in neuroleptic-naive patients with schizophrenia and related psychotic disorders before and after treatment.

A three-factor structure of schizophrenic symptoms has received considerable support, but there are no data on the factor structure of symptoms in neuroleptic-naive patients and how symptoms evolve after the inception of antipsychotic treatment. Seventy neuroleptic-naive patients with schizophrenia or related psychotic disorders were assessed with the Scales for the Assessment of Positive and Negative Symptoms before and after neuroleptic treatment. Ten global ratings of symptoms were subjected to factor analysis at the two time points and the factor solutions compared. A three-factor structure composed of psychotic, disorganization, and negative dimensions was found at the two assessment points. The negative and disorganization factors were highly correlated at each assessment and across assessments. While the symptom composition of the factors at the neuroleptic-naive assessment fitted that described in most previous studies, the composition of the negative and disorganization factors after neuroleptic treatment was somewhat different in that attention and inappropriate affect loaded on the negative factor instead of the disorganization factor. It is concluded that caution is warranted when using the three-factor model of schizophrenic symptoms as it may not be stable at different phases of the illness.     

Prevalence and clinical correlates of psychotic symptoms in Parkinson disease: a community-based study.

BACKGROUND: Hallucinations and delusions are frequent in patients with Parkinson disease (PD) and may have severe clinical consequences for those patients and their caregivers. However, the prevalence and clinical features of these symptoms have not been studied in a representative sample. OBJECTIVE: To study the prevalence and clinical correlates of psychosis in a population-based sample of patients with PD. METHOD: Total ascertainment of patients with PD in a defined geographical area in Norway was attempted through a detailed community study. Clinical evaluation consisted of a neurologic examination and assessments of depression and cognition. Psychosis was assessed with the thought disorder subscale of the Unified Parkinson's Disease Rating Scale. RESULTS: A total of 245 patients with PD were identified, 235 (95.9%) of whom participated in this study. Twenty-three patients (9.8%) had hallucinations with insight retained, and another 14 patients (6.0%) had more severe hallucinations or delusions. Psychotic symptoms were associated with age, stage and diagnostic subgroup of PD, severity of depression, and cognitive impairment. Type, duration, and dose of antiparkinson drug therapy did not differ between those patients with PD who had or did not have psychosis. In a polychotomous logistic regression analysis, severity of depression, cognitive impairment, and impairment of activities of daily living were the only significant concomitants of psychosis. CONCLUSIONS: Hallucinations and delusions are common in patients with PD. More advanced and widespread brain changes seem to increase the risk for developing psychosis in patients with PD receiving levodopa therapy.     

Psychiatric genetic counselling for parents of individuals affected with psychotic disorders: a pilot study

Aim: There has been increasing interest in the concept of applying genetic counselling to psychiatric disorders, but despite its relevance to psychiatric illness, and interest from the target group, there have been no empiric investigations of psychiatric genetic counselling. In a population of unaffected parents of individuals with first episode as well as more chronic psychotic disorders, we aimed to investigate whether psychiatric genetic counselling: is perceived to be useful, could increase understanding of the causes of psychiatric illness and decrease concern about other relatives becoming affected. Methods: Subjects (n = 13) participated in a genetic counselling session. The session was a clinical intervention similar to what would be carried out as part of a referral for any disease with a hereditary component, but specific for psychosis. Questionnaires were used to assess (pre‐counselling): motivations for attending, concern about other relatives developing psychiatric illness, and (post‐counselling) whether the intervention: (i) improved understanding of mental illness; (ii) modified concern about other relatives becoming affected; and (iii) was perceived to be useful. Results: Desire for knowledge motivated participation. Immediately after the session, and 1 month later >92% and 100% of participants, respectively, felt that the session was useful. Genetic counselling reduced concern about other relatives becoming affected as risks were lower than participants had expected. All participants felt that their understanding of the causes of psychiatric illness had improved through genetic counselling. Conclusion: Psychiatric genetic counselling may benefit parents of individuals with psychiatric illnesses. Avenues for future research are highlighted.     

The long-term level of functioning in patients admitted for psychotic disorders with and without substance abuse

The main objective of this study was to compare life skills between psychotic patients with substance abuse problems and psychotic patients without substance abuse problems. This is a cross-sectional study of 48 patients (26 inpatients and 22 outpatients) in a clinic for early intervention in psychosis. Patients were grouped into two categories based on if they had a substance abuse problem or not. Twenty-one (43.8%) had a substance abuse problem and 27 (56.2%) had not. We used several scales to measure substance abuse and the Life Skills Profile to measure aspects of functioning. A parametric test (t-test) was used to compare continuous variables. A non-parametric chi-square test was used to compare frequencies. The self-care subscore and the non-turbulence subscore were higher in the group with psychosis alone. These results were not significant controlling for age. The social contact subscore, the communication subscore, the responsibility subscore and the Life Skills Profile total score did not differ significantly between the groups. The abusers did not differ from the non-abusers in functioning in any area measured.     

