Serious Mental Illness Blog

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For Depression, Prescribing Exercise Before MedicationBy Olga KhazanAerobic activity has shown to be an effective treatment for many forms of depression. So why are so many people still on antidepressants?Joel Ginsberg was a sophomore at a college in Dallas when the social anxiety he had felt throughout his life morphed into an all-consuming hopelessness. He struggled to get out of bed, and even the simplest tasks felt herculean.“The world lost its color,” he told me. “Nothing interested me; I didn’t have any motivation. There was a lot of self-doubt.”He thought getting some exercise might help, but it was hard to motivate himself to go to the campus gym.“So what I did is break it down into mini-steps,” he said. “I would think about just getting to the gym, rather than going for 30 minutes. Once I was at the gym, I would say, ‘I’m just going to get on the treadmill for five minutes.’”Eventually, he found himself reading novels for long stretches at a time while pedaling away on a stationary bike. Soon, his gym visits became daily. If he skipped one day, his mood would plummet the next.“It was kind of like a boost,” he said, recalling how exercise helped him break out of his inertia. “It was a shift in mindset that kind of got me over the hump.”Depression is the most common mental illness—affecting a staggering 25 percent of Americans—but a growing body of research suggests that one of its best cures is cheap and ubiquitous. In 1999, a randomized controlled trial showed that depressed adults who took part in aerobic exercise improved as much as those treated with Zoloft. A 2006 meta-analysis of 11 studies bolstered those findings and recommended that physicians counsel their depressed patients to try it. A 2011 study took this conclusion even further: It looked at 127 depressed people who hadn’t experienced relief from SSRIs, a common type of antidepressant, and found that exercise led 30 percent of them into remission—a result that was as good as, or better than, drugs alone.Though we don’t know exactly how any antidepressant works, we think exercise combats depression by enhancing endorphins: natural chemicals that act like morphine and other painkillers. There’s also a theory that aerobic activity boosts norepinephrine, a neurotransmitter that plays a role in mood. And like antidepressants, exercise helps the brain grow new neurons.But this powerful, non-drug treatment hasn’t yet become a mainstream remedy. In a 2009 study, only 40 percent of depressed patients reported being counseled to try exercise at their last physician visit.Instead, Americans are awash in pills. The use of antidepressants has increased 400 percent between 1988 and 2008. They’re now one of the three most-prescribed categories of drugs, coming in right after painkillers and cholesterol medications.After 15 years of research on the depression-relieving effects of exercise, why are there still so many people on pills? The answer speaks volumes about our mental-health infrastructure and physician reimbursement system, as well as about how difficult it remains to decipher the nature of depression and what patients want from their doctors.Jogging as medicine“I am only a doctor, not a dictator,” insists Madhukar H. Trivedi, a professor of psychiatry at the University of Texas Southwestern Medical Center in Dallas. “I don’t tell patients what to do.”Trivedi is one of the forefathers of the movement to combat melancholy with physical exertion. He’s authored multiple studies on the exercise-depression connection, and workouts are now one of the many weapons in his psychiatric arsenal. But whether any given treatment is right for a particular person is entirely up to that patient, he said.“I talk about the pros and cons about all the treatment options available—exercise, therapy, and pills,” he said. “If a patient says, ‘I’m not really keen on medication and therapy, I want to use exercise,’ then if it’s appropriate, they can try it. But I give them caveats about how they should be monitoring it. I don’t say, ‘Go exercise and call me if it doesn’t work.’”Here’s how he goes about this unconventional type of prescription:“People will take the disease and treatment lightly if they know Paxil is coming.First, Trivedi must gently raise the idea of exercise as a treatment option—patients often don’t know to ask. (There are no televised pharmaceutical ads for running, he notes.) He then tells patients about the studies, the amount of exercise that would be required, and the heart rate they’d need to reach. Based on a recent study by Trivedi and others, he recommends three to five sessions per week. Each one should last 45 to 60 minutes, and patients should reach 50 to 85 percent of their maximum heart rates.He and the patient then blueprint a weekly workout schedule together. Not doing enough sessions, he warns, would be like a diabetic person “using insulin only occasionally.” He encourages patients to use FitBits or other monitoring gadgets to track their progress—and to guilt them off the couch.Trivedi says this approach rests on three key elements. “One, you have to be very clear with patients that just because exercise has been shown to be efficacious, it doesn’t work for everyone. Two, the dose of the treatment is very important; you can’t just go for a stroll in the park. And three, there has to be a constant vigilance about the monitoring of symptoms. If the treatment is not working, you need to do something.”That “something” could be adding antidepressants back into the mix—but only if the workouts have truly failed.“People will take the disease and treatment lightly,” he said, “if they know Paxil is coming.”The insurance challengeWhen it comes to non-drug remedies for depression, exercise is actually just one of several promising options. Over the past few months, research has shown that other common lifestyle adjustments, like meditating or getting more sleep, might also relieve symptoms. Therapy has been shown to work just as well as SSRIs and other medications. In fact, a major JAMA study a few years ago cast doubt on the effectiveness of antidepressants in general, finding that the drugs don’t function any better than placebo pills for people with mild or moderate depression.The half-dozen psychiatrists I interviewed said they’ve started to incorporate non-drug treatments into their plans for depressed patients. But they said they’re only able to do that because they don’t accept insurance. (One of the doctors works for a college system and only sees students.)That’s because insurers still largely reimburse psychiatrists, like all other doctors, for each appointment—whatever that appointment may entail—rather than for curing a given patient. It takes less time to write a prescription for Zoloft than it does to tease out a patient’s options for sleeping better and breaking a sweat. Fewer moments spent mapping out jogging routes or sleep schedules means being able to squeeze in more patients for medications each day.