- Email: [email protected]
Obstacles in assessing adherence to oral antipsychotic medications
330 patients which not only expands the range of treatment options available to these patients but enhances the patient's ability to continue full participation in research protocols even as they transition from an inpatient to an outpatient setting.
PREDICTING PATTERNS OF CHANGE IN DELUSIONAL CONVICTION, PREOCCUPATION, FEAR AND WELL-BEING DURING COGNITIVE BEHAVIORAL THERAPY M. van der Gaag,* L. R. Valmaggia Parnassia Psychiatric Institute, Den Haag, Zuid-Holland, Netherlands The aim of the study was to explore patterns of multidimensional change in delusions during Cognitive Behavioral Therapy (CBT) as compared to Supportive Counseling (SC) and to predict successful therapy. 62 Patients were recruited at different sites in the Netherlands and in Belgium. The patients were therapy-resistant to at least three different antipsychotic agents among which typical and atypical antipsychotic medication. The patients were randomized to CBT or SC. Well-trained psychologist-therapists were conducting treatment protocols for each intervention with a 16 session envelope. Measurement instruments were an adapted version of the Personal Questionnaire Rapid Scaling Technique (PQRST, Chadwick & Lowe, 1990) to monitor the conviction that the delusional belief is true, the preoccupation with the belief, and level of fear going with the belief. The BAP scale (Burger et al, 1980) is a scale to monitor general well-being. Ratings were done by independent blind raters. The effects of CBT and CT are reported by elsewhere by Valmaggia and van der Gaag. 50 Patients completed therapy and these data are analyzed using SAS/ETS. Four patterns of change were identified: (1) high well-being with mild psychosis and no-change; (2) moderate well-being with severe psychosis and no-change; (3) moderate well-being with mild psychosis and minimal change; (4) moderate well-being with severe psychosis and significant positive change. The study showed that delusions are not static beliefs but can vary on a weekly basis even in patients with treatment resistant positive symptoms. Age, education, duration of positive symptoms, number of admissions, number of medication taken, the three scales of the PANSS, Reaction to Hypothetical Contradiction (RTHC), depression (BDI), anxiety (STAI), insight, and selfesteem could not predict the pattern of change. Delusions are not static and can be ameliorated by CBT even in chronic therapyresistant patients. We have not been able to predict who will benefit from CBT.
THE RELATION BETWEEN A PROFESSIONAL CAREGIVER AND HIS CLIENT G. Van Humbeeck,* C. Van Audenhove LUCAS, Kqpuc~jenvoer 35, 3000 Leuven, K. U. Leuven, Leuven, Belgium There exists a well-established tradition in studying the influence of the (in)formal caregiver's expressed emotion (EE) towards patients with severe psychiatric disorders or physical illnesses. Research indicates that patients with schizophrenia who are living in a high EE
20.
