Highlights of the 2007 Institute on Psychiatric Services

The 2007 Institute on Psychiatric Services, held October 11–14 in New Orleans, drew 1,406 participants to a program of more than 258 lectures, symposia, workshops, and poster sessions. The American Psychiatric Association's (APA's) fall conference on clinical care and service systems has been held annually for 59 years. APA president Carolyn Robinowitz, M.D., chose "Recovery: Patients, Families, Communities" as the theme for the 2007 institute.

In remarks at the opening session, Dr. Robinowitz noted that care for chronic mental disorders entails developing multidisciplinary systems of care that promote resilience and that help individuals lead as full and unrestricted a life as possible. She outlined challenges to the delivery of mental health services. These include growing numbers of persons who lack health insurance or are underinsured, limited funding for neuroscience and health services research, the political failure to fund the State Children's Health Insurance Program, and the fragility of the health care system in dealing with natural disasters and the casualties of war. Dr. Robinowitz expressed optimism, however, that the public discussion of mental health needs of wounded service members and their families has helped to break down stigmatizing attitudes toward mental health treatment and will help direct Congress' attention to ensuring care for people living with mental illness.

Dr. Robinowitz pledged her commitment to advocate on behalf of patients and communities, and she urged her colleagues to make a similar commitment, noting that psychiatric professionals have an intellectual as well as moral authority to commit to core professional values and protect patients without being paternalistic. In the words of Dr. Robinowitz, "We are the only people who can provide access to care, assess the care, and ensure quality in integrating biological, psychological, and social factors."

Dr. Robinowitz invited Terry Cline, Ph.D., administrator of the Substance Abuse and Mental Health Services Administration (SAMHSA), to deliver the opening address. He described the federal agency as neither a behavioral health system nor a health care system but as a fragile crisis management system for providing care to people with acute illnesses. Dr. Cline noted that eligibility criteria for most community substance treatment programs are extremely tough and result in the turning away of many persons in need. He contrasted the situation with that of a cardiologist seeing a patient complaining of chest pains and other key symptoms and telling the patient to return for treatment after having a first heart attack. Dr. Cline also noted that early intervention health care does not get appropriate attention. Although there are pockets of excellent programs across the country, they are too isolated, and the network of care is disjointed.

Dr. Cline explained that despite its $3.3 billion budget, SAMHSA's resources are stretched thin, requiring a careful matrix for prioritizing programs and resources. A top priority is to improve disaster readiness plans because current systems have failed when stressed, as occurred in 2005 with Hurricane Katrina. SAMHSA is working with states to strengthen action plans as "living documents" so that information is current and ready when disaster strikes.

Dr. Cline also emphasized the findings of the President's New Freedom Commission that the mental health care system is fragmented. He noted state-level efforts to transform mental health care and described SAMHSA's federal action agenda for the transformation of the behavioral health system. A steering committee has developed 70 action items to address such issues as the integration of behavioral health care with primary health care, suicide, and Social Security Administration policies that seem to discourage people from obtaining employment.

Dr. Cline noted work on a strategic plan to address a mental health workforce development strategy, including funding to train mental health professionals and provide peer support and recovery support. He cited the startling statistic that people with serious mental illness die 25 years earlier than the normal life expectancy of 78 years, noting that the complications are due to physical health and not to suicide.

Dr. Cline noted additional fundamental issues, such as the "de facto mental health system"—prisons housing a high volume of people with mental illness who are not receiving treatment. Although evidence-based medicine is now the standard and has provided important new information, Dr. Cline noted the 15- to 20-year gap between research findings and implementation in practice. To close that gap, he indicated that SAMHSA's new Web-based registry of evidence-based practices is available to community mental health professionals and consumers via its information network. Finally, Dr. Cline emphasized the need for mental health professionals to collaborate with SAMHSA and other agencies to influence their communities to effect change.

