Drug monitoring of antipsychotics and antidepressants during acute admission in a psychiatric state hospital in Germany

In the treatment of affective and schizophrenic psychosis, modern atypical antipsychotic agents and newer antidepressive agents recently have increasingly been used. In this prospective naturalistic study, patients were examined who had previously been treated psychopharmaceutically for a schizophrenic (n = 52) or depressive (n = 38) disorder and were readmitted in a psychiatric emergency clinic. While Serum levels were examined major interest was to find out similarities or differences in the drug compliance of schizophrenic and depressive patients before rehospitalization.     

Outpatient Follow-Up Visit after Hospital Discharge Lowers Risk of Rehospitalization in Patients with Schizophrenia: A Nationwide Population-Based Study

Objective

Non-adherence to medication is a recognized problem in psychiatric patients and may be one of the most challenging aspects of treatment for patients with schizophrenia. Failure of follow-up care after discharge greatly increases non-adherence to prescribed medications, relapse and rehospitalization. However, it is still unknown whether and how much outpatient follow-up visits can mitigate the risk of rehospitalization. Therefore we sought to investigate the continuity and effectiveness of outpatient care after inpatient discharge and its effect on rehospitalization of patients with schizophrenia.

Methods

Data were extracted from National Health Insurance Claim Database covering the period from 2007 through 2010. We identified 10,246 patients aged 18 years or older who were admitted in psychiatric facilities with the diagnosis of schizophrenia between January 1 and December 31 in 2007. The number of outpatient visits within 60 days after discharge from index admission was defined as the indicator for the continuous care and rehospitalization was inspected during the following 36-month period. Cox''s proportional hazard model was used to examine the factors affecting the risk of rehospitalization including the number of outpatient visits, age, sex, comorbidities, antipsychotics, and characteristics of medical institution.

Results

We found that 12.7% (n=1,327) of the patients visited psychiatric outpatient department once within 60 days after hospital discharge, 34.8% (n=3,626) twice, and 27.8% (n=2,900) more than three times. Patients taking atypical antipsychotics showed higher proportion in 2 or more outpatient visits, whereas patients taking typical antipsychotics showed higher proportion in one or no outpatient visits. Cox hazard ratios of rehospitalization for the factor of 3 or more outpatient visits referenced to that of no follow-up visit were 0.567 (0.428-0.750, 95% confidence interval) within 90 days, 0.673 (0.574-0.789) within 180 days, 0.800 (0.713-0.898) within a year, 0.906 (0.824-0.997) within 2 years, and 0.993 (0.910-1.084) within 3 years.

Conclusion

Although continuous outpatient treatment is important for relapse prevention, patients with schizophrenia showed a low rate of outpatient visit as 62.6% of total patients in 2 or more visits within 60 days after discharge. Lack of follow-up treatment might lead to increase psychotic symptoms and raised risk of relapse and rehospitalization. Our data suggest that the number of outpatient visits within 60 days after discharge in patients with schizophrenia is an important indicator of rehospitalization within a year. Therefore, further efforts to examine factors affecting failure of outpatient follow-up after discharge are warranted.     

一次和多次住院精神分裂症患者再住院分析

目的 :比较 1次和≥ 2次住院精神分裂症患者出院后的再住院率 ,初步探讨影响再住院的相关因素。　方法 :1999年度出院的 833例住院精神分裂症患者纳入调查 ,使用自制的再住院及其相关因素调查表 ,于 2 0 0 3年 12月底前电话或入户调查出院后至少 4 8个月的情况。　结果 :6 6 4例完成调查 ,分为 1次住院组 (333例 )和多次住院组 (331例 )。用生存分析 (Kaplan Meier公式 )比较两组未再住院率 ,12个月末 (分别为 6 7 0 %和 6 1 6 % )、2 4个月末 (5 6 2 %和 4 8 9% )、36个月末 (4 6 0和 35 1% )和 4 8个月末 (4 1 1%和 2 8 7% )。Cox回归风险比例模型分析影响再住院的相关因素显示 ,与药物依从性、生活事件、自知力和家庭照顾相关 (P <0 0 5 ) ,药物依从性对再住院的贡献值 (1 719)最大。　结论 :1次住院精神分裂症患者出院后的再住院率较多次住院者低。药物依从性是影响再住院的主要因素     

Long-term effects of a psychoeducational psychotherapeutic intervention for schizophrenic outpatients and their key-persons – results of a five-year follow-up

