Disorders - Psychosis Disorders
Crespo-Facorro, B., Perez-Iglesias, R., Ramirez-Bonilla, M., Martinez-Garcia, O., LLorca, J., & Vazquez-Barquero, J.
Objective: Randomized controlled drug trials have demonstrated that antipsychotic medication is effective to rapidly improve psychotic symptomatology in first-episode psychosis. However, these results may not be generalizable to routine clinical practice. We evaluated the effectiveness, tolerability, and safety of olanzapine, risperidone, and haloperidol in individuals with first-episode nonaffective psychosis who are representative of clinical practice and who are treated in routine clinical settings.
Method: 172 patients participated in a practical clinical trial and were randomly assigned to haloperidol (N = 56), risperidone (N = 61), and olanzapine (N = 55). The mean modal daily doses were 5.4 mg/day for haloperidol, 4 mg/day for risperidone, and 15.3 mg/day for olanzapine; 98.3% of subjects were drug naive at baseline. Data from clinical measures of treatment response and tolerability and safety data from the 6-week acute phase of a large epidemiologic and longitudinal (February 2001 to February 2005) intervention program of first-episode psychosis (schizophrenia spectrum disorders, DSM-IV criteria) are reported.
Results: All 3 treatments showed similar effectiveness in reducing the severity of general, negative, and positive symptomatology after 6 weeks of treatment, as reported by mean change in total Clinical Global Impressions-Severity of Illness scale, Brief Psychiatric Rating Scale (BPRS), Scale for the Assessment of Positive Symptoms, and Scale for the Assessment of Negative Symptoms scores between baseline and 6 weeks. The proportion of study subjects responding, defined as 40% or greater BPRS total score improvement from baseline, was 57.1% (N = 32 of 56) haloperidol, 52.5% (N = 32 of 61) risperidone, and 63.6% (N = 35 of 55) olanzapine, with no statistical differences among groups. The frequency of extrapyramidal symptoms (chi(2) = 24.519; p < .001) and concomitant anticholinergic medication use (chi(2) = 57.842; p < .0001) was greater with haloperidol than olanzapine or risperidone. Olanzapine-treated patients had significantly more weight gain compared with the haloperidol and risperidone groups (P < .001).
Conclusion: Relatively low doses of haloperidol, risperidone, and olanzapine are equally effective for the acute treatment of first-episode nonaffective psychosis under usual conditions of real clinical practice.
Journal of Clinical Psychiatry, 67(10) : 1511-1521
- Year: 2006
- Problem: Psychosis Disorders
- Type: Randomised controlled trials
-
Stage: First episode (psychosis only)
-
Treatment and intervention: Biological Interventions (any)
, Typical Antipsychotics (first generation)
, Atypical Antipsychotics (second generation)
Bola, J. R.
This study investigates the question of whether short periods of medication-free research in early episode schizophrenia result in demonstrable long-term harm to human subjects. A meta-analysis of published quasi-experimental and random assignment studies that had a majority of first-or second-episode schizophrenia spectrum subjects, at least 1 initially unmedicated group, and a minimum of 1-year results was conducted. Only 6 studies, with 623 subjects, met inclusion criteria. The initially unmedicated groups showed a small, statistically nonsignificant long-term advantage (r = -0.09). Incorporating only random assignment studies into a composite effect size produced a similar near-zero result (r = 0.01). Good-quality evidence is inadequate to support a conclusion of long-term harm resulting from short-term postponement of medication in early episode schizophrenia research. A categorical prohibition against such research should be reconsidered. copyright The Author 2005. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center. All rights reserved.
Schizophrenia Bulletin., 32(2) : 288-296
- Year: 2006
- Problem: Psychosis Disorders
- Type: Systematic reviews
-
Stage: First episode (psychosis only)
-
Treatment and intervention: Biological Interventions (any)
, Medication dose reduction/discontinuation
Jackson, Henry, McGorry, Patrick, Edwards, Jane, Hulbert, Carol, Henry, Lisa, Harrigan, Susy, Dudgeon, Paul, Francey, Shona, Maude, Dana, Cocks, John, Killackey, Eoin, Power, Paddy
OBJECTIVES: Cognitively oriented psychotherapy for early psychosis (COPE) is aimed at facilitating the adjustment of the person, and preventing or alleviating secondary morbidity in the wake of the first psychotic episode. The present study reports on the outcomes of a controlled trial comparing two conditions: COPE versus No-COPE. METHOD: Ninety-one people participated in the trial which was analysed by intention-to-treat, including 12 people who were assigned to COPE but refused to participate. Assessments were conducted at pre-treatment, mid-treatment and post-treatment. Hospital readmission data were obtained through a Psychiatric Case Register. The study was conducted in a front-line public mental health service, the Early Psychosis Prevention and Intervention Centre (EPPIC). Clients in both COPE and No-COPE were provided with full access to the complete range of EPPIC services. RESULTS: There were no significant differences between the two conditions on the nine primary outcome variables. Hospital readmissions were assessed for each client at yearly intervals up to 4 years following the completion of treatment and again there were no significant between-group differences. CONCLUSIONS: The study indicated that there was no significant advantage to COPE over and above routine care at EPPIC.