Therapeutics: PsychosocialTrials
environment are significantly more apt to relapse than patients living in a low EE environment (Butzlaff & Hooley, 1998; Kazarian, 1992). Little research, however, has been conducted to examine the presence of high EE in professional relationships between professional caregivers and clients. In this research we examine wether EE exists in the relationship between a professional caregiver and his or her client. We predict that high EE exist and that it is mostly based on the amount of critical comments instead of the presence of EOI. We also investigate the relation between the level of EE and characteristics of the clients and the professionals. We expect high EE to be associated with poorer social functioning of the clients. The research group consisted of 56 professional caregivers and residents with schizophrenia, living in 9 sheltered living facilities in Belgium and 45 counselors of mentally handicapped residents, living in 3 residential facilities in Belgium. Assessment instruments for EE in our research were the Camberwell Family Interview (CFI), the Five Minute Speech Sample (FMMS) and the Perceived Criticism Scale (PCS). Other instruments were the Malines Activities Scale for social functioning, the PECC for the presence of symptoms in clients, the Utrecht Coping List, the NEO-PI and the UBOS (a burnout scale) for burnout. Our results indicated that (1) high EE was present in some professional relationships and this both in the residential care (mentally handicapped) als in sheltered living (schizophrenia), (2) high EE was related with a poorer social functiomng (clients) and with less flexibility (profesionals) and (3) there were no significant associations between EE and burnout. These results indicate that EE can be present in both formal and informal relationships. Because high EE is related with relapse, it is important that professional caregivers could learn some techniques to deal with clients in a low EE manner,
OBSTACLES IN ASSESSING ADHERENCE TO ORAL ANTIPSYCHOTIC MEDICATIONS D. I. Velligan,* M, DiCocco, D. A. Castillo, N. L. M a p l e s , Y. W. L a m , L. Ereshefsky, A. L. Miller Clinical Research Unit, San Antonio State Hospital, San Antonio, TX, USA Poor medication adherence predicts symptom exacerbation and hospitalization for patients with schizophrenia. Unfortunately, the accurate assessment of outpatient adherence to oral antipsychotic medications can be very difficult. Methods to assess adherence include self-report, caregiver report, pill counts, review of pharmacy records, use of electronic devices that record each time a pill container is opened (MEMS®), hair sample analysis, and measurement of drug and/or active metabolites in blood or urine. The accuracy of these measures can be affected by a wide range of factors including impaired recall, diet, use of unaccounted-for sample medications, concomitant medications, and multiple pill containers. Some methods of assessment provide both quantitative and qualitative evaluation of how closely a patient is following a prescribed regimen (e.g. MEMS®, sequential blood level analysis) while others are limited to dichotomizing patients into adherent versus non-adherent groups (e.g. hair sample analysis). Further difficulty is introduced by the fact that, for most medications, there is no consensus regarding what level of adherence is necessary to achieve a therapeutic effect. Dichotomizing patients based upon the presence or absence of drug will likely identify those who are actively refusing medications, but may misclassify the large number of poorly adherent individuals as adherent. We are currently studying many of these measures of adherence in a target sample of 90 schizophrenia patients recently dis-
International Congress on Schizophrenia Research 2003
20.
Therapeutics: PsychosocialTrials
331
charged from a state hospital. Not surprisingly, the concordance among measures of adherence is quite poor. While the more objective measures (e.g. pill counts, blood levels) may be considered by some to have greater validity than the more subjective measures (e.g. self-report), each method has significant advantages and major drawbacks that must considered when designing studies to examine treatment effects. While the use of conventional depot neuroleptics may improve both the ease and accuracy of adherence assessment, the side-effect profiles of these older medications make them an unattractive option for many patients. Supported by NIMH RO1 MH 62850
IS F1RST BEST? A PRELIMINARY STUDY OF THE EFFECTIVENESS OF THE SOUTHWARK FIRST EPISODE PSYCHOSIS TEAM (F1RST) VERSUS STANDARD CARE J. T. Wakers,* C. Hanlon, T. Taylor, M. S. O'Toole, R. I. Ohlsen, R. G. Purvis, L. Pilowsky