International mental health in countries in conflict

Using examples from many war-torn countries, a panel of researchers discussed the impact of conflict on mental health and priorities for healing psychic damage. A 2006 World Health Organization (WHO) survey of international nongovernment organizations (NGOs) indicated that less than half had engaged in mental health programs and only 3% offered a comprehensive mental health care program. Whereas posttraumatic stress disorder (PTSD) is frequently the focus of attention, the panelists emphasized the need to look at all psychiatric morbidity in situations of violent conflict. The presentation examined risk factors and protective factors, as well as the special impact that war has on children. Discussion also covered caregiving for the individual as well as for the community and the varied roles of mental health professionals in providing this care. All panelists were APA-Bristol-Myers Squibb Fellows, who were recognized as outstanding residents for 2006–2008.

Surveying data from several studies of the impact of war, Marcey Forgey, M.D., M.P.H., from the UCLA Semel Institute for Neuroscience, highlighted many of the psychological consequences of trauma and war. Trina Chang, M.D., M.P.H., with the Department of Psychiatry at Massachusetts General Hospital, explored strategies for intervention decisions given the vast needs in such conflicts. Sonali Sharma, M.D., M.Sc., with the Department of Psychiatry at Cornell University, looked at the broader issue of community healing and reconciliation, and Ilana Nossel, M.D., with the Department of Psychiatry at Columbia University, ended the seminar with a case study of the conflict in the Darfur region of Sudan.

Studies of conflicts in Afghanistan, Cambodia, Albania, Rwanda, and other countries showed myriad traumatic events experienced, including lack of food and shelter, destruction of property, severe illness without access to medical care, murder and other loss of family members, separation from families, forced fleeing, torture and abuse, and sexual violence. Psychiatric sequelae included anxiety, PTSD, major depressive disorder, and depression and PTSD in combination.

Dr. Forgey presented a pyramidal model for understanding the psychological consequences of trauma, which included, in descending order of prevalence, physical and mental exhaustion (among 100% of a war-torn population), desire for social justice or revenge, lack of trust, feelings of despair and hopelessness, family problems, severe functional impairments, physical disabilities, and serious mental illness.

With exposure to trauma, risk and protective factors mediate the development of psychiatric symptoms. Risk factors for mental illness among conflict-affected populations include exposure to armed conflict after age 12, torture, being female, socioeconomic hardship, marginalization, poor physical health resulting from poor sanitation and poor health care, poor nutrition, crowding, collapse of social networks, daily life stresses, inability to cope after the first month, perceived lack of control, and a preexisting history of psychiatric problems. Effects of conflict-related traumatic stress on children were categorized according to age, with unique symptoms for preschoolers, early and middle school children, and adolescents.

Protective factors for conflict-affected populations include social networks, social support, employment, recreation, rituals and ceremonies, coping skills, political and religious inspiration, refugee camps of limited size, and access for refugees to human rights organizations.

Which syndromes or disorders should be the focus of attention when needs are so vast? Five variables were discussed: the timing relative to the conflict (for example, providing mental first aid as an emergency measure), the site of the intervention (within the community, for example, versus in a refugee camp), mental health need, target populations, and types of treatment programs. A model for assessing mental health need gives top priority to disabling psychiatric illness, then severe psychological reactions to trauma, then psychosocial or behavioral problems that might resolve when stability is restored. WHO has encouraged focusing on medium- and long-term community-based services over short-term relief of psychological distress immediately after a trauma, which may simply be a typical response.

Interventions include providing support for those whose basic needs of food and shelter are not met, family reunification programs, helping people restore their livelihood, and providing safe spaces for education. A recent collaboration of United Nations agencies and NGOs provides comprehensive guidelines for providing mental health care and social support (www.who.int/hac/network/interagency/news/mental_health_guidelines/en).

Mental health professionals have a valuable role in community healing, especially in working with community leaders. Given that community contact and networks are protective factors against emotional distress, mental health professionals have a critical role in community development, network strengthening, building mutual supports, and providing counseling and intensive psychotherapy when needed.

For example, community elders can be positive examples of endurance and strength and help to convey the message that grief and stress are shared, normative experiences. Indigenous counseling is effective, whereas Western and "outside" therapies can sometimes be perceived as intrusive. Helping people to reengage in everyday life is key to restoring community health.