“[Psychiatrists] can probably do four medication-management visits in an hour,” said Chuck Ingoglia, a senior vice president at the National Council for Behavioral Health. “If they were doing therapy, they might see one person for 50 minutes.”An insurance company might pay an internist and a psychiatrist both $100 for an appointment, but a primary care check-up might take 15 minutes while a thorough conversation with a psychiatrist takes 40 or more.Because of these constraints, psychiatrists are among the least likely specialists to accept insurance—only about 55 percent of them do. Henry David Abraham, a psychiatrist in Lexington, Massachusetts, said he stopped accepting insurance once he realized his patient visits were becoming too rushed.“I was seeing patients for 15 minutes each to give them drugs,” he said. “What would my mentors say about that quality of care? They would say, ‘Horrible!’”He now sees patients on a sliding scale, with the wealthy essentially footing the bill for the poor. His sessions include a range of treatment options, including therapy.“One patient lost a husband to cancer, and medication may take the edge off of some of those emotions, but the process she requires is to work through the elements of grief,” he said. “There’s not a pill for that.”Meanwhile, psychiatrists who take insurance are increasingly less likely to offer talk therapy—or longer appointments of any kind—because licensed social workers and psychologists can offer the same types of sessions at lower rates.“If you’re an insurance company, and you can get a social worker to do therapy for $50, that becomes the floor,” Ingoglia said.When Brittany, a woman who lives in northern Virginia, first began experiencing panic attacks a few months ago, she turned to a series of providers in her insurance network. None of the doctors she saw wanted to discuss anything but drug options, she said.“They were all just throwing medication at me,” she said. (She asked that I not use her last name). “I said I don’t want medicine, but they didn’t want to talk about a long-term therapeutic plan.”She went through eight different providers before finally finding a psychiatrist who helped her establish a plan to do yoga several times a week to manage her panic disorder. Those psychiatrist appointments are 90 minutes long.Exacerbating all of this is the fact that there’s a shortage of psychiatrists, and the needs of people with mental health issues are increasingly being addressed by primary-care doctors, who now provide over a third of all mental health-care in the U.S. Sixty-two percent of all antidepressant prescriptions are now written by general practitioners, ob-gyns, and pediatricians.But general practitioners aren’t always as equipped as psychiatrists to diagnose and treat depression. In 2007, 73 percent of patients who were prescribed an antidepressant were not given psychiatric diagnoses. In other cases, primary care doctors may balk at the idea of prescribing any interventions because they don’t feel they know enough about depression.Writing in The New Yorker last year, primary care internist Suzanne Koven said she’s often at a loss when faced with “the lawyer who’s having trouble meeting deadlines and wants medication for attention-deficit disorder. Or the businesswoman whose therapist told her to see me about starting an antidepressant.”She feared she lacked “the time or training to diagnose and manage many psychiatric disorders,” she wrote.Managing life’s roadblocksLet’s say you’re a psychiatrist who has managed to start incorporating sleep, exercise, and other non-drug remedies into a patient’s depression treatment. Congratulations! You now face a patient who is, very possibly, lethargic, unsatisfied, and lying about how many times he or she went running last week.That is, if you can convince the patient to try anything other than drugs in the first place.Julia Samton, a psychiatrist who practices in New York City, said she prescribes medications as a “third-tier resort” after lifestyle changes and therapy have been ruled out. She spends 45 minutes on each appointment, attempting to punch through her patients’ stony Manhattanite exteriors and expose the foundations of their agony.“There are some people who say all they want is medication,” she said. “But they are the ones who are suffering tremendously and have a difficult time accessing their mental life. They want things fixed, and fixed right now.”She said some of her patients are lured by the drug ads they see on TV— charming little spots that make it look like a gloomy day is nothing an SSRI can’t handle.“It’s evocative to see a commercial where your world could change from black and white to color,” she said.Beth Salcedo is a psychiatrist near Washington, D.C. People in this perpetual type-A convention of a town tend to have too much work, too-lofty aspirations, too high a rent, and too little time left before their evening networking event starts.“I think it’s difficult to convince people to spend half an hour a day on exercise when they have kids, a job, and it can take months to see the benefit,” she said.Some patients claim they can’t make time for the gym, or are adamant that they can’t afford to sleep more than six hours each night. And lawyers who work 16-hour days are not going to sit through long counseling appointments no matter how many peer-reviewed studies you wave at them.“What do you do? Do you let them walk around depressed?” Salcedo said. “Or do you offer them a treatment that they’ll accept? Everyone has to do the thing that works for them.”And despite its merits, exercise is not nearly as portable or painless as a tablet.Salcedo had one patient whose mood entirely depended on her workouts. The hitch was that her exercise of choice was swimming—and the only pool she had access to was outdoors. “In the spring, fall, and winter, it wasn’t so easy,” Salcedo said.Depressed patients are also more likely than most to feel unmotivated, so even the best-laid exercise treatment plan can be thwarted by a few days of staying in bed for an extra hour.“Depressed patients have apathy or a lack of energy. Or they have anxiety disorders so they’re not going to go to the gym. Or they’re afraid to be seen jogging across Monument Avenue,” said Joan Plotkin Han, a staff psychiatrist at Virginia Commonwealth University in Richmond. Still, she pushes it with her more intrepid patients. “I don’t want to be that intimidating or threatening, but I’m a nag. And I will nag them.”Of course, sometimes exercise works as a multiplier, augmenting the effectiveness of an existing treatment, including drugs or therapy, or simply by helping the patient regain agency in their lives. Many patients recover from depression faster when the disease is attacked through multiple approaches simultaneously.Ginsberg said exercise didn’t cure him, but it did give him the energy to sort through the origins of his inner turmoil. And Brittany did eventually go on SSRIs to halt her nightly panic attacks—but now that yoga has her anxiety under control, she’s tapering off the drugs once again.Exercise, like any other treatment, won’t work for every depressed patient. But the psychiatrists who incorporate it into their practices are finding that the only way it can work is if it’s treated like real medicine.“The issue is that exercise seems as straightforward and simple as apple pie and your mom,” Trivedi said. “Everybody knows what it is, so it’s misunderstood. It’s important to explain to patients the seriousness of the disease they have and the nuances of the intervention they need.”