FIRST Team, PsychologicalMedicine, Institute of Psychiatry, London, UnitedKingdom This study aims to evaluate the Southwark F1RST Team and compare aspects of its service delivery and outcomes with standard care. Methods Subjects The Southwark First Onset Psychosis Team (FIRST Team) offers an innovative service for patients experiencing their first episode of psychosis. Evidence-based approaches are employed including assertive outreach, compliance therapy, psychoeducation and supported employment. 33 subjects have been recruited and form the experimental group in this study. The comparative group is an historical cohort recruited as part of a separate study drawn fi'om the same geographical area. Following identification these subjects were treated by community mental health teams, thus supplying the comparison of standard care. Subjects were matched for sex, age and DUE A comparison group of 33 patients was examined and the data for 10 subjects is presented. Outcomes A wide array of prospective measures was collected for the F1RST Team subjects. No prospective follow up data is available for the comparative group and thus retrospective case note analysis was used to measure CGI and GAS levels at 6 and 12 month follow up (Dill et al, 1989). These measures are also to be used to compare relapse rates. The two subject groups were also compared for outcomes of hospital admission, crisis community team involvement and pattern of medication use. Results The F1RST Team and standard care subjects showed significant improvement at 6 and 12 months. Mean improvement of CGI at 6 months was 12.7 (p=0.002) for F1RST Team andl 3.1 (p=0.02) for the comparison group and at 12 months 11.86 (p=0.001)for FIRST Team andl0.5 (p=0.04) for standard care. GAS scores at 6 months showed a mean improvement of 30(p=0.001) for F1RST compared to 28 (p=0.002) and at 12 months 35(p=0.002) for F1RST compared to 29(p=0.03). Regarding hospital admissions 4 F1RST Team subjects were admitted by 6 months and 1 further subject by 1 year. No patients in the F1RST Team sample had crisis community team involvement. 2 patients in the standard care group were admitted by 6 months,4 by 1 year and a further two subjects in this sample required crisis team involvement. Conclusions There was no significant difference between the two service models on any of the above measures at this preliminary stage of analysis. References Dill DL, Eisen SV, Grob MC. Validity of record
ratings of the global assessment scale. Comprehensive Psychiatry 1989;30(4):320-323.
DISCRIMINATIVE FACILITY AS A PREDICTOR OF PSYCHOLOGICAL HEALTH AMONGST PATIENTS WITH SCHIZOPHRENIA A. W o n g , * C. Y. Chiu, Y. H. C h e n
Department of Psychiatry, The University of Hong Kong, Hong Kong The present investigation examines the relationship among clinical symptoms, coping styles and subjective quality of life (QoL) in a sample of patients with schizophrenia. Seventy-six patients with schizophrenia were recruited three years after their first presentation of psychosis and asked to complete a set of assessments including clinical symptoms evaluation, cognitive functioning, QoL, as well as coping style measurements. Modest negative correlations were found between negative symptoms, general psychopathology and depression, and QoL in patients with schizophrenia. The strength of the association between different clusters of symptoms and QoL depends on the nature of the QoL index being used. In addition, cluster analysis identified three coping styles, namely high monitors, low monitors and poor discriminators, as measured by the Extended Miller Behaviour Style Scale (EMBSS). Poor discriminators had poorer subjective QoL in various domains and suffered more from the medication side effects and psychotic symptoms than did the other two monitoring groups. Thus, patients' coping style made a significant contribution to their QoL. These findings may have implications on rehabilitation programmes for patients with schizophrema.
CHANGING VOICES: A RANDOMISED CONTROL TRIAL OF GROUP COGNITIVE BEHAVIOURAL TREATMENT T. W y k e s , * N. T h o m p s o n , N. Green, S. Surgaldze, E Hayward
Psychology, Institute of Psychiatry, London, London, United Kingdom Cognitive behaviour therapy has been shown to be helpful for the positive symptoms of schizophrenia. These are intensive of time and personnel. Group cognitive treatments have many possible advantages over individual treatments, particularly for the social support and opportunities they offer for critically evaluating cognitive distortions that are thought to play a role in the experience of auditory hallucinations. Although group treatment has been reasonable successful for disorders such as depression and anxiety it has not been rigorously tested with patients who have diagnoses of schizophrenia. This is the first randomised control trial. The treatment incorporates the general components of cognitive behaviour therapy and was provided over 7 weeks by trained therapists. People with a diagnosis of schizophrenia who were continuing to experience distressing voices and who had a stable medication regime were recruited and randomised to either group treatment or treatment as usual and were assessed at week 0, 10 and 36 weeks. The main outcome measure was a self report measure of the experience of voices but secondary measures include self reported insight and psychiatric symptoms rated by a blind assessor. Analyses in which the baseline measure was the covariate showed significant gains following therapy which was effective in reducing voices. This effect was durable, i.e. it lasted to the follow-up.