Psychological Medicine, 35(9) : 1295-306
- Year: 2005
- Problem: Psychosis Disorders
- Type: Controlled clinical trials
-
Stage: First episode (psychosis only)
-
Treatment and intervention: Psychological Interventions (any)
, Other Psychological Interventions
Duggan, L., Fenton, M., Rathbone, J., Dardennes, R., El-Dosoky, A., Indran, S.
Background: Olanzapine is an atypical antipsychotic reported to be effective without producing disabling extrapyramidal adverse effects associated with older, typical antipsychotic drugs.Objectives: To determine the clinical effects and safety of olanzapine compared with placebo, typical and other atypical antipsychotic drugs for schizophrenia and schizophreniform psychoses.Search methods: We updated the first search [Biological Abstracts (1980-1999), The Cochrane Library (Issue 2, 1999), EMBASE (1980-1999), MEDLINE (1966-1999), PsycLIT (1974-1999) and The Cochrane Schizophrenia Group's Register (October 2000)] in October 2004 using the Cochrane Schizophrenia's Group's register of trials. We also searched references of all included studies for further trials, and contacted relevant pharmaceutical companies and authors.Selection criteria: We included all randomised clinical trials comparing olanzapine with placebo or any antipsychotic treatment for people with schizophrenia or schizophreniform psychoses.Data collection and analysis: We independently extracted data and, for homogeneous dichotomous data, calculated the random effects relative risk (RR), the 95% confidence intervals (CI) and the number needed to treat (NNT) on an intention-to-treat basis. For continuous data we calculated weighted mean differences.Main results: Fifty five trials are included (total n>10000 people with schizophrenia). Attrition from olanzapine versus placebo studies was >50% by six weeks, leaving interpretation of results problematic. Olanzapine appeared superior to placebo at six weeks for the outcome of 'no important clinical response' (any dose, 2 RCTs n=418, RR 0.88 CI 0.8 to 0.1, NNT 8 CI 5 to 27). Although dizziness and dry mouth were reported more frequently in the olanzapine-treated group, this did not reach statistical significance. The olanzapine group gained more weight.When compared with typical antipsychotic drugs, data from several small trials are incomplete. With high attrition in both groups (14 RCTs, n=3344, 38% attrition by six weeks, RR 0.81 CI 0.65 to 1.02) the assumptions included in all data are considerable. For the short term outcome of 'no important clinical response', olanzapine seems as effective as typical antipsychotics (4 RCTs, n=2778, RR 0.90 CI 0.76 to 1.06). People allocated olanzapine experienced fewer extrapyramidal adverse effects than those given typical antipsychotics. Weight change data for the short term are not statistically significant but results between three to 12 months suggest a clinically important average gain of four kilograms for people given olanzapine (4 RCTs, n=186, WMD 4.62, CI 0.6 to 8.64).Twenty three percent of people in trials of olanzapine and other atypical drugs left by eight weeks; 48% by three to12 months (11 RCTs, n=1847, RR 0.91 CI 0.82 to 1.00). There is little to choose between the atypicals, although olanzapine may cause fewer extrapyramidal adverse effects than other drugs in this category. Olanzapine produces more weight gain than other atypicals with some differences reaching conventional levels of statistical significance (1 RCT, n=980, RR gain at 2 years 1.73 CI 1.49 to 2.00, NNH 5 CI 4 to 7). There are very few data for people with first episode illness (1 RCT, duration 6 weeks, n=42). For people with treatment-resistant illness there were no clear differences between olanzapine and clozapine (4 RCTs, n=457).Authors' conclusions: The large proportion of participants leaving studies early in these trials makes it difficult to draw firm conclusions on olanzapine's clinical effects. For people with schizophrenia it may offer antipsychotic efficacy with fewer extrapyramidal adverse effects than typical drugs, but more weight gain. There is a need for further large, long-term randomised trials with more comprehensive data.