The study examines long-term effects on rehospitalization rates of a psychoeducationally and cognitive-behaviorally oriented intervention for schizophrenic outpatients and their key-persons. 191 patients and their key-persons were allocated by random into four different treatment groups and one control group. Five years after completion of treatment 126 patients were reexamined by interviews or case notes. The rate of patients experiencing psychiatric rehospitalization during the follow-up was assessed in each respective treatment group. Concerning rehospitalization rates there was no significant difference between controls (n = 35) and patients of the four treatment groups (n = 91). There were, however, fewer rehospitalized patients in the group with combined psychoeducational and cognitive treatment, including key-person counselling (42%), than in the control group (69%). Regarding the overall functioning, the patients in this treatment group did slightly better than those in the control group. These results are in accordance with the findings of comparable studies. Received: 15 September 1998 / Accepted: 23 April 1999     

利培酮对精神分裂症患者社会功能的研究

目的:比较利培酮与氯氮平治疗的精神分裂症患者出院后社会功能状况,方法:随机抽取30例服用利培酮,30例服用氯氮平的精神分裂症患者,用阳性症状和阴性症状量表(PANSS), 明精神病评定量表(BPRS),不良反应症状量表(TESS)评定.出院后半年用社会功能缺陷量表(SDSS)评定,并与某些因素进行相关分析及多元逐步回归分析.结果:半年随访发现,服用利培酮的精神分裂症患者在职业工作,婚姻职能,父母职能和社会退缩等社会功能方面明显好于氯氮平,多元逐步回归分析显示,影响社会功能的因素为经济损失多,男性,不能积极参加组织活动,不能与他人和睦相处,BPRS评分高者社会功能差,服用氯氮平的比利培酮差.结论:利培酮和氯氮平相比,治疗的优势主要不在于副反应方面,而在于能较好地改善社会功能.     

Factors affecting time to rehospitalization for patients with major depressive disorder

Major depressive disorder is a common psychiatric condition. Hospitalization is usually indicated for patients with more severe symptoms and severe functional impairment. Rehospitalization is known as the re-emergence of significant depressive symptoms. The purpose of the present study was to investigate the risk factors affecting time to rehospitalization. Rehospitalization status was monitored for all patients with major depressive disorder discharged from Kai-Suan Psychiatric Hospital between 1 January 2002 and 31 December 2003. Patients were followed up with respect to rehospitalization until 31 December 2004. The Kaplan-Meier method was used to calculate the median time to rehospitalization. Risk factors associated with rehospitalization were examined on Cox proportional hazards regression. Three hundred patients were recruited. Median time to readmission was 174 days (SD = 37). Comorbid alcohol abuse/dependence (hazard ratio [HR] = 1.841, 95% confidence interval [CI] = 1.229-2.758, P < 0.01), comorbid personality disorders (HR = 1.530, 95%CI = 1.053-2.223, P < 0.05), and the number of previous hospitalizations (HR = 1.121, 95%CI = 1.056-1.190, P < 0.001) were found to be predictors of the shorter time to rehospitalization over the 360-day study. Further research should be carried out to test risk factors in a prospective study, and to study the cost-effectiveness of interventions to reduce risk factors and rehospitalizations.     

社区综合干预对精神分裂症患者社会康复效果的对照研究

目的观察社区综合干预措施对精神分裂症患者出院后社会康复的疗效。方法采取随机抽样法,将284例出院的精神分裂症患者随机分为干预组（143例）和对照组（141例）,对干预组进行健康教育、用药指导、技能训练、家庭治疗等综合干预,持续1年;对照组仅进行门诊随访。在入组时、半年末、一年末分别对两组患者采用社会功能缺陷筛选量表（SDSS）、阳性与阴性症状量表（PANSS）进行评估和比较。结果入组时干预组与对照组的SDSS、PANSS评分差异无显著性;干预1年后,干预组SDSS评分（7．54±2．11）明显低于对照组（9．77±2．74）,差异具有非常显著性（P〈0．01）。干预组PANSS评分（38．88±9．58）、阳性量表评分（7．40±1．12）、阴性量表评分（11．32±5．92）,一般精神病理量表评分（20．16±5．19）均低于对照组（46．884±16．37、8．60±3．19、13．52±7．81、24．76±8．08）,差异具有非常显著性（P〈0．01）。干预组复发率18．18％（26例）低于对照组34．75％（49例）,差异有非常显著性（χ^2=10．03,P〈0．01）。结论综合干预措施有利于出院后精神分裂症患者的社会康复。     