Embracing a spectrum of recovery

In a well-attended lecture entitled "Recovery is in the Eye of the Beholder," Jacqueline Maus Feldman, M.D., said that providers need to embrace the concept of recovery for patients with schizophrenia and form a partnership with these patients as a way of helping to engage them on the road to recovery.

Bringing to the talk her experience as a medical director, executive director, and clinician at the University of Alabama at Birmingham Comprehensive Community Mental Health Center, Dr. Feldman noted that she feels as though her role as a member of the National Alliance on Mental Illness and having two close family members who have struggled with severe and persistent mental illness for much of their lives are the most important influences on her thinking about recovery for persons with mental illness.

"I think we're on the cusp of a major change when we start to talk about recovery," said Dr. Feldman. "When I started working with patients with schizophrenia 17 years ago, things were not very hopeful…. I think things are changing with how clinicians think about people with serious and persistent mental illness, and I think there's research that supports that people with serious and persistent mental illness can get better."

Dr. Feldman said that if clinicians are going to choose to work with patients with schizophrenia, recovery needs to be embraced. "If your stance is [the patient] can't get better, and there's nothing I can do to help [the patient] get better, then I think you should excuse yourself from the care of the patient, because what you're communicating to the patient is, 'Your life sucks, and it's not going to get any better.' I don't think that's fair or a valid way to approach the situation."

Recovery is no longer defined as remission, although remission can occur in this group of patients. "There's a spectrum of recovery," said Dr. Feldman. "We have to embrace that and not be hopeless if patients don't have total remission."

Recovery can now be defined as a person with a mental illness who is actively engaged in the treatment process, able to maintain wellness and responsibility for self-care, and able to replace professional supports with natural supports while rebuilding a meaningful life.

Forming a partnership with the patient is one of the key steps in recovery. Instead of having a more paternalistic partnership, the partnership should be consumer centered and consumer empowered, helping to determine what patients want and how the clinician can help them reach their goals.

As an example, Dr. Feldman spoke about a patient of hers who said he wanted to be President. When asked, "What is the first step you should take to be President?" he said, "Get my GED." In this way, she said, the patient was able to break his goal down to something that he was able to achieve. However, she noted that not every patient is going to be able to be as insightful as this patient. "I have patients who are intensely psychotic, but that doesn't mean that you can't help them or engage them."

Focusing on the similarities between clinicians and patients is also important in helping patients recover, said Dr. Feldman. "I would suggest that we all want to be relatively symptom free, we'd all like to be happy, we'd all like to be working or involved with something significant to us, we'd all like to have a roof over our head, we'd all like to have a long-term intimate relationship. I think what we tend to do is distance ourselves from people we think are different from us, and my stance is—and this is how I think I'm able to engage my patients better—I assume they want exactly what I want. They want to be happy, healthy, in love."

Comfort rooms in the Netherlands

Although the Netherlands passed a law over 12 years ago that ensured individuals' rights regarding their psychiatric treatment, the use of seclusion and restraint in psychiatric facilities has continued to increase. With attention to this trend, the Dutch national mental health organization set a goal to decrease use of seclusion and other coercion by 10%–30% and made research funds available for projects to meet that goal. René de Veen, M.D., chief psychiatrist within the Mediant health system, won funding to implement his potential solution. Inspired by a 2005 IPS presentation from Margaret Bennington-Davis, M.D., M.Ed., on her engagement model, Dr. de Veen and his team sought to implement the model to change the treatment culture within their psychiatric facility. The comfort room is the physical anchor point of their efforts to eliminate restraint and reduce seclusion on their ward. The use of the comfort room is embedded within the broader approach of the engagement model.

The pilot ward of the general psychiatric hospital consists of three eight-bed units, and the hospital serves a catchment area of nearly 400,000. The ward's admissions are primarily patients with chronic mental illness. Stays range from one night to long-term care.