International Congress on Schizophrenia Research 2003
PREDICTING PATTERNS OF CHANGE IN DELUSIONAL CONVICTION, PREOCCUPATION, FEAR AND WELL-BEING DURING COGNITIVE BEHAVIORAL THERAPY M. van der Gaag,* L. R. Valmaggia Parnassia Psychiatric Institute, Den Haag, Zuid-Holland, Netherlands The aim of the study was to explore patterns of multidimensional change in delusions during Cognitive Behavioral Therapy (CBT) as compared to Supportive Counseling (SC) and to predict successful therapy. 62 Patients were recruited at different sites in the Netherlands and in Belgium. The patients were therapy-resistant to at least three different antipsychotic agents among which typical and atypical antipsychotic medication. The patients were randomized to CBT or SC. Well-trained psychologist-therapists were conducting treatment protocols for each intervention with a 16 session envelope. Measurement instruments were an adapted version of the Personal Questionnaire Rapid Scaling Technique (PQRST, Chadwick & Lowe, 1990) to monitor the conviction that the delusional belief is true, the preoccupation with the belief, and level of fear going with the belief. The BAP scale (Burger et al, 1980) is a scale to monitor general well-being. Ratings were done by independent blind raters. The effects of CBT and CT are reported by elsewhere by Valmaggia and van der Gaag. 50 Patients completed therapy and these data are analyzed using SAS/ETS. Four patterns of change were identified: (1) high well-being with mild psychosis and no-change; (2) moderate well-being with severe psychosis and no-change; (3) moderate well-being with mild psychosis and minimal change; (4) moderate well-being with severe psychosis and significant positive change. The study showed that delusions are not static beliefs but can vary on a weekly basis even in patients with treatment resistant positive symptoms. Age, education, duration of positive symptoms, number of admissions, number of medication taken, the three scales of the PANSS, Reaction to Hypothetical Contradiction (RTHC), depression (BDI), anxiety (STAI), insight, and selfesteem could not predict the pattern of change. Delusions are not static and can be ameliorated by CBT even in chronic therapyresistant patients. We have not been able to predict who will benefit from CBT.
THE RELATION BETWEEN A PROFESSIONAL CAREGIVER AND HIS CLIENT G. Van Humbeeck,* C. Van Audenhove LUCAS, Kqpuc~jenvoer 35, 3000 Leuven, K. U. Leuven, Leuven, Belgium There exists a well-established tradition in studying the influence of the (in)formal caregiver's expressed emotion (EE) towards patients with severe psychiatric disorders or physical illnesses. Research indicates that patients with schizophrenia who are living in a high EE
20.
Therapeutics: PsychosocialTrials
environment are significantly more apt to relapse than patients living in a low EE environment (Butzlaff & Hooley, 1998; Kazarian, 1992). Little research, however, has been conducted to examine the presence of high EE in professional relationships between professional caregivers and clients. In this research we examine wether EE exists in the relationship between a professional caregiver and his or her client. We predict that high EE exist and that it is mostly based on the amount of critical comments instead of the presence of EOI. We also investigate the relation between the level of EE and characteristics of the clients and the professionals. We expect high EE to be associated with poorer social functioning of the clients. The research group consisted of 56 professional caregivers and residents with schizophrenia, living in 9 sheltered living facilities in Belgium and 45 counselors of mentally handicapped residents, living in 3 residential facilities in Belgium. Assessment instruments for EE in our research were the Camberwell Family Interview (CFI), the Five Minute Speech Sample (FMMS) and the Perceived Criticism Scale (PCS). Other instruments were the Malines Activities Scale for social functioning, the PECC for the presence of symptoms in clients, the Utrecht Coping List, the NEO-PI and the UBOS (a burnout scale) for burnout. Our results indicated that (1) high EE was present in some professional relationships and this both in the residential care (mentally handicapped) als in sheltered living (schizophrenia), (2) high EE was related with a poorer social functiomng (clients) and with less flexibility (profesionals) and (3) there were no significant associations between EE and burnout. These results indicate that EE can be present in both formal and informal relationships. Because high EE is related with relapse, it is important that professional caregivers could learn some techniques to deal with clients in a low EE manner,
