⭐⭐⭐⭐⭐ Schizophrenia Literature Review
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What is schizophrenia? - Anees Bahji
International guidelines identify relapse prevention as a key therapeutic aim [ 4 — 6 ]; however, there are currently no established criteria by which to define relapse, and our current understanding of relapse may not be sufficient to combat this problem effectively [ 6 , 7 , 12 , 13 ]. We conducted a structured literature search to investigate the reporting of relapse and the validity of hospitalization as a proxy for relapse in patients with schizophrenia. Additionally, the factors that may be used to predict a relapse and those factors associated with increased or decreased risk of relapse were also investigated.
A structured search of the National Center for Biotechnology Information NCBI PubMed database was performed to identify articles published from 1 January to 1 May that discussed relapse, and hospitalization as a proxy for relapse, in patients with schizophrenia. The primary objective of this literature search was to determine whether specific criteria have been used to define relapse in observational and naturalistic settings. The secondary aim was to identify possible factors that may drive or reduce relapse. Randomized clinical trials RCTs represent highly controlled situations in which patients are required to meet stringent inclusion criteria.
Furthermore, subjects are frequently randomized to a fixed medication dose, without provision for dose optimization to meet individual requirements, which may likely have an impact on patient outcomes. Patients are closely monitored in RCTs, and specific relapse definitions are imposed for consistency across study centres. Hence, RCTs are less informative in regard to routine definitions of relapse used in clinical practice and to factors associated with relapse in unselected clinical populations. Therefore, data from primary publications of randomized, placebo-controlled clinical trials of pharmacological agents were excluded from this literature search. Guidelines were reviewed using the same criteria as the abstracts identified in the PubMed search.
Following this review, the selection of literature included abstracts and five guidelines. Publications discussing the definition of relapse and factors that may predict, drive or reduce relapse are reviewed here. Those discussing the duration and frequency of relapse or associated cost and resource are reviewed elsewhere. Following abstract review, each corresponding full article was reviewed and excluded if not relevant to one of the four domains above.
Following this review stage, the selection of literature included journal papers and five guidelines. A final review of the literature was conducted. During this final review, the authors excluded those papers describing cost-effectiveness modelling studies that constituted secondary research as accurate interpretation and evaluation of such papers require an in-depth analysis of the methodologies and assumptions used, which was deemed to be beyond the scope of the current review.
Figure 1 details the full literature search process. Literature search process. The asterisk denotes that the final review process is described in detail in the main body of the text. Of the final selection of literature, 87 manuscripts included a definition of relapse. None of the identified guidelines defined relapse. Figure 2 describes the factors used alone or in combination to define relapse. Hospitalization was the most widely used factor as a proxy for relapse or as a component of the definition.
Reported components of the definition for relapse. In these 54 publications, hospitalization or exacerbation of symptoms leading to hospitalization was discussed in 56 separate instances. There were 53 instances of a scale being used to define relapse; however, multiple scales often appeared within the same definition. Generally, the scales used to define relapse assessed symptom severity and in particular the positive symptoms of schizophrenia. There was considerable variation between studies in the use of each scale, in terms of the thresholds applied, and subscales used within the relapse criteria.
There was wide variation between studies when using the CGI scale, since many different subscales and thresholds were proposed to define relapse. However, the threshold for relapse was broadly similar regardless of the CGI subscale used—with an overall increase or increase in a single factor to a score of 6 or 7 being the most frequent measure [ 18 , 19 , 60 , 65 , 66 ]. Exacerbation or re-emergence of symptoms was the fourth most common component of definitions identified in the literature search, second if combined with those exacerbations that led to hospitalization.
Ninety-four journal articles and five guidelines discussed the various factors that may drive or reduce relapse rates in patients with schizophrenia. There were 95 references to factors that may drive relapse Figure 3 , with non-adherence to antipsychotic medication the most frequently reported factor. Potential drivers of relapse. Patient-specific, lifestyle and disease-related factors associated with increased rates of relapse were also identified in the search Figure 3. There were 46 instances where treatment-related factors, such as side effects, dosing issues, efficacy and generic antipsychotic use, were associated with increased relapse rates Figure 3.