Hospital personnel are often the recipients of aggressive behavior from patients on the psychiatric ward, from verbal aggression to life-threatening incidents. The engagement model advocates a patient-centered focus on treatment. By increasing staff awareness of the effects of trauma—agitation, diminished impulse control, addictive behavior, and aggression, for example—staff gain new insight into why patients act out and can better deal with incidents when they can occur. The comfort room gives nurses a tangible alternative that creates a proactive connection with patients and can prevent problematic behavior from escalating.

The comfort room (one on each ward) is used after approximately half of aggressive incidents, according to Hans Poelert, the chief nurse and partner in the project. The room is available when a patient is agitated, feels aggressive, is experiencing psychotic fear, or otherwise would like to relax or seek comfort. Decorated in blues and greens and simply furnished with a comfortable chair and other items from IKEA, the comfort room provides a soothing space away from the patient's own room. Additional touches, provided on consultation with representatives from the patients' council, include a soft blanket, dimmable lights, and options to play music and use an aromatherapy dispenser.

Use of the comfort room is voluntary. Patients are logged in and out, and they fill out an evaluation form after each visit. The door is not locked; there is a call button for communication with nurses. Protocol is for nurses to check on patients once per hour. Seclusion in the Netherlands typically lasts several hours; overnight stays are not unusual. There is a growing awareness in the Netherlands that this type of intervention should be avoided as much as possible. According to Poelert, within 30 minutes of a visit to the comfort room, patients usually feel calm, and use of seclusion often is prevented.

The engagement model has transformed the treatment culture of the psychiatric ward into an atmosphere of cooperation among patients, staff, and hospital administrators. This transformation took careful planning and met with some resistance from staff. A project management group and a working group for each ward included patients' participation. Professionals and administrators worked on the supervision group, and a research group worked out the details of data collection. A training symposium was held before implemention, and coaching of staff is ongoing.

Before implementation, the representative from the patients' council, Yvonne Hekkink, joined the project's delegation on visits to sites in the United States, where the engagement model is used. Today, there are regular meetings between staff and patients to address concerns about safety and to appreciate shared experiences. A mental health consumer specialist who has herself experienced seclusion, Ms. Hekkink participates in the comfort room project as a liaison between patients and staff. The consumer specialist is a new position in the Netherlands, and the health system is preparing to build a national network of these specialists.

The researchers involved in the comfort room project reported on preliminary results of a three-year study of the association of comfort rooms with the incidence and duration of seclusion. The hypothesis, according to Fleur Vruwink, M.D., is that both measures will decrease. Data from the Mediant project will be incorporated into Argus, a nationwide study of seclusion and coercion practices in various psychiatric facilities across the Netherlands.

Smoking policies in state mental health treatment facilities

Smoking is prevalent among persons with mental illness. In fact, about 75% of persons with serious mental illness smoke, compared with 23% of the general population. In addition, persons with mental illness smoke more cigarettes, more efficiently than the general population, leading to their smoking 44% of all cigarettes in the United States.

Although smoking among patients with mental illness has long been viewed as a protected personal freedom—as well as a necessary evil that can decrease agitation among patients, deescalate certain situations, act as a reward, and improve compliance—as the dangers of smoking have become more well known and as smoking has become more socially unacceptable, more public health facilities are moving to become smoke free.

Describing steps to transitioning to a smoke-free environment, Peggy H. Jewell, M.D., Medical Director, Department of Health and Human Services, State of Oklahoma, Oklahoma City, and Mary Ellen Foti, M.D., Department of Psychiatry, University of Massachusetts Medical School, Worcester, gave a talk entitled "Smoking Policy and Treatment in State Operated Psychiatric Facilities" as part of a symposium entitled "How to Keep Your Patients From Dying."

A 2006 survey of 181 state mental health hospitals found that 41% do not allow smoking, either inside or on the grounds, and that more state mental hospitals are interested in becoming smoke free. Dr. Jewell spoke about the successful experience of the seven mental health and four substance abuse facilities of the Oklahoma Department of Mental Health and Substance Abuse Services in becoming smoke free in 2002.

