remission in schizophrenia: clinical and psychosocial dimensions prof yoram barak, md, mha

Prof Y BarakProf Y Barak 11

Remission in Schizophrenia: Clinical and PsychoSocial Dimensions

Prof Yoram BARAK, MD, MHA.ABARBANEL M.H.C.

Bat-Yam,ISRAEL


Remission in Schizophrenia

the Road to Recovery


Attain

Mainta

in

Acute Phase

Response

Remission/ Functional Remission

Stable

Recovery

Cure

(normal w

ithout treatment)

(“normal”)

(virtual absence of diagnostic symptom

s for 6

monts)

(no obvious evolution)

(decrease of

symptom

s)

Current and Future DirectionsCurrent and Future Directions

Resolution

(virtual absence of diagnostic symptom

s)

Sustained Remission > 6 months

(ill)


Long-term outcomes in schizophreniaLong-term outcomes in schizophrenia

Improve self-careReduce aggression

Reduce self-injury

‘Survive’ out of hospitalDe-institutionalisation

Reduce relapseMinimise positive symptoms

Increase ‘stable’ periodsMinimise negative symptoms

Pre-1960s

1960-70s

1980s

1990s

Focus on functionalityPotential for remission

2000+


Expanded model of remissionExpanded model of remissionin schizophreniain schizophrenia

Incr

easi

ng

seve

rity

Symptoms absent

Symptoms ‘mild’ or less

Diagnostic threshold

RES

OLU

TIO

N

6 months

‘Normalcy’ threshold

RELAPSERES

PON

SE

REMISSION

Peuskens J & Kane J. In preparation.


Adapted from Weiden et al, J Clin Psych 1996; 57: 53-60

Maintaining Stability Response

Functional, Quality of Life

Remission

Functional and Social Autonomy

Recovery

Remission in SchizophreniaImprovement dependency


What is RemissionWhat is Remission??

Remission in Remission in nonpsychiatric illnesses:nonpsychiatric illnesses:

The reduction or The reduction or the complete absence of the complete absence of disease symptoms.disease symptoms.

Remission in psychiatric Remission in psychiatric illnesses:illnesses:

Defined not by Defined not by the complete absence of the complete absence of symptoms but by minimal symptoms but by minimal symptoms with mild symptoms with mild disability.disability.


StoRMi - Study DesignStoRMi - Study Design::

Schizophrenia Schizophrenia or any other psychiatric disorders or any other psychiatric disorders requiring long-term antipsychotic treatmentrequiring long-term antipsychotic treatment

Symptomatically Symptomatically stable patientsstable patients on any previous on any previous antipsychotic medication for antipsychotic medication for 1 month1 month

Length of treatment: Length of treatment: 6 months +6 months6 months +6 months

22 participating countries22 participating countries

Number of recruited patients: Number of recruited patients: 1,9091,909


TreatmentTreatment

2525 מ"ג של זריקת ריספרידון לטווח ארוך ניתנה אחת מ"ג של זריקת ריספרידון לטווח ארוך ניתנה אחת חודשים. חודשים.66לשבועיים במשך לשבועיים במשך

באם לא הייתה הטבה בסימפטומים או אם לא הושגה באם לא הייתה הטבה בסימפטומים או אם לא הושגה 2-42-4תגובה מספקת לטיפול, ניתן היה להעלות במינון תגובה מספקת לטיפול, ניתן היה להעלות במינון

5050 או או 37.537.5שבועות לאחר הזריקה האחרונה למינון של שבועות לאחר הזריקה האחרונה למינון של מ"ג אחת לשבועיים.מ"ג אחת לשבועיים.

שבועות שבועות 33הטיפול האנטיפסיכוטי הקודם ניתן במשך הטיפול האנטיפסיכוטי הקודם ניתן במשך הראשונים לזריקה. הראשונים לזריקה.

