Most articles within this issue of IJPCP share an underlying theme: namely the assessment and treatment of psychotic symptoms. We start with three papers which examine patient attitudes towards clinical research, physician practice in monitoring the effects of treatment, and a comparison of symptom-sign profiles across ethnic groups in patients with four common psychiatric diagnoses.
In the first of these, Ingo Schafer and colleagues (Hamburg, Germany) used a questionnaire survey to assess the attitudes of 83 patients with schizophrenia spectrum disorders towards potential participation in clinical research. As might be predicted, there was greater expressed readiness to contribute to psychosocial enquiries rather than to neurobiological investigations: the principal motivation underlying participation was altruism, although many apparently hoped that participation in research might improve their chance of recovery.
Questionnaire-based methodology was also employed in the second paper, from Yves Lecrubier (Paris, France), which assesses reported clinical practice relating to metabolic syndrome in patients with bipolar disorder. Over 1200 psychiatrists in six countries participated in an on-line survey, which revealed greater concern about this syndrome and a higher reported frequency of monitoring of metabolic parameters among doctors based in the United States. The intriguing third paper in this group, by Lehlohonolo Mosotho and colleagues (Bloemfontein, South Africa), found that Sesotho-speaking patients diagnosed with major depression or an anxiety disorder had a greater frequency of delusions and hallucinations than is seen in more Westernized patients: and many were still prepared to undergo initial treatment in traditional healer medical settings.
By contrast, in most industrialised societies antipsychotic drugs represent the mainstay of treatment for psychotic symptoms. However they are far from ideal, one current concern regarding relating to an increased risk of cerebrovascular disease in elderly patients. In a longitudinal case-control study including 31 elderly dementing patients undergoing risperidone treatment for behavioural disturbances, Maria Teresa Amboage-Paz and Jose Antonio Diaz-Peromingo (Coruna, Spain) found risperidone had no untoward effects on lipid profile, fasting glucose, body mass index or waist circumference, although as expected, there was a high mortality in cases and controls, risk factors being cigarette smoking, cardiac valvular dysfunction, and atrial fibrillation.
Phil Lee and colleagues (Taipei, Taiwan) compared the effects of long-term naturalistic treatment with olanzapine, risperidone, quetiapine or haloperidol in over 4500 outpatients with schizophrenia. Olanzapine-treated patients showed a greater reduction in severity of negative, depressive and cognitive symptoms and a lower incidence of sexual and motor dysfunction, but gained more weight than patients treated with risperidone, quetiapine or haloperidol. An accompanying article, from Nese Direk and Alp Ucok (Istanbul, Turkey) demonstrates that involvement in a three-month structured diet programme can result in significant weight loss (6.2 kg in 32 outpatients with schizophrenia, compared to weight gain of 1.6 kg in controls).
Whilst programmes such as these are often helpful, many patients who experience adverse effects of prescribed antipsychotic medication wish to switch to alternative forms of treatment: in an evaluation of the effects of switching from risperidone to amisulpride in 23 patients with schizophrenia, Yu-Ting Wang and colleagues (Tainan, Taiwan) found that at 13 weeks, switching was associated with a significant reduction in symptom severity and a marginal improvement in cognitive function, but a risk of worsening hyperprolactinaemia.
Four papers relate to attempts to enhance the quality of patient care in routine clinical practice. Carol Paton and colleagues (Dartford, UK) used the technique of semi-structured interviews and academic detailing (the latter process typically being employed by pharmaceutical company representatives) to improve prescribing practice with respect to use of risperidone long acting injection (RLAI). Their simple intervention was associated with greater awareness of the pharmacokinetic parameters of RLAI (such as the flat dose-response curve) among prescribing doctors, and a reduction in the proportion of prescriptions for unnecessarily higher dosages. Unlike the situation with RLAI, clozapine dosages and plasma levels are thought to be correlated to overall clinical response: as such, Bennett and colleagues (Aberdeen, UK) evaluated the use of plasma clozapine levels in a maximum-security state hospital, and found that level monitoring had some value in managing side effects and suspected non-compliance.
Despite repeated and concerted efforts to improve the quality of practice regarding use of electroconvulsive therapy (ECT), in many psychiatric units this aspect of clinical practice remains less than ideal. Demi Onalja and colleagues (Coventry, UK) evaluated the effects of a clinical care pathway relating to ECT practice, and found it led to greater frequency of patient monitoring during treatment courses. However in many settings ECT is not permissible or encouraged, even in severely ill patients, and many doctors have to use alternative treatment approaches, such as combination treatment with an antipsychotic and antidepressant: however there are few relatively few studies of this approach. The report from Mazda Adli and colleagues (Berlin, Germany) is therefore welcome: they describe the findings of an open-label investigation of combination treatment with antidepressants and olanzapine in 17 inpatients with psychotic depression, reporting that it was effective in relieving depressive and psychotic symptoms, without causing extrapyramidal adverse effects.