Dr. Jewell said that making the transition to a smoke-free facility took about a year of preparation, which involved preparing staff and consumers about the upcoming change in policy. Considerable preparation is needed for staff members in order to lower their resistance to making this change, not only because of fear of patients' reactions to this change but also because staff who are smokers are directly affected.

Another commonly cited obstacle comes from patient advocacy groups, which support patients' right to smoke. In response to this obstacle, Dr. Foti said, "Is it truly freedom to pick a self-destructive or unhealthy habit, such as smoking? An addiction is not a real choice. Quitting is a real choice. And we believe that smoking kills. It kills people with mental illness disproportionately and earlier, and it's the leading contributor to early death and disease in this population."

Nine months before the transition in Oklahoma, employees were offered a 90-day supply of nicotine replacement products. A total of 375 employees took part in this program for a one-time expense of $25,000. Other expenses included $100,000 annually for nicotine replacement products for 8,864 consumers and $2,500 for signs and posters, a one-time expense. Maintenance work was another area of expense. Dr. Jewell said, "There were a lot of plumbing issues. People would go into the showers to smoke and put the cigarettes down the drain. There were window lock issues. Patients would also take the outlets apart so they could light cigarettes. They would dismantle the smoke detectors." She said that consumer violations should be treated as a treatment issue and that staff violations should be treated as a personnel issue.

However, Dr. Jewell said that more problems were anticipated than actually occurred. For example, although staff were viewed as potentially being the biggest problem, no changes in staff recruitment or retention were observed. In addition, Dr. Jewell said that behavioral problems were not observed among patients. "What we actually found was that there was a decrease in aggression. There was no increase in seclusion, there was no increase in discharged patients, and there was no increase in PRN medication," said Dr. Jewell.

The continuum between psychosis and ordinary mind

How much continuity is there between psychosis and the ordinary mind? Michael D. Garrett, M.D., with the Department of Psychiatry at SUNY Downstate Medical Center and the Psychoanalytic Institute at New York University Medical Center, is interested in the analogies to psychotic experience that exist in everyday life. His premise, presented in a well-attended lecture, is that if there is a continuum between the two, then the us-them barrier in the doctor-patient relationship can be bridged in the clinical experience.

Dr. Garrett then proceeded to build those bridges by pointing to evidence of a continuum in several areas. He reviewed several studies that indicate no single distinctive symptom of schizophrenia and that demonstrate a lack of overlap between diagnostic criteria for the disorder. Instead, one model indicates that the brain has a biological vulnerability from genetic and neurotoxic events early in life that breaks down when exposed to various biopsychosocial stressors, such as high expressed emotion in families, substance abuse, physical and sexual trauma, and immigration to another country.

Psychotic beliefs are often similar to aberrant beliefs before psychosis manifests itself. Dr. Garrett described a patient with the psychotic belief that he was being controlled by a dog. As the patient improved, the delusion was reduced to nightmares that featured a dog, and as he further improved, the patient revealed fear of a specific dog in his neighborhood. Dr. Garrett described the continuum of beliefs. A Gallup poll of 60,000 British adults indicated that 68% believed in God; 50% believed in thought transference; 50% in predicting the future; about 25% in ghosts, reincarnation, and horoscopes; 21% in the devil; and 10% in black magic. Dr. Garrett noted that society will accept a citizen who believes in the devil but would draw the line if the citizen were to express "my neighbor is the devil and must be killed," noting that along the continuum there is a catastrophic "disjunction of function."

Dr. Garrett also illustrated the continuum of cognition. The classic belief is that psychotic individuals are not rational, whereas nonpsychotic individuals are. However, a hypothesis that delusional persons exercise faulty, predicate logic (The President lives in a white house, I live in a white house; therefore, I am the President) was not supported; psychotic patients retain the ability to think logically. Delusions are thought to be logical explanations of anomalous sensory experience. Theories are judged delusional by others if data on which theories are based are not available to all.