For more mental health news, Click Here to access the Serious Mental Illness Blog

For Depression, Prescribing Exercise Before Medication
By Olga Khazan

Aerobic activity has shown to be an effective treatment for many forms of depression. So why are so many people still on antidepressants?

Joel Ginsberg was a sophomore at a college in Dallas when the social anxiety he had felt throughout his life morphed into an all-consuming hopelessness. He struggled to get out of bed, and even the simplest tasks felt herculean.
“The world lost its color,” he told me. “Nothing interested me; I didn’t have any motivation. There was a lot of self-doubt.”
He thought getting some exercise might help, but it was hard to motivate himself to go to the campus gym.
“So what I did is break it down into mini-steps,” he said. “I would think about just getting to the gym, rather than going for 30 minutes. Once I was at the gym, I would say, ‘I’m just going to get on the treadmill for five minutes.’”
Eventually, he found himself reading novels for long stretches at a time while pedaling away on a stationary bike. Soon, his gym visits became daily. If he skipped one day, his mood would plummet the next.
“It was kind of like a boost,” he said, recalling how exercise helped him break out of his inertia. “It was a shift in mindset that kind of got me over the hump.”
Depression is the most common mental illness—affecting a staggering 25 percent of Americans—but a growing body of research suggests that one of its best cures is cheap and ubiquitous. In 1999, a randomized controlled trial showed that depressed adults who took part in aerobic exercise improved as much as those treated with Zoloft. A 2006 meta-analysis of 11 studies bolstered those findings and recommended that physicians counsel their depressed patients to try it. A 2011 study took this conclusion even further: It looked at 127 depressed people who hadn’t experienced relief from SSRIs, a common type of antidepressant, and found that exercise led 30 percent of them into remission—a result that was as good as, or better than, drugs alone.
Though we don’t know exactly how any antidepressant works, we think exercise combats depression by enhancing endorphins: natural chemicals that act like morphine and other painkillers. There’s also a theory that aerobic activity boosts norepinephrine, a neurotransmitter that plays a role in mood. And like antidepressants, exercise helps the brain grow new neurons.
But this powerful, non-drug treatment hasn’t yet become a mainstream remedy. In a 2009 study, only 40 percent of depressed patients reported being counseled to try exercise at their last physician visit.
Instead, Americans are awash in pills. The use of antidepressants has increased 400 percent between 1988 and 2008. They’re now one of the three most-prescribed categories of drugs, coming in right after painkillers and cholesterol medications.
After 15 years of research on the depression-relieving effects of exercise, why are there still so many people on pills? The answer speaks volumes about our mental-health infrastructure and physician reimbursement system, as well as about how difficult it remains to decipher the nature of depression and what patients want from their doctors.

Jogging as medicine
“I am only a doctor, not a dictator,” insists Madhukar H. Trivedi, a professor of psychiatry at the University of Texas Southwestern Medical Center in Dallas. “I don’t tell patients what to do.”
Trivedi is one of the forefathers of the movement to combat melancholy with physical exertion. He’s authored multiple studies on the exercise-depression connection, and workouts are now one of the many weapons in his psychiatric arsenal. But whether any given treatment is right for a particular person is entirely up to that patient, he said.
“I talk about the pros and cons about all the treatment options available—exercise, therapy, and pills,” he said. “If a patient says, ‘I’m not really keen on medication and therapy, I want to use exercise,’ then if it’s appropriate, they can try it. But I give them caveats about how they should be monitoring it. I don’t say, ‘Go exercise and call me if it doesn’t work.’”
Here’s how he goes about this unconventional type of prescription:
“People will take the disease and treatment lightly if they know Paxil is coming.
First, Trivedi must gently raise the idea of exercise as a treatment option—patients often don’t know to ask. (There are no televised pharmaceutical ads for running, he notes.) He then tells patients about the studies, the amount of exercise that would be required, and the heart rate they’d need to reach. Based on a recent study by Trivedi and others, he recommends three to five sessions per week. Each one should last 45 to 60 minutes, and patients should reach 50 to 85 percent of their maximum heart rates.
He and the patient then blueprint a weekly workout schedule together. Not doing enough sessions, he warns, would be like a diabetic person “using insulin only occasionally.” He encourages patients to use FitBits or other monitoring gadgets to track their progress—and to guilt them off the couch.
Trivedi says this approach rests on three key elements. “One, you have to be very clear with patients that just because exercise has been shown to be efficacious, it doesn’t work for everyone. Two, the dose of the treatment is very important; you can’t just go for a stroll in the park. And three, there has to be a constant vigilance about the monitoring of symptoms. If the treatment is not working, you need to do something.”
That “something” could be adding antidepressants back into the mix—but only if the workouts have truly failed.
“People will take the disease and treatment lightly,” he said, “if they know Paxil is coming.”

The insurance challenge
When it comes to non-drug remedies for depression, exercise is actually just one of several promising options. Over the past few months, research has shown that other common lifestyle adjustments, like meditating or getting more sleep, might also relieve symptoms. Therapy has been shown to work just as well as SSRIs and other medications. In fact, a major JAMA study a few years ago cast doubt on the effectiveness of antidepressants in general, finding that the drugs don’t function any better than placebo pills for people with mild or moderate depression.
The half-dozen psychiatrists I interviewed said they’ve started to incorporate non-drug treatments into their plans for depressed patients. But they said they’re only able to do that because they don’t accept insurance. (One of the doctors works for a college system and only sees students.)
That’s because insurers still largely reimburse psychiatrists, like all other doctors, for each appointment—whatever that appointment may entail—rather than for curing a given patient. It takes less time to write a prescription for Zoloft than it does to tease out a patient’s options for sleeping better and breaking a sweat. Fewer moments spent mapping out jogging routes or sleep schedules means being able to squeeze in more patients for medications each day.
“[Psychiatrists] can probably do four medication-management visits in an hour,” said Chuck Ingoglia, a senior vice president at the National Council for Behavioral Health. “If they were doing therapy, they might see one person for 50 minutes.”
An insurance company might pay an internist and a psychiatrist both $100 for an appointment, but a primary care check-up might take 15 minutes while a thorough conversation with a psychiatrist takes 40 or more.
Because of these constraints, psychiatrists are among the least likely specialists to accept insurance—only about 55 percent of them do. Henry David Abraham, a psychiatrist in Lexington, Massachusetts, said he stopped accepting insurance once he realized his patient visits were becoming too rushed.
“I was seeing patients for 15 minutes each to give them drugs,” he said. “What would my mentors say about that quality of care? They would say, ‘Horrible!’”
He now sees patients on a sliding scale, with the wealthy essentially footing the bill for the poor. His sessions include a range of treatment options, including therapy.
“One patient lost a husband to cancer, and medication may take the edge off of some of those emotions, but the process she requires is to work through the elements of grief,” he said. “There’s not a pill for that.”
Meanwhile, psychiatrists who take insurance are increasingly less likely to offer talk therapy—or longer appointments of any kind—because licensed social workers and psychologists can offer the same types of sessions at lower rates.
“If you’re an insurance company, and you can get a social worker to do therapy for $50, that becomes the floor,” Ingoglia said.When Brittany, a woman who lives in northern Virginia, first began experiencing panic attacks a few months ago, she turned to a series of providers in her insurance network. None of the doctors she saw wanted to discuss anything but drug options, she said.
“They were all just throwing medication at me,” she said. (She asked that I not use her last name). “I said I don’t want medicine, but they didn’t want to talk about a long-term therapeutic plan.”
She went through eight different providers before finally finding a psychiatrist who helped her establish a plan to do yoga several times a week to manage her panic disorder. Those psychiatrist appointments are 90 minutes long.
Exacerbating all of this is the fact that there’s a shortage of psychiatrists, and the needs of people with mental health issues are increasingly being addressed by primary-care doctors, who now provide over a third of all mental health-care in the U.S. Sixty-two percent of all antidepressant prescriptions are now written by general practitioners, ob-gyns, and pediatricians.
But general practitioners aren’t always as equipped as psychiatrists to diagnose and treat depression. In 2007, 73 percent of patients who were prescribed an antidepressant were not given psychiatric diagnoses. In other cases, primary care doctors may balk at the idea of prescribing any interventions because they don’t feel they know enough about depression.
Writing in The New Yorker last year, primary care internist Suzanne Koven said she’s often at a loss when faced with “the lawyer who’s having trouble meeting deadlines and wants medication for attention-deficit disorder. Or the businesswoman whose therapist told her to see me about starting an antidepressant.”
She feared she lacked “the time or training to diagnose and manage many psychiatric disorders,” she wrote.