Cochrane Database of Systematic Reviews, (2) : CD001359
- Year: 2005
- Problem: Psychosis Disorders
- Type: Systematic reviews
-
Stage: Disorder established (diagnosed disorder)
-
Treatment and intervention: Biological Interventions (any)
, Atypical Antipsychotics (second generation)
Penn, David L., Waldheter, Evan J., Perkins, Diana O., Mueser, Kim T., Lieberman, Jeffrey A.
OBJECTIVE: This article reviews research on psychosocial treatment for first-episode psychosis. METHOD: PsycINFO and MEDLINE were systematically searched for studies that evaluated psychosocial interventions for first-episode psychosis. RESULTS: Comprehensive (i.e., multielement) treatment approaches show promise in reducing symptoms and hospital readmissions, as well as improving functional outcomes, although few rigorously controlled trials have been conducted. Individual cognitive behavior therapy has shown modest efficacy in reducing symptoms, assisting individuals in adjusting to their illness, and improving subjective quality of life, but it has shown minimal efficacy in reducing relapse. Some controlled research supports the benefits of family interventions, while less controlled research has evaluated group interventions. CONCLUSIONS: Adjunctive psychosocial interventions early in psychosis may be beneficial across a variety of domains and can assist with symptomatic and functional recovery. More randomized, controlled trials are needed to evaluate the effectiveness of these interventions, particularly for multielement, group, and family treatments. [References: 100]
American Journal of Psychiatry, 162(12) : 2220-32
- Year: 2005
- Problem: Psychosis Disorders
- Type: Systematic reviews
-
Stage: First episode (psychosis only)
-
Treatment and intervention: Psychological Interventions (any)
Schooler, Nina, Rabinowitz, Jonathan, Davidson, Michael, Emsley, Robin, Harvey, Philip D., Kopala, Lili, McGorry, Patrick D., VanHove, Ilse, Eerdekens, Marielle, Swyzen, Wim, DeSmedt, Goedele, EarlyPsychosisGlobalWorkingGroup
OBJECTIVE: The first episode of psychotic illness is a key intervention point. The initial experience with medication can affect willingness to accept treatment. Further, relapse prevention is a treatment cornerstone during the first years of illness because active psychotic illness may affect lifetime outcomes. Thus, initial treatment of active symptoms and subsequent relapse prevention are central goals of pharmacotherapy. This study compared long-term effectiveness of risperidone versus haloperidol in first-episode psychosis patients. METHOD: First-episode psychosis patients (N=555, mean age=25.4 years) participated in a double-blind, randomized, controlled flexible-dose trial that compared risperidone (mean modal dose=3.3 mg) and haloperidol (mean modal dose=2.9 mg). The median treatment length was 206 days (maximum=1,514). RESULTS: Positive and Negative Syndrome Scale scores and Clinical Global Impression ratings improved significantly relative to baseline, with no significant differences between groups. Three-quarters of the patients achieved initial clinical improvement, defined as >20% reduction in total Positive and Negative Syndrome Scale score. However, among those who achieved clinical improvement, 42% of the risperidone group experienced a relapse compared with 55% of the haloperidol group. The median time to relapse was 466 days for risperidone-treated subjects and 205 days for those given haloperidol. These differences were statistically significant based on Kaplan-Meier survival analysis. Adverse effects distinguished the treatments: there were significantly more extrapyramidal signs and symptoms and adjunctive medication use in the haloperidol group and greater prolactin elevation in the risperidone group. There was less weight gain with haloperidol initially but no significant differences between groups at endpoint. CONCLUSIONS: Relatively low doses of antipsychotic drugs lead to significant symptom amelioration in the majority of first-episode psychosis patients. In the long term, risperidone prevents relapse in more patients and for a longer time and also induces less abnormal movements than haloperidol.
American Journal of Psychiatry, 162(5) : 947-53
- Year: 2005
- Problem: Psychosis Disorders
- Type: Randomised controlled trials
-
Stage: First episode (psychosis only)
-
Treatment and intervention: Biological Interventions (any)
, Typical Antipsychotics (first generation)
, Atypical Antipsychotics (second generation)
Rosenbaum, B., Valbak, K., Harder, S., Knudsen, P., , Koster, A., Lajer, M., Lindhardt, A., Winther, G., Petersen, L., Jorgensen, P., Nordentoft, M., Andreasen, A. H.