Delay in treatment delivery and interruptions to treatment due to loss of medical insurance coverage were also identified. In this study, a mild relapse was defined as a recurrence or exacerbation of psychotic symptoms in 1 week for which an increase in antipsychotic medication was required, without a significant decline in social functioning [ 75 ]. There were 49 occurrences in 46 publications of factors that may reduce the rate of relapse Figure 4. The potential for antipsychotic therapy to reduce relapse rates was examined in a total of 25 publications.
Differences in the RR for relapse were also observed between olanzapine and other second-generation antipsychotics SGAs [ 21 ]. Factors that may reduce relapse rates. Individual citations of each factor: a single reference may include citations of more than one factor. The antipsychotic medication category does not include the other pharmacological therapy factors. Another study showed that patients who were treated with depot antipsychotics had a higher rate of major relapses and hospitalization compared with patients who had not received depot antipsychotics [ 76 ].
Moreover, it was not reported whether relapse occurred prior to, or following, initiation of treatment with the depot antipsychotic [ 76 ]. The effect of risperidone long-acting injectable RLAI on relapse rates and duration of hospitalization or relapse compared with baseline [ 22 , ] or compared with patients treated with oral antipsychotics was reported in several publications [ 18 , 23 ]. In one post hoc analysis of two similarly designed 2-year studies one RLAI and one oral antipsychotic study , RLAI administration was associated with a relapse rate of 9. In a study comparing hospitalization at 1 and 2 years after RLAI initiation, greater decreases from baseline in the number of patients hospitalized and the number and length of hospital stays in patients who continued with RLAI treatment were observed, compared with those who discontinued [ 24 ].
Non-pharmacological interventions, such as psychoeducation and cognitive behavioural therapy CBT , were also commonly reported as factors that may reduce relapse. However, these interventions were evaluated in patients already receiving treatment with antipsychotic medication [ 4 ]. The consistent and correct assessment and management of relapse in patients with schizophrenia are vital for clinical practice and important factors for controlled clinical trials.
As such, an awareness of the factors that may be associated with increased and decreased rates of relapse should invariably aid clinical practice and benefit patients. Interestingly, none of the international and national guidelines define relapse, potentially indicating that in clinical practice, a psychiatrist is deemed able to identify a relapsing patient. Alternatively, acutely exacerbated patients may present with a range of signs and symptoms to such a variable degree as to hinder the provision of a unique reliable definition of relapse.
Csernansky and colleagues [ 17 ] proposed a set of multifactorial criteria for defining relapse, including hospitalization, and suggested that any single factor could be used as a clinical determinant of relapse. Within the studies identified in this search, many factors were used to define relapse. In particular, the majority of the retrospective database analyses identified in this literature search specifically investigated hospitalization when conducting their analyses, rather than relapse or other parameters that could potentially be used to define relapse that may not have been available in the original data source. It is also likely that hospitalization is frequently used to define relapse since it is simple to measure and provides tangible data to analyse.
However, schizophrenia is a heterogeneous condition in which a patient might relapse moderate symptom exacerbation and not be hospitalized or conversely might be hospitalized for other reasons, such as social or somatic causes, but have relatively stable psychiatric symptoms. Clinical scales and criteria were also frequently identified in the literature and provide a clinically validated and standardized method of assessment. In clinical studies, where symptoms are measured at baseline and then at set intervals, scales are ideal to characterize patients; however, they can be time-consuming and require additional training to perform since most of them are not intuitive, and are therefore often inconvenient for use in routine clinical practice.
Behavioural changes and clinical assessments were least frequently used to define relapse in patients with schizophrenia and were poorly defined in the literature, but are likely to be used in everyday clinical practice. The low frequency of use in clinical studies probably reflects that physician variability may be a significant factor in behavioural and clinical definitions. Indeed, it is well established that treatment with antipsychotic medication can offer an effective option for relapse prevention as well as other beneficial patient outcomes. For instance, in an analysis of a nationwide cohort of 2, consecutive patients hospitalized for the first time with a diagnosis of schizophrenia in Finland, 1, patients Increasing gaps in medication intake over 1 year can result in a greater risk of hospitalization up to a fourfold increase [ 26 ].