Managing life’s roadblocks
Let’s say you’re a psychiatrist who has managed to start incorporating sleep, exercise, and other non-drug remedies into a patient’s depression treatment. Congratulations! You now face a patient who is, very possibly, lethargic, unsatisfied, and lying about how many times he or she went running last week.
That is, if you can convince the patient to try anything other than drugs in the first place.
Julia Samton, a psychiatrist who practices in New York City, said she prescribes medications as a “third-tier resort” after lifestyle changes and therapy have been ruled out. She spends 45 minutes on each appointment, attempting to punch through her patients’ stony Manhattanite exteriors and expose the foundations of their agony.
“There are some people who say all they want is medication,” she said. “But they are the ones who are suffering tremendously and have a difficult time accessing their mental life. They want things fixed, and fixed right now.”
She said some of her patients are lured by the drug ads they see on TV— charming little spots that make it look like a gloomy day is nothing an SSRI can’t handle.
“It’s evocative to see a commercial where your world could change from black and white to color,” she said.
Beth Salcedo is a psychiatrist near Washington, D.C. People in this perpetual type-A convention of a town tend to have too much work, too-lofty aspirations, too high a rent, and too little time left before their evening networking event starts.
“I think it’s difficult to convince people to spend half an hour a day on exercise when they have kids, a job, and it can take months to see the benefit,” she said.
Some patients claim they can’t make time for the gym, or are adamant that they can’t afford to sleep more than six hours each night. And lawyers who work 16-hour days are not going to sit through long counseling appointments no matter how many peer-reviewed studies you wave at them.
“What do you do? Do you let them walk around depressed?” Salcedo said. “Or do you offer them a treatment that they’ll accept? Everyone has to do the thing that works for them.”
And despite its merits, exercise is not nearly as portable or painless as a tablet.
Salcedo had one patient whose mood entirely depended on her workouts. The hitch was that her exercise of choice was swimming—and the only pool she had access to was outdoors. “In the spring, fall, and winter, it wasn’t so easy,” Salcedo said.
Depressed patients are also more likely than most to feel unmotivated, so even the best-laid exercise treatment plan can be thwarted by a few days of staying in bed for an extra hour.
“Depressed patients have apathy or a lack of energy. Or they have anxiety disorders so they’re not going to go to the gym. Or they’re afraid to be seen jogging across Monument Avenue,” said Joan Plotkin Han, a staff psychiatrist at Virginia Commonwealth University in Richmond. Still, she pushes it with her more intrepid patients. “I don’t want to be that intimidating or threatening, but I’m a nag. And I will nag them.”
Of course, sometimes exercise works as a multiplier, augmenting the effectiveness of an existing treatment, including drugs or therapy, or simply by helping the patient regain agency in their lives. Many patients recover from depression faster when the disease is attacked through multiple approaches simultaneously.
Ginsberg said exercise didn’t cure him, but it did give him the energy to sort through the origins of his inner turmoil. And Brittany did eventually go on SSRIs to halt her nightly panic attacks—but now that yoga has her anxiety under control, she’s tapering off the drugs once again.
Exercise, like any other treatment, won’t work for every depressed patient. But the psychiatrists who incorporate it into their practices are finding that the only way it can work is if it’s treated like real medicine.
“The issue is that exercise seems as straightforward and simple as apple pie and your mom,” Trivedi said. “Everybody knows what it is, so it’s misunderstood. It’s important to explain to patients the seriousness of the disease they have and the nuances of the intervention they need.”





For more mental health news, Click Here to access the Serious Mental Illness Blog

Filed under depression depressed major depressive disorder major depression mental illness mental illness mental health health healthy exercise jog jogging run running news science sad sadness seasonal affective disorder disorder diagnosis psychology psychiatry med meds drug drugs treat treatment