Background: First-episode psychosis intervention may improve the course and outcome of schizophrenic disorders. Aims: To describe the Danish National Schizophrenia Project and to measure the outcome of two different forms of intervention after 1 year, compared with standard treatment. Method: A prospective, longitudinal, multicentre investigation included 562 patients, consecutively referred over a 2-year period, with a first episode of psychosis. Patients were allocated to supportive psychodynamic psychotherapy as a supplement to treatment as usual, an integrated, assertive, psychosocial and educational treatment programme or treatment as usual. Results: There was a non-significant tendency towards greater improvement in social functioning in the integrated treatment group and the supportive psychodynamic psychotherapy group compared with the treatment as usual group. Significance was reached for some measures when the confounding effect of drug and alcohol misuse was included. Conclusions: Integrated treatment and supportive psychodynamic psychotherapy in addition to treatment as usual may improve outcome after 1 year of treatment for people with first-episode psychosis, compared with treatment as usual alone.
British Journal of Psychiatry., 186 : 394-399
- Year: 2005
- Problem: Psychosis Disorders
- Type: Controlled clinical trials
-
Stage: First episode (psychosis only)
-
Treatment and intervention: Service Delivery & Improvement, Psychological Interventions (any)
, Other service delivery and improvement interventions
Ueland, T., Rund, B. R.
OBJECTIVE: To investigate the long-term effects of a cognitive remediation programme for adolescents with early onset psychosis. METHOD: Twenty-five subjects (cognitive remediation, n=14; control, n=11) were assessed on cognitive, clinical and psychosocial measures 1 year after discharge. All patients had received a psychoeducational programme, while the experimental group received the addition of a 30-h cognitive remediation programme. RESULTS: A significant overall improvement for eight of 10 cognitive and three of four outcome measures was found. After controlling for IQ, there was a differential improvement in early visual information processing (P<0.05) in favour of the remediation group. No other between-group differences were found. CONCLUSION: The remediation programme may have a favourable long-term effect for early visual information processing. Improved cognitive functioning in both groups may be caused by beneficial elements in the psychoeducational programme. Because the study may be underpowered, the results should be interpreted with caution. Copyright (c) Blackwell Munksgaard 2005
Acta Psychiatrica Scandinavica, 111(3) : 193-201
- Year: 2005
- Problem: Psychosis Disorders
- Type: Randomised controlled trials
-
Stage: Disorder established (diagnosed disorder)
-
Treatment and intervention: Psychological Interventions (any)
, Cognitive remediation therapy
Strakowski, Stephen M., Johnson, Jacqueline L., DelBello, Melissa P., Hamer, Robert M., Green, Alan I., Tohen, Mauricio, Lieberman, Jeffrey A., Glick, Ira, Patel, Jayendra K.
Objectives: Schizophrenia causes significant impairments of quality of life. As treatment approaches have advanced, more attention has been given to re-integrating patients into their psychosocial environments, rather than simply monitoring psychotic symptoms. The development of the second-generation antipsychotics raised hope that these medications would provide better quality of life improvement than conventional antipsychotics. This improvement is particularly relevant early in the course of schizophrenia. Methods: To address these considerations, improvements in measures of general health and social function (determined using the SF-36) were assessed in 195 patients with first-episode schizophrenia for up to one year following randomization to either olanzapine or haloperidol in a double blind clinical trial. We hypothesized that olanzapine would demonstrate better improvement on these measures than haloperidol. In order to test this hypothesis, we used a repeated measure model with SF-36 scores as the outcome, and treatment group, time, time2, time-by-treatment group interaction, and time2-by-treatment group interaction as fixed effects. Results: Both treatments demonstrated similar changes on the SF-36. Independent of treatment, patients demonstrated significant improvements in most of the SF-36 subscales, which approached normative scores by the end of one year of treatment. Forty-six of 100 olanzapine-treated patients and 37 of 95 haloperidol-treated patients completed the one year of this study (p < .4). Conclusions: These results suggest an important initial treatment goal for patients with new onset schizophrenic disorders, namely that they can expect to recover significant quality of life and social function at least initially in treatment. (PsycINFO Database Record (c) 2007 APA, all rights reserved) (journal abstract).