The use of continuous medication, through increased adherence to antipsychotic medication or use of medications that give assured delivery, was the most frequently identified factor associated with reduced relapse or hospitalization rates [ 18 , 22 , 23 , ]. These findings highlight the current focus on antipsychotic medication in the literature and the importance of monitoring and improving medication adherence in patients with schizophrenia. With the exception of RCTs conducted by the same pharmaceutical company, each study used a distinct definition of relapse. Nevertheless, hospitalization, due to an exacerbation of psychotic symptoms, was a key component of most of the methods used to define relapse.
While the search was designed to capture definitions of relapse as they relate to routine clinical practice, rather than more selected clinical populations, nevertheless consideration of RCTs of antipsychotic treatments is informative, particularly in terms of their impact on relapse reduction since this is frequently included as one of the study outcomes. Systematic review and meta-analysis of RCTs are often used as a method of comparing the effects of different antipsychotics. One such study suggested that SGAs may have a greater ability to prevent relapse than first-generation antipsychotics FGAs [ 86 ], but the influence of patient adherence to treatment on this finding is uncertain, and the extent of the difference varied between treatments [ ].
Leucht et al. The authors speculated that publication bias in older studies prior to requirements for registration and publication of results of all clinical trials , changing definitions of relapse over time and increasing use of oral SGAs as comparators may all influence the difference in findings between older and more recent RCTs. One interpretation of these differences in findings is that RCTs may over-represent patients with greater adherence to treatment, and with less severe illness compared with the wider population of patients with schizophrenia. This clear superiority was maintained in subgroup analyses of FGA LAI antipsychotics, SGA LAI antipsychotics, studies published before , studies published after , studies reporting intention-to-treat analyses and studies reporting observed cases, with the authors concluding that analyses of naturalistic studies may better represent the clinical population likely to be treated with LAI antipsychotics in routine care.
First, we begin with a brief history of schizophrenia and treatment. According to Walker et al schizophrenia started to appear …show more content… Cognitive behavioral therapy had brought desirable result to some severe mental disorder such as bipolar disorder, substance abuse, obsessive-compulsive disorder and especially schizophrenia. In this article, Rector there is six steps to the treatment approach of schizophrenia. Cognitive behavioral therapy has efficacy and effectiveness on schizophrenia on exist in scientific. The cognitive behavioral therapy positive finding on schizophrenia had become a guideline in the prominent expert treatment. In UK has already used cognitive behavioral therapy as a mandated treatment to all schizophrenia patients as diagnosis Rector, …show more content… This made the interest of using cognitive behavioral therapy has been widely increased in United Kingdom for the patient that continuously experience with the problem.
Moreover, cognitive behavioral therapy effectively shorter the period of the patient who taking long term medication and also disable the side effect of the medication,. The researcher show cognitive behavioral focus unlike other intervention because it focuses on the schizophrenia patient central experience and understand them. The researcher show the cognitive behavioral therapy principal aim is to reduce schizophrenia patient stress with resistance to medication and interference.
It is also quite a complex illness that affects daily functioning of those who suffer from it. Professionals across several fields who treat schizophrenics do not share a consensus regarding the cause of schizophrenia, though there are a few theories regarding potential and definitive causes. The on-set of schizophrenia often takes place in adolescence and adulthood, but there are cases when there is childhood on-set schizophrenia. Schizophrenia in children. No matter what race, age, or gender everyone with this mental illness is affected in the same way. There are several factors that cause disability in everyday life. This literature.
Some of these disorders can be uncontrollable and can make it harder on the patients who are trying to get better. Disorders are not sicknesses that can be cured and gone with a couple of doses of medicine, disorders are serious problems a person has to deal with usually if not for a large amount of time, it can be every day for the rest. Mental disorders affect many people throughout the United States. Although it is not a direct link to criminal behavior, it is a major risk factor and oftentimes criminal offenders are found to have them. Mental disorders cause their victims delusions, hallucinations, paranoia, and aggression. Sometimes with the more serious disorders may absolve an.
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