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At last, a promising alternative to antipsychotics for schizophreniaBy Daniel and Jason Freeman, the authors of Paranoia: The 21st Century FearFor many, the side-effects of antipsychotics are worse than the symptoms they’re meant to treat. No wonder some people with schizophrenia refuse to take them.Imagine that, after feeling unwell for a while, you visit your GP. “Ah,” says the doctor decisively, "what you need is medication X. It’s often pretty effective, though there can be side-effects. You may gain weight. Or feel drowsy. And you may develop tremors reminiscent of Parkinson’s disease." Warily, you glance at the prescription on the doctor’s desk, but she hasn’t finished. "Some patients find that sex becomes a problem. Diabetes and heart problems are a risk. And in the long term the drug may actually shrink your brain … "
This scenario may sound far-fetched, but it is precisely what faces people diagnosed with schizophrenia. Since the 1950s, the illness has generally been treated using antipsychotic drugs – which, as with so many medications, were discovered by chance. A French surgeon investigating treatments for surgical shock found that one of the drugs he tried – the antihistamine chlorpromazine – produced powerful psychological effects. This prompted the psychiatrist Pierre Deniker to give the drug to some of his most troubled patients. Their symptoms improved dramatically, and a major breakthrough in the treatment of psychosis seemed to have arrived.
Many other antipsychotic drugs have followed in chlorpromazine’s wake and today these medications comprise 10% of total NHS psychiatric prescriptions. They are costly items: the NHS spends more on these medications than it does for any other psychiatric drug, including antidepressants. Globally, around $14.5bn is estimated to be spent on antipsychotics each year.
Since the 1950s the strategy of all too many NHS mental health teams has been a simple one. Assuming that psychosis is primarily a biological brain problem, clinicians prescribe an antipsychotic medication and everyone does their level best to get the patient to take it, often for long periods. There can be little doubt that these drugs make a positive difference, reducing delusions and hallucinations and making relapse less likely – provided, that is, the patient takes their medication.
Unfortunately, dropout rates are high. This is partly because individuals sometimes don’t accept that they are ill. But a major reason is the side-effects. These vary from drug to drug, but they’re common and for many people are worse than the symptoms they are designed to treat.In addition, antipsychotics don’t work for everyone. It is estimated that six months after first being prescribed them, as many as 50% of patients are either taking the drugs haphazardly or not at all.
The conventional treatment for this most severe of psychiatric illnesses, then, is expensive, frequently unpleasant, and not always effective even for those who carry on taking the drugs. But it is what we have relied upon – which helps to explain why the results of a clinical trial, recently published in The Lancet, have generated so much interest and debate.
A team led by Professor Anthony Morrison at the University of Manchester randomly assigned a group of patients, all of whom had opted not to take antipsychotics, to treatment as usual (involving a range of non-pharmaceutical care) or to treatment as usual plus a course of cognitive therapy (CT). Drop-out rates for the cognitive therapy were low, while its efficacy in reducing the symptoms of psychosis was comparable to what medication can achieve.
So what exactly is CT for schizophrenia? At its core is the idea that the patient should be encouraged to talk about their experiences – just as they would for every other psychological condition. Psychosis isn’t viewed as a biological illness that one either has or does not have. Instead, just like every other mental disorder, psychotic experiences are seen as the severest instances of thoughts and feelings – notably delusions and hallucinations – that many of us experience from time to time.
Working together, the patient and therapist develop a model of what’s causing the experiences, and why they’re recurring. These factors will vary from person to person, so what is produced is a bespoke account of the individual’s experience, which is then used to guide treatment. For example, a person so worried by paranoid fears that they won’t set foot outside might be helped to trace the roots of their anxiety to past experiences; to gradually test out their fearful thoughts; and to learn to manage their anxiety while getting on with the activities they enjoy. An individual troubled by hearing voices will be helped to understand what’s triggering these voices, and to develop a more confident, empowering relationship with them.
These are early days. Nevertheless, most of the meta-analyses of CT’s efficacy for psychosis, when added to standard treatment, have indicated definite (albeit modest) benefits for patients, with the latest showing that CT is better than other psychological treatments for reducing delusions and hallucinations. The latest guidelines from the UK’s National Institute for Health and Care Excellence (Nice) recommend it for those at risk of psychosis and, when combined with medication, for people with an ongoing problem.
But not everyone is convinced, and although the research published in The Lancet is encouraging, it was small scale. CT for psychosis is still evolving, and we think that evolution should prioritise three key areas.First, we must focus on understanding and treating individual psychotic experiences. As we’ve reported in a previous post, there is increasing reason to doubt the usefulness of the diagnosis “schizophrenia”. The term has been used as a catch-all for an assortment of unusual thoughts and feelings that often have no intrinsic connections, and aren’t qualitatively different from those experienced by the general population. Each psychotic experience may therefore require a tailored treatment.Second, we must build on the recent transformation in understanding the causes of psychotic experiences, taking one factor at a time (insomnia, say, or worry), developing an intervention to change it, and then observing the effects of that intervention on an individual’s difficulties.And finally, we must listen to what patients want from their treatment – for example, by focusing on improving levels of wellbeing, which tend to be very low among people with schizophrenia.
What about costs compared with drug treatment? A course of CBT is typically just over £1,000, but if it leads to a reduction in the amount of time patients spend in hospital and their use of other services, or a return to work, then it easily pays for itself.
The Nice guidance on psychosis and schizophrenia, updated this year, is unequivocal:"The systematic review of economic evidence showed that provision of CBT to people with schizophrenia in the UK improved clinical outcomes at no additional cost. This finding was supported by economic modelling undertaken for this guideline, which suggested that provision of CBT might result in net cost savings to the NHS, associated with a reduction in future hospitalisation rates."
If the real promise of cognitive therapy can be fulfilled, we may at last have a genuinely effective, relatively cheap, and side-effect-free alternative to antipsychotics for those patients who don’t wish to take them.


For more mental health news, Click Here to access the Serious Mental Illness Blog

At last, a promising alternative to antipsychotics for schizophrenia
By Daniel and Jason Freeman, the authors of Paranoia: The 21st Century Fear

For many, the side-effects of antipsychotics are worse than the symptoms they’re meant to treat. No wonder some people with schizophrenia refuse to take them.

Imagine that, after feeling unwell for a while, you visit your GP. “Ah,” says the doctor decisively, "what you need is medication X. It’s often pretty effective, though there can be side-effects. You may gain weight. Or feel drowsy. And you may develop tremors reminiscent of Parkinson’s disease." Warily, you glance at the prescription on the doctor’s desk, but she hasn’t finished. "Some patients find that sex becomes a problem. Diabetes and heart problems are a risk. And in the long term the drug may actually shrink your brain … "

This scenario may sound far-fetched, but it is precisely what faces people diagnosed with schizophrenia. Since the 1950s, the illness has generally been treated using antipsychotic drugs – which, as with so many medications, were discovered by chance. A French surgeon investigating treatments for surgical shock found that one of the drugs he tried – the antihistamine chlorpromazine – produced powerful psychological effects. This prompted the psychiatrist Pierre Deniker to give the drug to some of his most troubled patients. Their symptoms improved dramatically, and a major breakthrough in the treatment of psychosis seemed to have arrived.

Many other antipsychotic drugs have followed in chlorpromazine’s wake and today these medications comprise 10% of total NHS psychiatric prescriptions. They are costly items: the NHS spends more on these medications than it does for any other psychiatric drug, including antidepressants. Globally, around $14.5bn is estimated to be spent on antipsychotics each year.

Since the 1950s the strategy of all too many NHS mental health teams has been a simple one. Assuming that psychosis is primarily a biological brain problem, clinicians prescribe an antipsychotic medication and everyone does their level best to get the patient to take it, often for long periods. There can be little doubt that these drugs make a positive difference, reducing delusions and hallucinations and making relapse less likely – provided, that is, the patient takes their medication.

Unfortunately, dropout rates are high. This is partly because individuals sometimes don’t accept that they are ill. But a major reason is the side-effects. These vary from drug to drug, but they’re common and for many people are worse than the symptoms they are designed to treat.
In addition, antipsychotics don’t work for everyone. It is estimated that six months after first being prescribed them, as many as 50% of patients are either taking the drugs haphazardly or not at all.

The conventional treatment for this most severe of psychiatric illnesses, then, is expensive, frequently unpleasant, and not always effective even for those who carry on taking the drugs. But it is what we have relied upon – which helps to explain why the results of a clinical trial, recently published in The Lancet, have generated so much interest and debate.