Mental state understanding in adult psychiatric disorders: impact on symptoms, social functioning and treatment

Many adults with serious mental illness experience difficulties thinking about their own mental states and the mental states of others. Increasing amounts of evidence have suggested that these difficulties underpin many of the struggles these persons subsequently experience trying to cope with symptoms and distress, to solve social problems and to negotiate with others in order to accomplish important life goals. In this special issue, the contributing authors explore the problems associated with impaired mental state understanding in different psychiatric conditions using a wide range of tools, from laboratory tasks, to self-reports, to discourse analysis. Also, both population-based studies and single-case analyses are adopted. The intent is to shed light how various difficulties in understanding mental states can be detected using different approaches and how findings can be meaningfully integrated within an internally consistent theoretical framework.     

Results of a screening survey for co-morbid substance misuse amongst patients in treatment for psychotic disorders: prevalence and service needs in an inner London borough

Background: There is great concern in the UK, and other countries, about the clinical management of psychosis and substance misuse co-morbidity. However, relatively little is known about the UK prevalence and management of co-morbidity. Method: We implemented a screening survey of patients who were in treatment with an inner London adult mental health service and measured the prevalence of substance misuse amongst 851 psychotic patients. Caseworkers reported substance misuse and assessed clinical management arrangements. Results: Current prevalence of substance misuse was 24.4 % (95% CI: 21.3–27.1). Rates of co-morbidity were higher in males (31 % vs 16 %, χ² 1df=26.0, P < 0.001) and patients over 51 (χ² 3df=50.1, P < 0.001). Adjusted odds of co-morbidity in patients under 51 were 0.19 (95 % CI: 0.10–0.34) and 0.47 for females (95 % CI: 0.32–0.69). Substance misuse interventions were provided to 20 % of co-morbid patients – Only 5 % were compliant. Conclusions: The findings suggest substance misuse may be highly prevalent amongst psychotic patients. Most co-morbid patients do not receive appropriate treatment. The development of evidence-based interventions should be a priority. Accepted: 2 April 2001     

Chronically mentally ill patients with and without substance use disorders: a pilot study

The study was designed to assess characteristics of chronic mentally ill patients with and without a substance use disorder. Study patients (n=48) had either psychiatric illness alone (they received conventional psychiatric rehabilitation) or dual diagnoses (they received mental illness and substance abuse services). All patients were administered the Brief Symptom Inventory (BSI), the Client Satisfaction Questionnaire, the Perceived Social Support Scales, and the Composite International Diagnostic Interview. Higher proportions of dually diagnosed patients had schizophrenia, had higher scores on the BSI, and were less satisfied with treatment.     

有精神病性症状的躁狂发作患者近期疗效比较

目的比较单一经典抗精神病药物（奋乃静）或心境稳定剂（碳酸锂）合并小剂量经典抗精神病药物（奋乃静）治疗有精神病性症状的躁狂发作患者的疗效和安全性;探讨影响患者近期疗效的主要因素。方法（1）将符合入组标准的精神病性症状的躁狂发作患者70例随机分为甲组34例和乙组36例两组进行为期6周治疗。甲组为单一中至大剂量经典抗精神病药物（奋乃静）治疗;乙组为心境稳定剂（碳酸锂）合并中至小剂量经典抗精神病药物（奋乃静）治疗。以Bech—Rafaelsen躁狂量表（BRMs）和临床总体印象量表（CGI）评定患者的疗效,以不良反应症状量表（TESS）评定患者的副反应;（2）采用临床流行病学方法,探讨影响有精神病性症状的躁狂发作患者近期疗效的主要因素。结果（1）在治疗第6周末,甲组患者的临床治愈率38．2％,有效率94．1％（33／34）;乙组的临床治愈率63．9％,有效率100％（36／36）,乙组在临床疗效及药物不良反应上均显著性优于甲组（P〈0．05）;（2）有精神病性症状的躁狂发作患者的近期疗效好,影响有精神病性症状的躁狂发作患者近期疗效的主要因素为患者的起病年龄、病前社会功能、病程特点及患者的精神病性症状与心境的协调性,以急性起病、病前社会功能良好、间歇性病程及患者的精神病性症状与患者心境相协调者的近期疗效为佳。结论（1）心境稳定剂合并小剂量经典抗精神病药物在治疗有精神病性症状的躁狂发作时,临床疗效优于单一经典抗精神病药物治疗且副反应相对少;（2）有精神病性症状的躁狂发作患者的近期疗效好,患者的近期疗效受多种因素的影响。