OBSTACLES IN ASSESSING ADHERENCE TO ORAL ANTIPSYCHOTIC MEDICATIONS D. I. Velligan,* M, DiCocco, D. A. Castillo, N. L. M a p l e s , Y. W. L a m , L. Ereshefsky, A. L. Miller Clinical Research Unit, San Antonio State Hospital, San Antonio, TX, USA Poor medication adherence predicts symptom exacerbation and hospitalization for patients with schizophrenia. Unfortunately, the accurate assessment of outpatient adherence to oral antipsychotic medications can be very difficult. Methods to assess adherence include self-report, caregiver report, pill counts, review of pharmacy records, use of electronic devices that record each time a pill container is opened (MEMS®), hair sample analysis, and measurement of drug and/or active metabolites in blood or urine. The accuracy of these measures can be affected by a wide range of factors including impaired recall, diet, use of unaccounted-for sample medications, concomitant medications, and multiple pill containers. Some methods of assessment provide both quantitative and qualitative evaluation of how closely a patient is following a prescribed regimen (e.g. MEMS®, sequential blood level analysis) while others are limited to dichotomizing patients into adherent versus non-adherent groups (e.g. hair sample analysis). Further difficulty is introduced by the fact that, for most medications, there is no consensus regarding what level of adherence is necessary to achieve a therapeutic effect. Dichotomizing patients based upon the presence or absence of drug will likely identify those who are actively refusing medications, but may misclassify the large number of poorly adherent individuals as adherent. We are currently studying many of these measures of adherence in a target sample of 90 schizophrenia patients recently dis-
International Congress on Schizophrenia Research 2003
20.
Therapeutics: PsychosocialTrials
331
charged from a state hospital. Not surprisingly, the concordance among measures of adherence is quite poor. While the more objective measures (e.g. pill counts, blood levels) may be considered by some to have greater validity than the more subjective measures (e.g. self-report), each method has significant advantages and major drawbacks that must considered when designing studies to examine treatment effects. While the use of conventional depot neuroleptics may improve both the ease and accuracy of adherence assessment, the side-effect profiles of these older medications make them an unattractive option for many patients. Supported by NIMH RO1 MH 62850
IS F1RST BEST? A PRELIMINARY STUDY OF THE EFFECTIVENESS OF THE SOUTHWARK FIRST EPISODE PSYCHOSIS TEAM (F1RST) VERSUS STANDARD CARE J. T. Wakers,* C. Hanlon, T. Taylor, M. S. O'Toole, R. I. Ohlsen, R. G. Purvis, L. Pilowsky
FIRST Team, PsychologicalMedicine, Institute of Psychiatry, London, UnitedKingdom This study aims to evaluate the Southwark F1RST Team and compare aspects of its service delivery and outcomes with standard care. Methods Subjects The Southwark First Onset Psychosis Team (FIRST Team) offers an innovative service for patients experiencing their first episode of psychosis. Evidence-based approaches are employed including assertive outreach, compliance therapy, psychoeducation and supported employment. 33 subjects have been recruited and form the experimental group in this study. The comparative group is an historical cohort recruited as part of a separate study drawn fi'om the same geographical area. Following identification these subjects were treated by community mental health teams, thus supplying the comparison of standard care. Subjects were matched for sex, age and DUE A comparison group of 33 patients was examined and the data for 10 subjects is presented. Outcomes A wide array of prospective measures was collected for the F1RST Team subjects. No prospective follow up data is available for the comparative group and thus retrospective case note analysis was used to measure CGI and GAS levels at 6 and 12 month follow up (Dill et al, 1989). These measures are also to be used to compare