Schizophrenia Research, 78(2-3) : 161-169
- Year: 2005
- Problem: Psychosis Disorders
- Type: Randomised controlled trials
-
Stage: First episode (psychosis only)
-
Treatment and intervention: Biological Interventions (any)
, Typical Antipsychotics (first generation)
, Atypical Antipsychotics (second generation)
Ueland, Torill,
Objective: To examine if a cognitive remediation program could be a positive supplement to a psychoeducational treatment program for adolescents with early onset psychosis. Method: Twenty-six subjects, randomly assigned to cognitive remediation (n = 14) or control group (n = 12), were assessed on cognitive, clinical, psychosocial and behavioural measures. Results: No significant between-group differences in pre- and posttreatment scores were found. This may be due to low statistical power. Exploratory within-group analyses showed that the training group improved on five of the 10 cognitive, and three of the five functioning outcome measures, while the control group improved on three of the cognitive, and one functioning outcome variable. Conclusion: Based on these results we cannot conclude that the addition of this cognitive remediation program, yields better results than psychoeducation alone. However, within-group analyses indicate that on specific cognitive functions, as well as on some functioning outcome measures, the remediation program may have a positive effect. (PsycINFO Database Record (c) 2007 APA, all rights reserved) (journal abstract).
Acta Psychiatrica Scandinavica, 109(1) : 70-74
- Year: 2004
- Problem: Psychosis Disorders
- Type: Randomised controlled trials
-
Stage: Disorder established (diagnosed disorder)
-
Treatment and intervention: Psychological Interventions (any)
, Cognitive remediation therapy
Tarrier, Nicholas, Lewis, Shon, Haddock, Gillian, Bentall, Richard, Drake, Richard, Kinderman, Peter, Kingdon, David, Siddle, Ronald, Everitt, Julie, Leadley, Karen, Benn, Andy, Grazebrook, Katy, Haley, Cliff, Akhtar, Shahid, Davies, Linda, Palmer, Steve, Dunn, Graham,
BACKGROUND: The initial phase of a trial of cognitive-behavioural therapy (CBT) for acutely ill patients with schizophrenia of recent onset showed that it speeded recovery. AIMS: To test the hypothesis that CBT in addition to treatment as usual (TAU) during the first or second acute episode of schizophrenia will confer clinical benefit over a follow-up period. METHOD: This was an 18-month follow-up of a multicentre prospective trial of CBT or supportive counselling administered as an adjunct to TAU, compared with TAU alone, for patients hospitalised for an acute episode of schizophrenia of recent onset. Primary outcomes were total and positive symptom scales, time to relapse and re-hospitalisation. RESULTS: There were significant advantages for CBT and supportive counselling over TAU alone on symptom measures at 18 months but no group difference was seen for relapse or re-hospitalisation. There was a significant centre-treatment interaction, reflecting centre differences in the effect of introducing either treatment, but not in the comparison of CBT and supportive counselling. Medication dosage and compliance did not explain group differences. CONCLUSIONS: Adjunctive psychological treatments can have a beneficial long-term effect on symptom reduction.
British Journal of Psychiatry, 184 : 231-9
- Year: 2004
- Problem: Psychosis Disorders
- Type: Randomised controlled trials
-
Stage: First episode (psychosis only)
, Disorder established (diagnosed disorder)
-
Treatment and intervention: Psychological Interventions (any)
, Cognitive & behavioural therapies (CBT)
Morrison, Anthony P., French, Paul, Walford, Lara, Lewis, Shon W., Kilcommons, Aoiffe, Green, Joanne, Parker, Sophie, Bentall, Richard P.
Background: Advances in the ability to identify people at high risk of developing psychosis have generated interest in the possibility of preventing psychosis. Aims: To evaluate the efficacy of cognitive therapy for the prevention of transition to psychosis. Method: A randomised controlled trial compared cognitive therapy with treatment as usual in 58 patients at ultrahigh risk of developing a first episode of psychosis. Therapy was provided over 6 months, and all patients were monitored on a monthly basis for 12 months. Results: Logistic regression demonstrated that cognitive therapy significantly reduced the likelihood of making progression to psychosis as defined on the Positive and Negative Syndrome Scale over 12 months. In addition, it significantly reduced the likelihood of being prescribed antipsychotic medication and of meeting criteria for a DSM-IV diagnosis of a psychotic disorder. Analysis of covariance showed that the intervention also significantly improved positive symptoms of psychosis in this population over the 12-month period Conclusions: Cognitive therapy appears to be an acceptable and efficacious intervention for people at high risk of developing psychosis. (PsycINFO Database Record (c) 2007 APA, all rights reserved) (journal abstract).
British Journal of Psychiatry, 185(4) : 291-297
- Year: 2004
- Problem: Psychosis Disorders
- Type: Randomised controlled trials
-
Stage: At risk (indicated or selected prevention)
-
Treatment and intervention: Psychological Interventions (any)
, Cognitive & behavioural therapies (CBT)