A team led by Professor Anthony Morrison at the University of Manchester randomly assigned a group of patients, all of whom had opted not to take antipsychotics, to treatment as usual (involving a range of non-pharmaceutical care) or to treatment as usual plus a course of cognitive therapy (CT). Drop-out rates for the cognitive therapy were low, while its efficacy in reducing the symptoms of psychosis was comparable to what medication can achieve.

So what exactly is CT for schizophrenia? At its core is the idea that the patient should be encouraged to talk about their experiences – just as they would for every other psychological condition. Psychosis isn’t viewed as a biological illness that one either has or does not have. Instead, just like every other mental disorder, psychotic experiences are seen as the severest instances of thoughts and feelings – notably delusions and hallucinations – that many of us experience from time to time.

Working together, the patient and therapist develop a model of what’s causing the experiences, and why they’re recurring. These factors will vary from person to person, so what is produced is a bespoke account of the individual’s experience, which is then used to guide treatment. For example, a person so worried by paranoid fears that they won’t set foot outside might be helped to trace the roots of their anxiety to past experiences; to gradually test out their fearful thoughts; and to learn to manage their anxiety while getting on with the activities they enjoy. An individual troubled by hearing voices will be helped to understand what’s triggering these voices, and to develop a more confident, empowering relationship with them.

These are early days. Nevertheless, most of the meta-analyses of CT’s efficacy for psychosis, when added to standard treatment, have indicated definite (albeit modest) benefits for patients, with the latest showing that CT is better than other psychological treatments for reducing delusions and hallucinations. The latest guidelines from the UK’s National Institute for Health and Care Excellence (Nice) recommend it for those at risk of psychosis and, when combined with medication, for people with an ongoing problem.

But not everyone is convinced, and although the research published in The Lancet is encouraging, it was small scale. CT for psychosis is still evolving, and we think that evolution should prioritise three key areas.
First, we must focus on understanding and treating individual psychotic experiences. As we’ve reported in a previous post, there is increasing reason to doubt the usefulness of the diagnosis “schizophrenia”. The term has been used as a catch-all for an assortment of unusual thoughts and feelings that often have no intrinsic connections, and aren’t qualitatively different from those experienced by the general population. Each psychotic experience may therefore require a tailored treatment.
Second, we must build on the recent transformation in understanding the causes of psychotic experiences, taking one factor at a time (insomnia, say, or worry), developing an intervention to change it, and then observing the effects of that intervention on an individual’s difficulties.
And finally, we must listen to what patients want from their treatment – for example, by focusing on improving levels of wellbeing, which tend to be very low among people with schizophrenia.

What about costs compared with drug treatment? A course of CBT is typically just over £1,000, but if it leads to a reduction in the amount of time patients spend in hospital and their use of other services, or a return to work, then it easily pays for itself.

The Nice guidance on psychosis and schizophrenia, updated this year, is unequivocal:
"The systematic review of economic evidence showed that provision of CBT to people with schizophrenia in the UK improved clinical outcomes at no additional cost. This finding was supported by economic modelling undertaken for this guideline, which suggested that provision of CBT might result in net cost savings to the NHS, associated with a reduction in future hospitalisation rates."

If the real promise of cognitive therapy can be fulfilled, we may at last have a genuinely effective, relatively cheap, and side-effect-free alternative to antipsychotics for those patients who don’t wish to take them.



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Parkinsonism a Major Mortality Risk Factor in SchizophreniaBy Daniel M. Keller, PhD
There may be differences between different antipsychotic medications and their possible contribution. ”Specific treatments with clozapine or olanzapine could be related to more comorbidity and mortality,”
Compared with control individuals, patients with schizophrenia have significantly more physical comorbidity, including the novel finding that Parkinsonism is a major risk factor for inhospital mortality in this population, new research shows.A case-control study of general hospital admissions showed that the most common comorbidity among patients with schizophrenia was type 2 diabetes mellitus (T2DM). Twenty more physical diseases were also more prevalent, many of them associated with diabetic complications. Interestingly, Parkinsonism was a major risk factor for inhospital mortality in schizophrenia.The research was a collaboration between investigators in Germany and the United Kingdom. Speaking here at the 22nd European Congress of Psychiatry (EPA), Dieter Schoepf, MD, of the Department of Psychiatry at the University Hospital of Bonn, Germany, said that the study population comprised all admissions to 3 general hospitals in Manchester, United Kingdom (N = 369,488) between January 1, 2000, and June 30, 2012.It included 1418 patients who met diagnostic criteria for schizophrenia at initial admission according to the tenth revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10). Control patients were 14,180 age- and gender-matched hospital patients at initial admission.Five Major FindingsThe study produced 5 major findings related to comorbidities affecting hospitalized patients with schizophrenia. First, they had a nearly 2-fold increased hospital-based mortality rate (18.0%) compared with control patients (9.7%) during the observation period. And the schizophrenic patients died at a younger mean age (64.4 ± 1.0 vs 66.2 ± 0.4 years, respectively).Second, "schizophrenics as compared to controls had a more severe course of illness and a shorter survival after their initial hospitalization," Dr. Schoepf reported. For the entire group of schizophrenic patients, survival averaged 1895 ± 35.1 days vs 2161 ± 11.6 days for all control patients. For deceased patients in each group, survival averaged 951.4 ± 62.9 vs 1030 ± 28.0 days, respectively.Third, patients with schizophrenia had substantially more physical diseases. Among 21 diseases with increased prevalence among the study population compared with control patients, odds ratios (ORs) ranged from 5.3 for fracture of the femur neck to 1.3 for asthma."T2DM was the most common disproportionally increased physical comorbidity," Dr. Schoepf said. Its prevalence among schizophrenic patients was double that of the control patients (17.4% vs 8.5%; OR = 2.3; 95% confidence interval [CI], 2.0 - 2.6).The fourth major finding was that among schizophrenic patients who died, T2DM was the most common physical comorbidity, contributing to about one third (31.4%) of those deaths, compared with 16.9% of deceased control patients.Parkinsonism affected 1.6% of the study group vs 0.4% of control patients (OR = 4.7; 95% CI, 2.8 - 7.7). It was present in 5.5% of deceased study group patients but in only 1.5% of control patients who died.Excluding Parkinsonism, a major risk factor for death among the schizophrenic group, the researchers developed a model that identified 9 other mortality risk factors that “had an equal impact on inhospital death in schizophrenics as compared to controls,” Dr. Schoepf reported.Although the prevalence of these risk factors differed between the 2 groups, their impact on inhospital mortality did not differ when these comorbidities were present in patients in either group. The comorbidities were as follows: T2DM, chronic obstructive pulmonary disease, pneumonia, bronchitis, iron-deficiency anemia, type 1 diabetes, ischemic stroke, nonspecific renal failure, and alcoholic liver disease.Novel ResultSpeaking with Medscape Medical News, session chair Guillermo Lahera Forteza, MD, PhD, professor of psychiatry at the University of Alcalá, Spain, who was not involved in the study, praised it as "impressive…especially the relationship between Parkinsonism and mortality in patients with schizophrenia. I was really shocked about this figure." He added that the relationship between T2DM and mortality has been well known, but the finding about Parkinsonism is something new.Dr. Lahera Forteza said he has questions about the causes of death in cases in which comorbidities exist. There may be differences between different antipsychotic medications and their possible contribution."Specific treatments with clozapine or olanzapine could be related to more comorbidity and mortality," he said, but Dr. Schoepf noted that there are not enough data from this study on this point.Dr. Lahera Forteza advises physicians “to restudy every treatment when the patient has this kind of comorbidity ― to re-evaluate and reassess the pharmacological treatment in every patient.” In addition, physicians should recognize the impact of lifestyle on these patients, who often smoke, drink alcohol, and do not get enough exercise. Negative symptoms, cognitive impairment, and social stigma can all affect lifestyle and contribute to or exacerbate physical comorbidities.Dr. Schoepf and Dr. Lahera Forteza report no relevant financial relationships. The study had no commercial funding.