Post-discharge Contact with Mental Health Clinics and Psychiatric Readmission: A 6-month Follow-up Study

Background: Continuity of mental health care is a major topic in the post deinstitutionalization era, especially concerning its possible importance as a contributing factor in preventing rehospitalization. Objectives: To examine a) the association between continuing care and time to rehospitalization; and b) the predictors of time to first outpatient contact after discharge from psychiatric hospital. Methods: Hospitalization records of all patients discharged from the Tirat Carmel psychiatric hospital in Israel, between January 1, 2006, and December 31, 2006, the National Register of Psychiatric Hospitalizations database and administrative databases of all psychiatric outpatient clinics in this catchment area were used to monitor continuing care and rehospitalization within 180 days from discharge. Predictors of time to rehospitalization and outpatient visits were examined using a Cox proportional hazards regression model. Results: Out of the 908 discharged inpatients, 29% were rehospitalized and 59% visited an outpatient clinic during the study period. Of those who visited a clinic, 22% were rehospitalized compared with 40% of those who did not visit. Not making aftercare contact with a mental health clinic during the study period and/ or having a history of more than four hospitalizations were significant predictors of earlier psychiatric readmission. Males and patients diagnosed with schizophrenia or affective disorders made contact with outpatient clinics significantly earlier. Patients who were discharged from the hospital after a daycare period contacted outpatient clinics significantly later than those who were not in daycare. Conclusions: The findings suggest that psychiatric rehospitalization is associated with discontinuity of contact with psychiatric services but not with diagnosis. Patients with schizophrenia or affective disorders were found to adhere to a greater degree to clinical aftercare, which may explain why they are not rehospitalized earlier than less severe patients.     

Rehospitalization rates of patients recently discharged on a regimen of risperidone or clozapine.

OBJECTIVE: The purpose of this study was to examine rehospitalization rates of people receiving risperidone or clozapine who had been discharged from state psychiatric hospitals in Maryland. METHOD: Rehospitalization status was monitored for all patients discharged from state psychiatric facilities on a regimen of either risperidone or clozapine between March 14, 1994, and Dec. 31, 1995. Patients were followed up with respect to readmission until Dec. 31, 1996. Time to readmission was measured by the product-limit (Kaplan-Meier) formula. Risk factors associated with rehospitalization were examined. RESULTS: One hundred sixty patients were discharged on risperidone, 75 having the diagnosis of schizophrenia. The patients with schizophrenia were more likely to be readmitted than the 85 patients with other mental disorders. Recidivism rates for schizophrenic patients discharged on risperidone versus those discharged on clozapine were not significantly different over the 24-month study period. However, no patient who received clozapine and remained discharged for more than 10 months (N = 49) was readmitted, while the readmission rate for risperidone-treated patients appeared to be steady up to 24 months. At 24 months 87% of the clozapine-treated patients and 66% of the risperidone-treated patients remained in the community. No clinical or demographic variables were found to predict rehospitalization. CONCLUSIONS: This study demonstrates that the rehospitalization rates of patients taking the second-generation antipsychotics risperidone and clozapine are lower than those in previously published reports of conventional antipsychotic treatment.     

Aftercare of psychiatric patients and its relation to rehospitalization.

In their study of the effects of posthospital treatment on psychiatric patients the authors found that those who entered aftercare were rehospitalized less often than those who did not. They found the rehospitalization rate was higher for schizophrenic patients than for patients in other diagnostic groups, and that schizophrenic patients who did not enter aftercare were rehospitalized at a higher rate than those who did. They found no difference between rehospitalization rates of patients who continued with their hospital therapist after discharge and those patients who worked with a new therapist.     

