The Canadian Journal of Psychiatry

To review the preclinical and clinical properties of various established and putative antipsychotic medications, namely clozapine, risperidone, amisulpride, olanzapine, quetiapine, sertindole, and ziprasidone.

This paper proposes a decision algorithm for comparing drugs used for psychotic disorders, based on biochemical profile, experimental pharmacology, postiron emission tomography (PET) scan results, and clinical efficacy on positive, negative, anxious, depressive, and cognitive symptoms. This “quotient” aims to compare the different available drugs, regardless of their development and registration status.

Antipsychotic drugs have been classified in many ways, mainly according to their chemical structure, clinical effects, receptor affinity, or side effects. Preclinical data have indicated that these drugs might be effective antipsychotic agents, causing fewer extrapyramidal side effects than most of the previously marketed drugs. However, the biological basis for the putative superiority of these drugs in treating psychosis has yet to be ascertained.

Although most antipsychotics have been shown to be at least equivalent to haloperidol on positive symptoms, they must be studied further to establish their absolute and relative efficacy on positive symptoms, negative and primary negative symptoms, cognition, psychotic anxiety, psychotic depression, suicidality, and quality of life. These drugs should be valuable in treating schizophrenia, but their merit in the long-term management of patients with schizophrenia still needs to be confirmed.

To review the nature of cognitive-behavioural interventions for psychosis and to evaluate evidence of their effectiveness.

Electronic (Medline and Psychinfo) and bibliography-based searches were carried out to locate descriptions and evaluations of cognitive-behavioural interventions for psychosis.

Various cognitive-behavioural interventions have been used for reducing psychosis. These have usually been applied to auditory hallucinations and/or delusions in otherwise treatment-resistant patients. Most evaluations comprise case studies or simple pre-post designs. Controlled trial evaluations are few, and although the results are promising, methodological problems limit the conclusions that can be drawn concerning the clinical utility of such approaches.

More and better controlled trial evaluations of cognitive-behavioural interventions are needed in this area. If further research supports the efficacy of these techniques, issues related to clinical effectiveness, mediators of treatment effects, risks, and cost-effectiveness will also need to be addressed.

Faire le point sur les moyens utilisés afin deprévenir l'apparition du trouble de stress post-traumatique (TSPT) avant un traumatisme.

Recension et analyse des écrits (principalement des articles) répertoriés à l'aide des bases de données Medline, Psycinfo et Pilot.

Les recherches font surtout ressortir l'identification des facteurs de risque et le renforcement de la résistance des individus comme moyen de prévention primaire du TSPT. La gravité du traumatisme demeure de loin le facteur de risque le plus important. Les approches psychoéducatives pour renforcer les défenses des individus et empêcher le développement d'un TSPT ont été privilégiées dans l'armée. Toutefois, aucun programme de préventionpré-trauma visant d'autres métiers à risque n'a été retrouvé dans l'analyse de la documentation.

L'utilité des facteurs de risque identifiés dans la documentation pour la prévention primaire du TSPT est limitée puisque ceux-ci, saufle traumatisme lui-même, n'influencent que faiblement le développement du TSPT en cas de traumatisme grave. Les approches psychoéducatives de renforcement de la résistance des individus à risque d'exposition apparaissent prometteuses, mais leur potentiel doit être mieux exploré par la recherche auprès de groupes de métiers à risque. Enfin, l'identification de possibles facteurs de protection, l'effet de la génétique et des variables biologiques, l'effet additif d'exposition à des stresseurs et celui des stresseurs chroniques sont d'autres pistes de recherche suggérées par les auteurs dans la prévention primaire (pré-trauma) du TSPT.

To identify why Review Boards revoked certificates for involuntary hospitalization.

The outcome of all applications for a Review Board hearing at 2 psychiatric hospitals in Ontario were recorded from the beginning of 1987 to the end of 1996. All cases where a certificate of involuntary hospitalization was revoked were identified. For each of these cases, the clinical record, including the Review Board's written reasons for its decision, was reviewed.

During the study period, 2644 patients applied for a review of their involuntary hospitalization. Only 42% of applications reached a hearing. Of these, 9% were revoked. Several recurring reasons for overturning certificates were identified. These included the physician relying too much on hearsay evidence, relatives supporting discharge at the hearings, and the patient clearly having recovered by the time the hearing took place.

Relatives or staff who observe dangerous behaviour should be encouraged to give evidence at hearings. The treatment team should take careful note of the views of patients 'families and friends and review the patients 'progress before hearings.

To review the steps required to develop an outcome evaluation package and to report on the 12-month outcome of an integrated day program.

Based on the identification of salient outcome predictors, standardized instruments were selected. A cohort of 78 patients was assessed at the time of admission to the program, at discharge, and 3, 6, and 12 months afterward.

Improvements were sustained over 1 year in all areas including treatment needs, quality of life, and readiness to change.

The gap between the “cultures” of treatment and research must be narrowed. Following evidence of a program's general effectiveness through outcome monitoring, a randomized control design is optimal for specific interventions. The optimal length of follow-up depends on the perceived confounds.

To appreciate the extent and the features of dissociation in a hypothesized highly dissociated population, rape trauma victims, while assessing construct validity and internal consistency of a French version of the Dissociative Experiences Scale (DES), a simple screening instrument for dissociative symptoms.

One hundred and forty rape victims (mean age 23. 6 years, 9% male) consecutively attending a Consultation for Victims of Psychological Trauma at the university hospital in Tours, France, were assessed through a French version of the 28-item self-rated DES.

The mean score (24.1) was high, and 33% of the scores exceeded a threshold set at 30. The Principal Components Analysis of the DES ratings yielded a 3-factor solution: depersonalization-derealization, amnestic fragmentation of identity, and absorption-imaginative involvement. DES reliability was studied through computation of Cronbach 's α coefficient (0.94).

During validation of a French version of the DES, the study showed that dissociation is considerably linked to rape-trauma victim populations.

To examine hospital outcome measures for individuals with chronic and severe mental illnesses before and after their registration in an assertive community treatment (ACT) program in Edmonton, Alberta.

Data were collected from Alberta Health on individuals who were registered in ACT from April 1993 to April 1995. For each individual, hospital outcome measures were calculated for the 365 days prior to and 365 days after registration for ACT (thus covering April 1, 1992-March 31,1996).

Data were collected from 295 individuals. Compared with 1 year prior to beginning ACT, there was a 34% reduction in hospital separations for patients with psychiatric diagnoses. The average length of stay (LOS) for each separated patient decreased by 56%, and the hospitalization days for each patient separated also decreased by 39%. The number of emergency visits for psychiatric reasons was reduced by 32%, and the number of clients visiting emergency departments for psychiatric reasons declined by 30%.

In the 1-year period after registration in an ACT program, hospital outcome measures were improved in this cohort of 295 individuals with severe and chronic mental illnesses.