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Parkinsonism a Major Mortality Risk Factor in Schizophrenia
By Daniel M. Keller, PhD

There may be differences between different antipsychotic medications and their possible contribution. ”Specific treatments with clozapine or olanzapine could be related to more comorbidity and mortality,”

Compared with control individuals, patients with schizophrenia have significantly more physical comorbidity, including the novel finding that Parkinsonism is a major risk factor for inhospital mortality in this population, new research shows.
A case-control study of general hospital admissions showed that the most common comorbidity among patients with schizophrenia was type 2 diabetes mellitus (T2DM). Twenty more physical diseases were also more prevalent, many of them associated with diabetic complications. Interestingly, Parkinsonism was a major risk factor for inhospital mortality in schizophrenia.
The research was a collaboration between investigators in Germany and the United Kingdom. Speaking here at the 22nd European Congress of Psychiatry (EPA), Dieter Schoepf, MD, of the Department of Psychiatry at the University Hospital of Bonn, Germany, said that the study population comprised all admissions to 3 general hospitals in Manchester, United Kingdom (N = 369,488) between January 1, 2000, and June 30, 2012.
It included 1418 patients who met diagnostic criteria for schizophrenia at initial admission according to the tenth revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10). Control patients were 14,180 age- and gender-matched hospital patients at initial admission.

Five Major Findings
The study produced 5 major findings related to comorbidities affecting hospitalized patients with schizophrenia. First, they had a nearly 2-fold increased hospital-based mortality rate (18.0%) compared with control patients (9.7%) during the observation period. And the schizophrenic patients died at a younger mean age (64.4 ± 1.0 vs 66.2 ± 0.4 years, respectively).
Second, "schizophrenics as compared to controls had a more severe course of illness and a shorter survival after their initial hospitalization," Dr. Schoepf reported. For the entire group of schizophrenic patients, survival averaged 1895 ± 35.1 days vs 2161 ± 11.6 days for all control patients. For deceased patients in each group, survival averaged 951.4 ± 62.9 vs 1030 ± 28.0 days, respectively.
Third, patients with schizophrenia had substantially more physical diseases. Among 21 diseases with increased prevalence among the study population compared with control patients, odds ratios (ORs) ranged from 5.3 for fracture of the femur neck to 1.3 for asthma.
"T2DM was the most common disproportionally increased physical comorbidity," Dr. Schoepf said. Its prevalence among schizophrenic patients was double that of the control patients (17.4% vs 8.5%; OR = 2.3; 95% confidence interval [CI], 2.0 - 2.6).
The fourth major finding was that among schizophrenic patients who died, T2DM was the most common physical comorbidity, contributing to about one third (31.4%) of those deaths, compared with 16.9% of deceased control patients.
Parkinsonism affected 1.6% of the study group vs 0.4% of control patients (OR = 4.7; 95% CI, 2.8 - 7.7). It was present in 5.5% of deceased study group patients but in only 1.5% of control patients who died.
Excluding Parkinsonism, a major risk factor for death among the schizophrenic group, the researchers developed a model that identified 9 other mortality risk factors that “had an equal impact on inhospital death in schizophrenics as compared to controls,” Dr. Schoepf reported.
Although the prevalence of these risk factors differed between the 2 groups, their impact on inhospital mortality did not differ when these comorbidities were present in patients in either group. The comorbidities were as follows: T2DM, chronic obstructive pulmonary disease, pneumonia, bronchitis, iron-deficiency anemia, type 1 diabetes, ischemic stroke, nonspecific renal failure, and alcoholic liver disease.

Novel Result
Speaking with Medscape Medical News, session chair Guillermo Lahera Forteza, MD, PhD, professor of psychiatry at the University of Alcalá, Spain, who was not involved in the study, praised it as "impressive…especially the relationship between Parkinsonism and mortality in patients with schizophrenia. I was really shocked about this figure." He added that the relationship between T2DM and mortality has been well known, but the finding about Parkinsonism is something new.
Dr. Lahera Forteza said he has questions about the causes of death in cases in which comorbidities exist. There may be differences between different antipsychotic medications and their possible contribution.
"Specific treatments with clozapine or olanzapine could be related to more comorbidity and mortality," he said, but Dr. Schoepf noted that there are not enough data from this study on this point.
Dr. Lahera Forteza advises physicians “to restudy every treatment when the patient has this kind of comorbidity ― to re-evaluate and reassess the pharmacological treatment in every patient.” In addition, physicians should recognize the impact of lifestyle on these patients, who often smoke, drink alcohol, and do not get enough exercise. Negative symptoms, cognitive impairment, and social stigma can all affect lifestyle and contribute to or exacerbate physical comorbidities.

Dr. Schoepf and Dr. Lahera Forteza report no relevant financial relationships. The study had no commercial funding.