Prognosis of the course of schizophrenic psychoses compared to other psychiatric illnesses

Summary In a prospectively designed study of the course of illness of 161 hospitalized psychiatric patients, data regarding outcome could be obtained for 93% 1 year after clinic discharge. It was possible to reexamine 67% of the patients by means of direct interviews. No significant differences appeared in the comparison of the course of illness outcomes (symptoms, rehospitalization, occupation and social contacts) of patients with schizophrenic psychoses, affective psychoses, neuroses or a group of mixed other diagnoses (predominantly alcohol dependency). For the group of neuroses there was a particularly striking discrepancy between the self- and the observer-ratings at the time of discharge from inpatient index-treatment. From this finding and from the comparatively more intense prominence of depressive symptoms at the time of follow-up, one can presume that there has been insufficient after-care treatment of this patient group considering the recorded treatment data. This seems to hold true for the group of alcohol dependents as well. In contrast, the after-care treatment of patients with affective and schizophrenic psychoses seems more likely to be ensured today. Despite this, however, for the latter the close link between the rate of relapse and the rate of rehospitalization can apparently scarcely be influenced.     

Predicting the outcome of psychotherapy for schizophrenics. Relative contributions of patient, therapist, and treatment characteristics.

This study was designed to assess the relative prognostic importance of patient factors, therapist characterists, and treatment mode. The sample was 100 schizophrenic outpatients referred to a community mental health center following psychiatric hospitalization. Patients were randomly assigned to either group (N=50) or individual (N=50) psychotherapy. Criteria were rehospitalization and two clinician ratings--adjustment and social effectiveness--at a two-year follow-up. The best predictor of rehospitalization was the number of previous hospitalizations. The best predictor of adjustment status at two years was pretreatment adjustment level. Also, patients with good prognostic indices made relatively large gains. Predictors of outcome for group-treated patients did not differ from those for individually treated patients. Controlling for initial status, treatment mode was almost as good as predictor of adjustment gains as were other patient factors.     

Symptoms of depression and posttraumatic stress disorder in an outpatient population before and after Hurricane Katrina

The aim of the present investigation was to evaluate symptoms of depression and posttraumatic stress disorder (PTSD) in an outpatient psychiatric population before and after Hurricane Katrina. The sample consisted of 156 patients (110 females; M(age)=41.2 years, SD=10.9) at an outpatient psychiatric clinic who completed measures of psychological symptoms as part of their regular clinical care in the month before (n=76; 49%) and the 1 month after (n=80; 51%) Hurricane Katrina made landfall. Partially consistent with prediction, depression scores were significantly higher in the month following the hurricane, but PTSD scores were not significantly different. Depressive symptoms after the hurricane were predicted by watching television coverage of the looting that occurred in New Orleans and by the amount of time the participant was without electricity. Symptoms of PTSD after the hurricane were predicted by the participants' use of general television viewing as a coping strategy, the amount of time they spent watching television coverage of the looting in New Orleans, and the use of prayer as a coping behavior. Of these variables, only prayer was associated with a decrease in PTSD symptoms. Findings are discussed in relation to the need for collaborative efforts between clinically oriented and research-oriented institutions to study the impact of large-scale disasters on a variety of populations.     

Improvement of exploratory eye movements in schizophrenic patients during recovery period

In the present paper exploratory eye movements were examined as biologic markers in both acute schizophrenic patients (acute patients discharged after approximately 3 months and treated as outpatients, n = 8; acute patients who were still in hospital after 6 months, n = 8) and chronic schizophrenic patients (hospital stay >5 years, n = 15) in comparison with age-matched healthy subjects (n = 30). Using an eye-mark recorder, exploratory eye movements were analyzed for mean gazing time (MGT), and total eye scanning length (TESL) as subjects viewed six simple pictures in preparation for copying them. In acute schizophrenic patients discharged after 6 months (DP), MGT became significantly shorter and TESL became longer after 3 or 6 months treatment. In acute schizophrenic patients during admission after 6 months, TESL became longer after 3 or 6 months of treatment. However, no significant changes were observed in chronic patients in these measures. In schizophrenic patients, negative symptom scores were positively correlated with MGT (r = 0.43; P < 0.001), and negatively correlated with TESL (r = -45; P < 0.001). These findings suggest that exploratory eye movements are a biologic state and trait marker useful for evaluation of schizophrenia.     