Another classic belief is that delusional beliefs are held with firm conviction that is unresponsive to contradictory evidence. However, studies indicate that nondelusional people often have an exaggerated sense of correctness. Garrett cited a study in which students answered a series of questions and indicated their degree of certainty; answers believed 100% correct were correct only 20%–30% of the time. In the normal mind, there are irrational degrees of certainty, and we ignore evidence in contradiction to our beliefs. From a cognitive point of view, these processes probably sustain delusional beliefs, which may help explain why people with schizophrenia are adamant that their delusions are real.

Dr. Garrett also provided examples of a continuum of perception of ordinary experience and psychosis. Because hallucinations occur in various disease states, they can be considered latent in the ordinary mind but brought to the fore with disease. He described a study of a large sample of college students in which 5% reported having a repeated hallucinatory experience that was similar to an example provided (communicating with a deceased grandmother while housecleaning) and 75% reported having had at least one hallucinatory experience. Dr. Garrett also discussed the sensory-deprivation tanks popular in the 1960s that elicited strong imagery among users. People use perception to determine what is real, and it can be extremely compelling.

Dr. Garrett also pointed to research in object relations theory to indicate how we split mental phenomena into good and bad objects in everyday life, with the bad objects becoming the paranoid persecutor that operates outside the good self, as in the expression "My head is killing me." In psychosis, the paranoid persecutor can lead to fears of being watched by the CIA, attempted poisoning, and so on.

Dr. Garrett's final example of a continuum between psychosis and the ordinary mind involved the audience in his "the phone rings once" exercise, which began with a typical scenario of a phone ringing once as someone prepares to go out. The scenario continued to recur, with increasingly disturbing circumstances, pointing to the possibility that auditory hallucinations are critical internal objects of perception.

What are the implications for treatment with a continuum between psychosis and the ordinary mind? The classic diagnostic interview is a series of questions about symptoms. For a psychotic individual, such questions can quickly be perceived as labeling, and patients may be quick to withdraw. If the physician can relate some similar psychosis-like experiences to somewhat normalize the delusions the patient is experiencing, the patient may feel more open about trusting the clinician and revealing those experiences.

Cardiometabolic risk and schizophrenia

Why are persons with major mental disorder at higher risk for cardiometabolic problems and what can psychiatrists and primary care physicians do about it? Those were two questions answered by John W. Newcomer, M.D., professor of psychiatry, psychology, and medicine and medical director at the Center for Clinical Studies, both at Washington University Medical School in St. Louis, Missouri, in his lecture entitled "Cardiometabolic Risk in Individuals With Schizophrenia."

Dr. Newcomer detailed the importance of screening persons with major mental disorders for cardiometabolic problems and, when necessary, using appropriate interventions to lower morbidity and mortality rates in this population.

"Patients with major mental disorder have a significantly shorter lifespan," said Dr. Newcomer. "And one of the surprises for researchers in this area is that it's really not suicide that is the cause of premature deaths. The leading cause of death with patients with major mental disorders is cardiovascular disease."

Dr. Newcomer said that compared with the general population, persons with major mental disorders, such as schizophrenia, schizoaffective disorder, bipolar disorder, and even major depression, lose 25 to 30 mean years of potential life. A majority of those deaths are caused by premature cardiovascular disease. He added that although cardiovascular death rates declined in the general population from 1979 to 1995, they increased between 1970 and 2003 for patients with schizophrenia.

"We can say with great confidence that patients with major mental disorder are not enjoying this benefit of reduced cardiovascular mortality that we are seeing in the general population," said Dr. Newcomer. "One of the reasons that this may be going on is a failure in secondary prevention—that is, treating the illness once it happens—among people with major mental disorders."

Not only is there a shortfall in secondary prevention for this group; primary prevention is also lacking. "There are a lot of modifiable risk factors," said Dr. Newcomer. Schizophrenia is associated with an increased prevalence of modifiable cardiovascular disease risk factors—overweight, obesity, smoking, diabetes, hypertension, and dyslipidemia—all of which are commonly undertreated in this population.

Obesity is a particular concern, because it acts as an independent cardiometabolic risk factor and contributes to the development of other risk factors, such as dyslipidemia and hypertension. In addition, obesity is a major risk factor for type II diabetes, with the relative risk of diabetes increasing with body mass index. Increased abdominal fat is strongly associated with insulin resistance, which can lead to impaired glucose regulation.

