Changes in emotional processing precede and predict clinical benefit
Schizophrenia – new targets?
Schizophrenia – imaging prognosis
Social disconnectedness – not the same as just plain lonely
SD, unlike loneliness, is an objective term to describe social isolation, Junghee Lee, UCLA, Los Angeles, USA, explained. It is prevalent in schizophrenia and is important because it affects survival direly – and to a greater extent than smoking. Unlike loneliness, you can die from SD.
Both social cognition and affiliation are affected in psychosis. This makes its study difficult. After all, how to you recruit socially-reclusive people to a clinical study?
‘Lonely hearts’ pages
By advertising, it would appear! Two small adverts were posted requesting people with few friends and no real inclination to make friends to respond. And respond they did – 66 calls over 3 days. By a sifting process, the general population was enriched for 28 individuals who were engaged in the community (i.e. they worked) but were socially isolated.
Unlike patients with schizophrenia, however, such individuals showed no evidence of social cognition deficits. They did show low levels of social affiliation. It seems, in the community, there are people who naturally avoid social situations. Intriguingly, their curiosity as to why this might be was what induced them to answer the ads.
ICF Core sets – what are they?
Melissa Selb, of the WHO ICF Research Branch, Germany,, explained how, as part of its drive for health for all, the WHO has changed tack. Now instead of compiling only mortality and morbidity (ICD) statistics, it is collating the associated functioning and disability (ICF) that accompanies a condition.
Functioning and disability refer to a person’s:
Participation – e.g supported work programme
Activities e.g ability to wash oneself
Body function e.g thought function
Body structure e.g brain function
Environmental interactions e.g medication, family
Aspects of each of these were taken into consideration when creating the ICD-11 report with specific reference to schizophrenia. In total, 1400 ICF categories were described. As these are cumbersome to use, ICF core sets and brief core sets have been developed, making the classification system more user-friendly.
The ICF core sets were developed in 3 phases: a preparatory phase, phase I and phase II. Currently, the guidelines are in Phase II of development but the other phases were outlined.
Georgina Guilera, University of Barcelona, Spain, described the initial preparatory phase of the WHO project. Here the functional and environmental factors associated with schizophrenia were considered from 4 perspectives – clinical, research, patient and health care professional.
Clinical Perspective - multicentre study
To address the clinical perspective, an empiric, multicentre study was conducted. Five Spanish centres contributed to this study and data were collected by health care professionals using the extended WHO checklist. Their responses were extracted and translated into ICF categories. ICF categories described functional impairment in body function (32), activities and participation (45) and environment (18).
Research perspective - literature review
A systematic literature review was undertaken to address the research perspective. A total of 206 studies identified ICF categories. These described functional impairment in body function (30), body structure (2) activities and participation (34) and environment (4).
The mortality associated with social disconnectedness in schizophrenia is greater than for smoking
Patient perspective - 11 focus group
For the patients’ perspective, a qualitative study was undertaken comprising 11 focus groups (7 for patients and 4 for caregivers) in Spain and US. The outcomes yielded ICF categories for body function (45), body structure (6) activities and participation (60) and environment (38).
And Phase I...
Overall, the preparatory phase identified 184 candidate categories – clearly far too many for daily use. Oscar Pino, University of Barcelona, described how these were whittled down to generate comprehensive ICF core sets and brief core sets.
Consensus of core and brief sets
International experts in schizophrenia from a variety of fields were invited to consider the candidate categories and to achieve consensus on the minimum that should be included. This minimum number should describe exhaustively the key functional disabilities of those with schizophrenia. If consensus was less than 40%, categories were excluded; if consensus was greater than 75%, they were kept. Those falling between these values were discussed in a second session to attain consensus.
Eventually, a comprehensive ICF core set was achieved containing 97 ICF categories: body function (17), body structure (0) activities and participation (48) and environment (32). Following further discussion and some serious ranking, a brief core set of 25 ICF categories was agreed.
And phase II
Now that all this work has been completed, validation of the categories generated in phase I is being undertaken. Outcomes are awaited with interest.
Functioning in schizophrenia – key components
Poor functioning is an acknowledged hallmark of schizophrenia.
Schizophrenia – asking the right questions
Life-long schizophrenia managed or even manageable?
Spot psychosis early – but how?
Early intervention – bust or breakthrough?
Does natural selection favour depression?
High depression rate open secret among junior doctors and psychologists
What is the nature of your work?
Our multidisciplinary team provides an acute psychiatry service for Delft and the surrounding countryside between Rotterdam and The Hague, and also a functional assertive community treatment programme. I see around fifty patients with an acute depressive episode each year, but in total there are 550-600 people in assertive community treatment.
Not all have major depressive disorder (MDD). There are also patients with schizophrenia, schizoaffective or personality disorders, even some on the autistic spectrum.
Many MDD patients live at home. We also have patients living in intermediate care: institutions of 20-40 people which provide social support and activities as well as medication. Nurses visit at least weekly to hear from the support workers. Evolving, this may require hospitalisation. But, given the pressure on hospital beds, we try to handle problems proactively to keep patients in the community if possible.
What is the biggest challenge in treating MDD in your practice?
The fact that so many patients are suicidal. To deal with that we have to see some patients every day, or every other day. And if they don’t come to us we visit them. The team has psychiatric social workers and nurses but if a patient has active suicidal ideation, a psychiatrist in training will accompany them to the patient’s home.
How do you treat MDD?
With antidepressants, group therapy, social support and encouragement with employment. Our clinical psychologists offer cognitive behavioural and other psychological therapies. We also try to involve the patient’s own support networks.
And our team has three support workers who are themselves psychiatric patients. They will sometimes accompany patients into situations where they feel fearful; and they have a role in activating and motivating patients who continue to have problems.
What proportion of MDD patients have residual symptoms even when they have responded by conventional criteria?
Of the people in the assertive community treatment programme, who I follow long term, between a quarter and a third have some core depressive symptoms even after several lines of medical treatment. For some of these patients we offer ECT.
A feature of the service is that you try to prevent the development of metabolic abnormalities?
Many patients treated with drugs, not just those on antipsychotics, are at risk. So we see MDD patients at least yearly, more frequently if necessary, and measure blood pressure, weight, waist circumference, blood glucose, lipids and so on. With patients likely to evolve metabolic syndrome, we notify their family doctors.
We also offer advice on diet. There are even “eating healthy breakfast” sessions where patients can learn about making positive food choices.
From mood to metabolism: integrated care in major depression
Dr van der Drift works for GGZ Delfland, a regional provider of community mental health services in The Netherlands.