思瑞康改善精神分裂症患者社会功能的作用

目的比较思瑞康(seroquel)与氯氮平治疗对改善精神分裂症患者社会功能的作用。方法随机收集20例服用思瑞康、20例服用氯氮平的精神分裂症患者,用阳性症状和阴性症状量表(PANSS)、简明精神病评定量表(BPRS)、不良反应评定量表(TESS)分别评定：并在出院后半年用社会功能缺陷量表(SDSS)评定,同时与影响其某些因素进行相关分析及多元逐步回归分析。结果半年后随访发现,服用思瑞康的精神分裂症患者在职业工作、婚姻职能、父母职能和社会退缩、责任心和计划性方面明显好于氯氮平。多元逐步回归分析显示,影响社会功能的因素为不能积极参加组织活动、得到家庭支持和照顾少、经济损失多、不能与他人和睦相处、BPRS评分高者社会功能差,服用氯氮平的比思瑞康差。半年随访时思瑞康TESS评分较低,两组比较有显著性差异。结论思瑞康与氯氮平相比不仅不良反应轻微。而且能很好的改善社会功能。     

Temperament and character personality profile in relation to suicide attempts in patients with schizophrenia

Introduction

Schizophrenia is associated with a significant risk of suicide, and suicide still remains one of the main causes of death in schizophrenic patients. Beside classic risk factors for suicidality, temperament and character traits have been researched and considered as risk factors for suicidal behavior in recent years.

Method

Subjects were 94 patients with schizophrenia who were under treatment. All patients were in a stable phase of the illness. Patients with lifetime suicide attempt (n = 46) and without suicidal attempt (n = 48) were compared with each other in terms of temperament and character traits by using the Temperament and Character Inventory.

Results

Harm avoidance and persistence scores were higher in suicidal schizophrenic patients compared with nonsuicidal schizophrenic patients. The scores of self-directedness and cooperativeness were lower in suicidal schizophrenic patients compared with nonsuicidal schizophrenic patients. These 4 variables remained significant predictors of lifetime suicidal attempts in a logistic regression model.

Conclusion

To the best of our knowledge, the present study is the first that specifically compares schizophrenic patients with and without suicidal behavior by the Cloninger temperament and character model. Our data indicate that schizophrenic patients will show a greater risk for suicide according to certain personality configurations. However, to establish causal relationships between personality and suicidality in schizophrenia, longitudinal studies are warranted within a multifactorial interactive framework of biologic and clinical variables.     

Fluphenazine outpatient clinics: a pharmacist's role.

Twenty-five schizophrenic outpatients were treated in a pharmacist-administered fluphenazine decanoate clinic for periods of up to 1 year. These patients had a significantly lower rehospitalization rate, a decrease in medication related side effects, and showed improvement in functional capacity. The results suggest that a pharmacist can be clinically beneficial to schizophrenic outpatients and may help to reduce the cost of treatment programs.     

Neuronal dysfunction of the frontal lobe in schizophrenia

Localized in vivo proton magnetic resonance spectroscopy (MRS) was performed to evaluate metabolic alterations in the right and left frontal lobe before and after antipsychotic treatment of schizophrenic patients (n=24) and a group of healthy normal subjects (n=20). Proton metabolic ratios obtained from the 8 cm3 voxels in the right and left frontal lobes were compared with the clinical assessment for each subject. There was no significant difference in the metabolic ratios between the right and the left frontal lobes in either the schizophrenic group or the control group, indicating no laterality. Compared with those of the normal control group, NAA/Cr ratio of the schizophrenic patients showed significantly lower value. The NAA/Cr ratio of the schizophrenic patients was not changed after antipsychotic treatment. The present study supports the 'hypofrontality' hypothesis of schizophrenia.     

A case-control study of the seasonality effects on schizophrenic births on a tropical island

A substantial body of evidence from dozens of studies in many different countries suggests an excess number of individuals with schizophrenia are born in winter months. The presence of a seasonality effect in regions with year-round warm climate, however, has rarely been examined. The major purpose of this project was to better understand if the seasonality effect on schizophrenic births that has been reported in other, mostly cold regions of the Northern Hemisphere, also can be detected in a warm, tropical climate. We set out to study birth months as risk factors, quantifying the risk for being born with schizophrenia for every month of the winter season in terms of incidence rate ratios (IRRs) in the central region of Puerto Rico. We also analyzed climatic data in order to determine if there was any correlation between the rate of schizophrenic births (n=710) to births in the general population (n=101,248) and average rainfall and temperature for every month of the year in our period of study (January 1932-December 1967). Our results suggest that the risk of developing schizophrenia is 36.5% higher for people born in February than for people born in the other months of the year (95% C.I.=6.6-74.8%). We also found correlations between the rate of schizophrenic to control births for any given month, and rainfall 4 months earlier (r=0.66, p=0.010), and temperature 5 months earlier (r=0.64, p=0.013) that remained significant after correcting for multiple comparisons.