relapse rates. The two subject groups were also compared for outcomes of hospital admission, crisis community team involvement and pattern of medication use. Results The F1RST Team and standard care subjects showed significant improvement at 6 and 12 months. Mean improvement of CGI at 6 months was 12.7 (p=0.002) for F1RST Team andl 3.1 (p=0.02) for the comparison group and at 12 months 11.86 (p=0.001)for FIRST Team andl0.5 (p=0.04) for standard care. GAS scores at 6 months showed a mean improvement of 30(p=0.001) for F1RST compared to 28 (p=0.002) and at 12 months 35(p=0.002) for F1RST compared to 29(p=0.03). Regarding hospital admissions 4 F1RST Team subjects were admitted by 6 months and 1 further subject by 1 year. No patients in the F1RST Team sample had crisis community team involvement. 2 patients in the standard care group were admitted by 6 months,4 by 1 year and a further two subjects in this sample required crisis team involvement. Conclusions There was no significant difference between the two service models on any of the above measures at this preliminary stage of analysis. References Dill DL, Eisen SV, Grob MC. Validity of record
ratings of the global assessment scale. Comprehensive Psychiatry 1989;30(4):320-323.
DISCRIMINATIVE FACILITY AS A PREDICTOR OF PSYCHOLOGICAL HEALTH AMONGST PATIENTS WITH SCHIZOPHRENIA A. W o n g , * C. Y. Chiu, Y. H. C h e n
Department of Psychiatry, The University of Hong Kong, Hong Kong The present investigation examines the relationship among clinical symptoms, coping styles and subjective quality of life (QoL) in a sample of patients with schizophrenia. Seventy-six patients with schizophrenia were recruited three years after their first presentation of psychosis and asked to complete a set of assessments including clinical symptoms evaluation, cognitive functioning, QoL, as well as coping style measurements. Modest negative correlations were found between negative symptoms, general psychopathology and depression, and QoL in patients with schizophrenia. The strength of the association between different clusters of symptoms and QoL depends on the nature of the QoL index being used. In addition, cluster analysis identified three coping styles, namely high monitors, low monitors and poor discriminators, as measured by the Extended Miller Behaviour Style Scale (EMBSS). Poor discriminators had poorer subjective QoL in various domains and suffered more from the medication side effects and psychotic symptoms than did the other two monitoring groups. Thus, patients' coping style made a significant contribution to their QoL. These findings may have implications on rehabilitation programmes for patients with schizophrema.
CHANGING VOICES: A RANDOMISED CONTROL TRIAL OF GROUP COGNITIVE BEHAVIOURAL TREATMENT T. W y k e s , * N. T h o m p s o n , N. Green, S. Surgaldze, E Hayward
Psychology, Institute of Psychiatry, London, London, United Kingdom Cognitive behaviour therapy has been shown to be helpful for the positive symptoms of schizophrenia. These are intensive of time and personnel. Group cognitive treatments have many possible advantages over individual treatments, particularly for the social support and opportunities they offer for critically evaluating cognitive distortions that are thought to play a role in the experience of auditory hallucinations. Although group treatment has been reasonable successful for disorders such as depression and anxiety it has not been rigorously tested with patients who have diagnoses of schizophrenia. This is the first randomised control trial. The treatment incorporates the general components of cognitive behaviour therapy and was provided over 7 weeks by trained therapists. People with a diagnosis of schizophrenia who were continuing to experience distressing voices and who had a stable medication regime were recruited and randomised to either group treatment or treatment as usual and were assessed at week 0, 10 and 36 weeks. The main outcome measure was a self report measure of the experience of voices but secondary measures include self reported insight and psychiatric symptoms rated by a blind assessor. Analyses in which the baseline measure was the covariate showed significant gains following therapy which was effective in reducing voices. This effect was durable, i.e. it lasted to the follow-up.
International Congress on Schizophrenia Research 2003