1111

Risperidone

Olanzapine

Quetiapine

Amisulpiride

Ziprasidone

Conv Depot

Conv. Oral

Other

Treatment change fromTreatment change from

More than 1 drug

per patient possible

Risperidone

732 = 39%

Conv. Depot

813 = 43%

Conv. Oral 254 = 14%

Olanzapine 192 = 10%

Quetiapine 49 = 3%

Amisulpiride 57 = 3%

Other 87 = 5%

Ziprasidone 6 = 0%


StoRMi trialStoRMi trial

תוצאותתוצאות


PANSS total score: PANSS total score: by baseline severity by baseline severity

P 0.001 at all timepoints compared to baseline

Mild < 74.5Moderate

>74.5- 106.5 Severe > 106.5

PANSS Ranges at Baseline

46

48

50

52

54

56

58

Basel

ine

Month

s 1

Month

s 3

Month

s 6

Endpoint

66

71

76

81

86

91

Basel

ine

Month

s 1

Month

s 3

Month

s 6

Endpoint

66

76

86

96

106

116

126

Basel

ine

Month

s 1

Month

s 3

Month

s 6

Endpoint


StoRMiStoRMi- - סיכום תוצאות סיכום תוצאות יעילותיעילות

ספקטרום רחב של חולים פסיכוטיים עשוי ליהנות •.RCמהמעבר ל

חולים יציבים הראו שיפור נוסף בבקרה על •הסימפטומים וסבילות לטיפול.

איכות החיים והפונקציונליות של החולים מצביעה על •איכות טיפולית חדשה.

נמצאה יעילה.RCהתחלת טיפול עם •


“Remission in Schizophrenia:Proposed Criteria and Rationale for

Consensus”Am J Psychiatry 2005; 162:441–449

Nancy C. Andreasen, M.D., Ph.D. William T. Carpenter, Jr., M.D. John M. Kane, M.D. Robert A. Lasser, M.D. Stephen R. Marder, M.D. Daniel R. Weinberger, M.D.


Abstract (1)Abstract (1)

New advances in the understanding of schizophrenia etiology, course, and treatment have increased interest on the part of patients, families, advocates, and professionals in the development of consensus-defined standards for clinical status and improvement, including illness remission and recovery.



As demonstrated in the area of mood disorders, such standards provide greater clarity around treatment goals, as well as an improved framework for the design and comparison of investigational trials and the subsequent evaluation of the effectiveness of interventions.



Unlike the approach to mood disorders, however, the novel application of the concept of standard outcome criteria to schizophrenia must reflect the wide heterogeneity of its long-term course and outcome, as well as the variable effects of different treatments on schizophrenia symptoms.



As an initial step in developing operational criteria, an expert working group reviewed available definitions and assessment instruments to provide a conceptual framework for symptomatic, functional, and cognitive domains in schizophrenia as they relate to remission of illness.



The first consensus-based operational criteria for symptomatic remission in schizophrenia are based on distinct thresholds for reaching and maintaining improvement, as opposed to change criteria, allowing for alignment with traditional concepts of remission in both psychiatric and nonpsychiatric illness.



This innovative approach for standardizing the definition for outcome in schizophrenia will require

further examination of its validity and utility, as well as future refinement, particularly in relation to psychosocial and cognitive function and dysfunction.

These criteria should facilitate research and support

a positive, longer-term approach to studying outcome in patients with schizophrenia.


Combining Clinical & PsychoSocial Domains:Combining Clinical & PsychoSocial Domains:The Israeli ProjectThe Israeli Project

We aim to create a 2-pronged scaleWe aim to create a 2-pronged scale Clinical – as defined by Andreasen et al.Clinical – as defined by Andreasen et al. Psychosocial –reflecting:Psychosocial –reflecting:

Quality of LifeQuality of Life NeedsNeeds I-ADLI-ADL


……on on all 8 symptom itemsall 8 symptom items P1 DelusionsP1 Delusions P2 Conceptual P2 Conceptual

disorganizationdisorganization P3 Hallucinatory behaviorP3 Hallucinatory behavior G9 Unusual thought contentG9 Unusual thought content G5 Mannerisms and G5 Mannerisms and

posturing posturing N1 Blunted affect N1 Blunted affect N4 Social withdrawalN4 Social withdrawal N6 Lack of spontaneity/flow N6 Lack of spontaneity/flow

of conversationof conversation

Remission Criteria in Schizophrenia Patient achieves intensity level…

Absent

Minimal

Mild

Moderate

Moderate severe

Severe

Extreme

1

2

3

4

5

6

7

•…PANSS scale level of mild or less

•Time criteria of at least 6 months


Contents:

Improved Understanding and Treatment of Schizophrenia.

From the symposium ‘Acute to Long-term Treatment in Schizophrenia: Effectiveness is a Moving Target’ at the 19th European Congress of Neuropsychopharmacology, September 16–20 2006, Paris, France

European Neuropsychopharmacology (2007) 17, iii


Risk factors for schizophrenia — All roads lead to dopamine. M. Di Forti, J.M. Lappin and R.M. Murray (UK) S101

Management of agitation in the acute psychotic patient — Efficacy without excessive sedation. F. Can˜as (Spain) S108

The stable patient with schizophrenia — From antipsychotic effectiveness to adherence. P. Thomas (France) S115

The long term — Maximising potential for The long term — Maximising potential for rehabilitation in patients with schizophrenia. rehabilitation in patients with schizophrenia.

A. Fagiolini and A. Goracci (USA, Italy) S123

European Neuropsychopharmacology (2007) 17, iii


The long term — Maximising potential for The long term — Maximising potential for rehabilitation in patients with schizophrenia.rehabilitation in patients with schizophrenia.

Aims of rehabilitation in schizophrenia:Therapeutic programmes that are developed to optimize the

potential for rehabilitation in patients with schizophrenia should aim to maximise the patients' daily functioning in an attempt to enable them to engage in employment and increase their self-sufficiency.

Rehabilitation should also attempt to enable patients with schizophrenia to integrate into society, improving their social interactions and activities.

The complex nature of health-related quality of life (QoL) in schizophrenia patients has been recognised and another aim of rehabilitation is to improve this aspect.

All of these aims should be considered when evaluating the effectiveness of any treatment that patients receive.



Aims of rehabilitation in schizophrenia:The employment prospects for patients with schizophrenia may

be impeded by clinical symptoms, and data from the CATIE study clearly illustrate this (Rosenheck et al., 2006).

No employment activity was reported for 72.9% of the patients in the month before the baseline assessment; 14.5% of the patients had been engaged in competitive employment, and the remaining 12.6% had participated in non-competitive employment.

Less severe symptoms of schizophrenia, better neurocognitive functioning and higher intrapsychic functioning scores (which evaluated a range of psychological characteristics) were associated with participation in employment.



Aims of rehabilitation in schizophrenia:

Sociocultural context may be one of the major factors that can influence rehabilitation in patients with schizophrenia, and policy makers should give consideration to the creation of resources for the rehabilitation of schizophrenia patients within communities that complement the success that can be achieved with regard to reducing their psychotic symptoms (Mubarak, 2005).



Aims of rehabilitation in schizophrenia:Almost half (46.5%) of schizophrenia patients

report dissatisfaction with their overall QoL.By creating opportunities to improve social

functioning, it may also be possible to improve patients' subjective QoL;

treatment that addresses psychotic symptoms in isolation from these factors may not facilitate QoL improvements.


Real World research FindingsReal World research Findings

Schizophr ResSchizophr Res. . 2007 Mar 27;2007 Mar 27; [[Epub Epub ahead of print]ahead of print]

Remission in prognosis of functional outcomeRemission in prognosis of functional outcome: : A A new dimension in the treatment of patients new dimension in the treatment of patients with psychotic disorderswith psychotic disorders..