In addition, some antipsychotic medications are associated with substantial weight gain, insulin resistance, and hyperglycemia, all of which increase the risk of diabetes and cardiovascular disease. Adiposity-dependent and adiposity-independent risk of dyslipidemia has also been observed with some medications. Among the second-generation antipsychotics, clozapine and olanzapine are associated with the highest risk of substantial weight gain, as well as with an increased risk of diabetes and dyslipidemia.

However, the talk ended on a hopeful note. "If you can start interventions, there's a tremendous opportunity to improve outcomes for people with serious mental disorders," said Dr. Newcomer. "Ten percent reductions in total cholesterol give you 30% reductions in coronary heart disease death rates over the next ten years. Small decreases in blood pressure pay off big time, smoking cessation has a huge effect, and just maintaining ideal body weight has a tremendous effect in reducing risk."

"Primary prevention can help ten to 100 times more people than secondary prevention," said Dr. Newcomer. "If you wait until the person has diabetes, wait until he has his first myocardial infarction, you can still help, but you can help many, many more people if you start paying attention earlier and try to not let people get into the risk categories."

Pharmacologic treatment of schizophrenia

Schizophrenia, a disease that affects just 1% of the population, is ranked as the eighth leading cause of functional disability worldwide among persons aged 15–44 years, according to a World Health Organization report from 1996.

Pharmacotherapy is the standard treatment used in managing this disease over the short and long term, and in fact, medication nonadherence is the single greatest predictor of relapse. Although nonadherence is a problem in the management of all types of chronic illnesses, it is a particular challenge in schizophrenia, a complex disease that can affect almost every domain of thought, behavior, mood, and affect.

John M. Kane, M.D., chairman, Department of Psychiatry, The Zucker Hillside Hospital, Glen Oaks, New York, and professor of psychiatry, neurology, and neuroscience, Albert Einstein College of Medicine, Bronx, New York, gave a lecture entitled "Pharmacologic Treatment of Schizophrenia: How Far Have We Come?" in which he provided an overview of the latest findings from clinical trials, as well as how these findings relate to clinical practice.

Dr. Kane emphasized the need to develop quantitative measures that clinicians can use to document adverse and therapeutic responses to pharmacologic treatment. Creation of these measures could help to determine the effectiveness and tolerability of the psychotropic medication and assist in decisions about whether the dosage or medication should be changed or whether adjunctive medications should be added.

Adverse response, such as side effects, needs to be monitored and taken very seriously, said Dr. Kane. He noted that akinesia has been shown to be the leading side effect eliciting moderate-to-severe distress and said that another study showed that people with schizophrenia who stopped taking antipsychotics were more likely to be nonadherent if they experienced extrapyramidal symptoms during their first trial of antipsychotics. "Side effects can have a profound effect on what happens afterward. We need to be careful, especially in the beginning," said Dr. Kane.

Therapeutic response also needs to be monitored, and Dr. Kane suggested that weekly measurements would be helpful. To demonstrate this point, he reviewed results of a 2007 study by Leucht and colleagues that was published in the Journal of Clinical Psychiatry. Results from this study demonstrated that patients with no reduction in symptoms after a two-week drug trial were unlikely to show minimal improvements at week 4. However, he noted that randomized studies are needed to prove that switching antipsychotics after two weeks is effective in this context.

Dr. Kane also reviewed the results of a 2003 report by Agid and colleagues that was published in the Archives of General Psychiatry and involved a meta-analysis of 53 studies with 8,177 patients. Results showed the largest proportion of response (as measured by improvement in psychotic symptoms) was observed after only one week of antipsychotic drug treatment.

"If we can combine predictor data with measurement-based decision making, we might actually be able to come up with an algorithm that says if you have been seeing this degree of response after a week, as measured by these rating scale items, that means this patient has a relatively low likelihood of responding to this drug and you should do something else," said Dr. Kane. However, he noted that research is needed in order to find the next step in treatment.