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Utah has highest rate of mental illness in U.S., study saysBy Natalie CroftsUtah has the highest rate of mental illness in the nation, according to a new survey.About 22.4 percent of the adult population in Utah experienced a mental disorder in the past year, according to recently released statistics. Out of those people, 5.14 percent had a severe mental disorder that interfered with their daily activities.
The study was conducted by the Substance Abuse and Mental Health Services Administration, which is an agency within the U.S. Department of Health and Human Services.
The study estimated 42.5 million people over the age of 18 in the U.S. have experienced a mental illness in the past year, at a rate of 18.2 percent. Severe mental illness affected 9.3 million people, at a rate of 4 percent.
"The presence of Severe Mental Illness and Any Mental Illness in every state reinforces that mental illness is a major public health concern in the United States," researchers wrote. "Factors that potentially contribute to the variation are not well understood and need further study."The state with the lowest rate of mental illness was New Jersey, with 3.1 percent of the adult population experiencing a severe mental illness and 14.2 percent experiencing any mental illness.
The statistics were based on findings from the annual National Survey on Drug Use and Health, which is sponsored by SAMHSA. They conducted interviews with a representative sample of 92,400 people aged 18 or older.
States with Highest Rate of Mental Illness:Utah (22.4 percent)Oklahoma (21.9 percent)West Virginia (21.4 percentOregon (20.9 percent)Washington (20.8 percent)States with Lowest Rate of Mental Illness:New Jersey (14.7 percent)Illinois (15.9 percent)Nevada (16.1 percent)Connecticut (16.7 percent)North Carolina (16.8 percent)


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Utah has highest rate of mental illness in U.S., study says
By Natalie Crofts

Utah has the highest rate of mental illness in the nation, according to a new survey.

About 22.4 percent of the adult population in Utah experienced a mental disorder in the past year, according to recently released statistics. Out of those people, 5.14 percent had a severe mental disorder that interfered with their daily activities.

The study was conducted by the Substance Abuse and Mental Health Services Administration, which is an agency within the U.S. Department of Health and Human Services.

The study estimated 42.5 million people over the age of 18 in the U.S. have experienced a mental illness in the past year, at a rate of 18.2 percent. Severe mental illness affected 9.3 million people, at a rate of 4 percent.

"The presence of Severe Mental Illness and Any Mental Illness in every state reinforces that mental illness is a major public health concern in the United States," researchers wrote. "Factors that potentially contribute to the variation are not well understood and need further study."
The state with the lowest rate of mental illness was New Jersey, with 3.1 percent of the adult population experiencing a severe mental illness and 14.2 percent experiencing any mental illness.

The statistics were based on findings from the annual National Survey on Drug Use and Health, which is sponsored by SAMHSA. They conducted interviews with a representative sample of 92,400 people aged 18 or older.

States with Highest Rate of Mental Illness:
Utah (22.4 percent)
Oklahoma (21.9 percent)
West Virginia (21.4 percent
Oregon (20.9 percent)
Washington (20.8 percent)

States with Lowest Rate of Mental Illness:
New Jersey (14.7 percent)
Illinois (15.9 percent)
Nevada (16.1 percent)
Connecticut (16.7 percent)
North Carolina (16.8 percent)



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Factors predicting disengagement from psychosis early intervention identifiedBy Afsaneh Gray, medwireNews ReporterA study of first-episode psychosis patients in Hong Kong has found that those with fewer negative symptoms at presentation and poor medication compliance were more likely than others to disengage from an early intervention program.“We have confirmed reports in previous studies, which were mostly conducted in western populations, that diagnosis of a non-schizophrenia-spectrum psychotic disorder, lower baseline negative symptom severity, poor medication compliance and substance abuse history predicted service disengagement,” write study author Wing Chang (The University of Hong Kong) and colleagues.The team identified 700 patients aged 15 to 25 years who were enrolled in the Early Assessment Service for Young People with Psychosis (EASY) program between 2001 and 2003.Data on each patient were retrieved from clinical records, and the Clinical Global Impressions–Severity Scale was used to determine symptom severity. Information on medication compliance was derived from sources including case management notes, medical records and information from caregivers.Disengagement was defined as missing all outpatient appointments until the end of the 2-year service despite therapeutic need and active follow-up from staff, and occurred in 94 patients.The mean age of participants was 20.65 years and the median duration of untreated psychosis was 91 days. Most (69.14%) patients had a diagnosis of a schizophrenia spectrum disorder (ie, schizophrenia or schizoaffective disorder).Multivariate analysis identified three factors that were independently associated with disengagement. Patients were 56% less likely to disengage if they had schizophrenia-spectrum disorders, rather than other types of psychosis. They were 63% less likely to disengage if they were adherent to their medication, and they were 24% less like to disengage if they had high baseline negative symptom scores (>3).Substance abuse history within the initial 6 months of the program increased the chances of disengagement, but, due to the small number of patients affected, was not included in the final multivariate analysis.The team also found that 63% of disengaged patients were in symptomatic remission during the month in which they left the EASY program.“Early intervention teams should pay attention to factors associated with disengagement, and monitor at risk patients closely to detect signs of non-adherence,” Chang and colleagues conclude in Schizophrenia Research.


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Factors predicting disengagement from psychosis early intervention identified
By Afsaneh Gray, medwireNews Reporter

A study of first-episode psychosis patients in Hong Kong has found that those with fewer negative symptoms at presentation and poor medication compliance were more likely than others to disengage from an early intervention program.
“We have confirmed reports in previous studies, which were mostly conducted in western populations, that diagnosis of a non-schizophrenia-spectrum psychotic disorder, lower baseline negative symptom severity, poor medication compliance and substance abuse history predicted service disengagement,” write study author Wing Chang (The University of Hong Kong) and colleagues.
The team identified 700 patients aged 15 to 25 years who were enrolled in the Early Assessment Service for Young People with Psychosis (EASY) program between 2001 and 2003.
Data on each patient were retrieved from clinical records, and the Clinical Global Impressions–Severity Scale was used to determine symptom severity. Information on medication compliance was derived from sources including case management notes, medical records and information from caregivers.
Disengagement was defined as missing all outpatient appointments until the end of the 2-year service despite therapeutic need and active follow-up from staff, and occurred in 94 patients.
The mean age of participants was 20.65 years and the median duration of untreated psychosis was 91 days. Most (69.14%) patients had a diagnosis of a schizophrenia spectrum disorder (ie, schizophrenia or schizoaffective disorder).
Multivariate analysis identified three factors that were independently associated with disengagement. Patients were 56% less likely to disengage if they had schizophrenia-spectrum disorders, rather than other types of psychosis. They were 63% less likely to disengage if they were adherent to their medication, and they were 24% less like to disengage if they had high baseline negative symptom scores (>3).
Substance abuse history within the initial 6 months of the program increased the chances of disengagement, but, due to the small number of patients affected, was not included in the final multivariate analysis.
The team also found that 63% of disengaged patients were in symptomatic remission during the month in which they left the EASY program.
“Early intervention teams should pay attention to factors associated with disengagement, and monitor at risk patients closely to detect signs of non-adherence,” Chang and colleagues conclude in Schizophrenia Research.



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