Helldin L, Kane JM, Karilampi U, Norlander T, Archer THelldin L, Kane JM, Karilampi U, Norlander T, Archer T..



INTRODUCTION: INTRODUCTION: The aim of the present study was to investigate The aim of the present study was to investigate

whether or not the new concept of remission in whether or not the new concept of remission in the treatment of schizophrenia is of importance the treatment of schizophrenia is of importance for functional outcome. for functional outcome.

The hypothesis was that patients having attained The hypothesis was that patients having attained remission would function at a higher level and remission would function at a higher level and have a lower care requirement than those who have a lower care requirement than those who had not attained remission.had not attained remission.


Real World research FindingsReal World research FindingsMATERIALS AND METHODS: MATERIALS AND METHODS:

Remission is defined through the application of the Positive and Negative Syndrome Remission is defined through the application of the Positive and Negative Syndrome Scale (PANSS) instrument whereby none of the eight chosen items, representing Scale (PANSS) instrument whereby none of the eight chosen items, representing core symptoms, should be found to present a value exceeding 3 points. core symptoms, should be found to present a value exceeding 3 points.

The utility of attaining the severity criteria for remission, or not, was examined with The utility of attaining the severity criteria for remission, or not, was examined with regard to activity of daily living (ADL) ability, establishment of social functioning regard to activity of daily living (ADL) ability, establishment of social functioning and social network, and amount of health care and community support that the and social network, and amount of health care and community support that the patient consumed. patient consumed.

Two hundred and forty-three patients were examined, of whom 93 patients (38%) had Two hundred and forty-three patients were examined, of whom 93 patients (38%) had attained remission and 150 patients (62%) had not. The present patient population, attained remission and 150 patients (62%) had not. The present patient population, consisting of 50% of all available patients with schizophrenia spectrum disorder consisting of 50% of all available patients with schizophrenia spectrum disorder within a homogeneous catchment area in NU Health Care, western Sweden, within a homogeneous catchment area in NU Health Care, western Sweden, meeting the right diagnostic criteria, were in their habitual condition and were meeting the right diagnostic criteria, were in their habitual condition and were unaffected by any other functionally debilitating disorder, in particular dementia.unaffected by any other functionally debilitating disorder, in particular dementia.

As a control patients diagnoses were used as the independent variable to exclude that As a control patients diagnoses were used as the independent variable to exclude that they better explain outcome than remission.they better explain outcome than remission.



RESULTS: RESULTS: It was found that patients that attainted the specified remission criteria showed It was found that patients that attainted the specified remission criteria showed

a significantly superior outcome in all assessed areas with regard to activity a significantly superior outcome in all assessed areas with regard to activity of daily life, social functioning in society and consumption of health care.of daily life, social functioning in society and consumption of health care.

Remission patients functioned more effectively in social contexts in Remission patients functioned more effectively in social contexts in association with superior education, more often had occupations, possessed association with superior education, more often had occupations, possessed more established social networks and were more likely to be found living more established social networks and were more likely to be found living under family-like conditions. under family-like conditions.

They exhibited a lower need for support in order to fulfill their everyday They exhibited a lower need for support in order to fulfill their everyday activities. activities.

Also, patients in remission required markedly less health care resources, both Also, patients in remission required markedly less health care resources, both in the form of psychiatric treatment and community habitation support. In in the form of psychiatric treatment and community habitation support. In contrast diagnoses only made difference in 4 of 14 outcome parameters.contrast diagnoses only made difference in 4 of 14 outcome parameters.



DISCUSSION: DISCUSSION:

The results suggest that the concept of remission The results suggest that the concept of remission has important implications for the treatment of has important implications for the treatment of patients with chronic psychosis. patients with chronic psychosis.

One possible conclusion is that if more patients One possible conclusion is that if more patients attain remission, the patient's and society's attain remission, the patient's and society's burden resultingfrom the illness will decrease.burden resultingfrom the illness will decrease.


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