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in Chronic Schizophrenia
Report of National Institute of Mental Health\p=m-\
Psychopharmacology Research Branch Collaborative Study Group
Robert F. Prien, PhD, and Jonathan O. Cole, MD, Washington, DC
Education % attending 43 54 48
high school at the 0.1 level. When all de
% completing 17 28 22 grees of improvement (slight
high school plus marked) were included
Work history % never employed 20 40 29
% employed only 49 19 35
in the analysis, the high dose
in unskilled jobs group showed a significant
ly higher incidence of im-
of the placebo group, and 14% of the routine provement than each of the other treat
treatment group were found to be slightly ments.
improved. Younger, More Hospitalized Patients
Table 2 presents global ratings by treat (Under 40, Hospitalized Over Ten Years).
ment group, age, and length of hospitaliza This subgroup of patients also appeared to
tion. The major results from Table 2 are benefit from the high dose treatment. How
summarized below. ever, slight improvement accounted for prac
Younger, Less Hospitalized Patients (Un tically all the difference between the high
der 40, Hospitalized Under Ten Years). dose group and each of the other treatments.
Marked improvement occurred in only 4% for significance it was found that the only
of the high dose patients. significant improvement in global severity
Older, Less Hospitalized Patients (Over of illness occurred among younger, less hos
40, Hospitalized Under Ten Years).The pitalized patients on high dose. Significant
greatest improvement on low dose and rou worsening occurred with the placebo group
tine treatment occurred with this subgroup at all levels of age and hospitalization.
of patients. The high dose group also Despite the significant improvement ef
showed a high incidence of improvement fected in younger, less hospitalized high
with these patients but did not differ signif dose patients, one might ask to what extent
icantly from the routine treatment and low these patients were still mentally ill after
dose groups. treatment. Table 3 gives the distribution of
Older, More Hospitalized Patients (Over pretreatment and posttreatment scores on
40, Hospitalized Over Ten Years).This the Global Severity of Illness Scale. It may
high dose treatment was least effective with be seen that improvement in younger, less
this subgroup of patients. Only 14% of the hospitalized patients consisted mainly of a
high dose patients improved as compared to shift from marked and moderate illness to
16% of the low dose patients and 10% of mild and borderline illness: 25% were rated
the placebo patients. mildly or borderline mentally ill after treat
There is one other noteworthy finding ment as compared to 6% prior to treat
from the Global scale. In the placebo group, ment.
clinical change was clearly a function of Changes in Specific Symptoms and Be
age: 66% of the patients under 40 were haviors.The DRI, IMPS, and NOSIE
found to be worse as contrasted with only provide measures of 21 specific symptoms
31% of the patients over 40. and behaviors. The results from these three
Global Severity of Illness Scale.The co- instruments correspond very closely to re
variance analyses of the Global Severity of sults from the global scales. Briefly, the re
Illness Scale showed that high dose was sig sults may be summarized as follows:
nificantly more effective than low dose and 1. On all three scales high dose was
routine treatment only with younger, less found to be the most effective treatment for
hospitalized patients. High dose was signifi younger, less hospitalized patients. Signifi
cantly more effective than placebo at all cant treatment differences for this subgroup
levels of age and hospitalization. of patients are shown in Table 4. It may be
When pre-post change scores were tested seen that high dose was significantly more
NOSIE
+ 2.0*
behavior. The placebo group
IMPS
Excitement_+ 7.4* 0.0 16.0* +5.8*
+6.0*
had the highest percentage
Hostile-Belligerence_+ 8.3* 3.7 13.7*
ofdropouts (38%), followed
Paranoid Projection + 4.1* 4.5 11.3* 1.6
Grandiose-Expansiveness + 0.2 2.1 4.0 +2.0 by the high dose group
PerceptuarpTstortions_+ 6.8* 2.9
Intropunitiveness' +
Retardation and Apathy_+ 1.4 3.9
+
Motor Disturbances + 4.7* 1.0 21.4*
group, while the placebo
+0.5
13.0* +2.4
Conceptual Disorganization + 3.8
group had the highest inci
1.6
Younger, less hospitalized patients are patients under age 40 who have dence of dropouts due to
been hospitalized less than ten years.
Mean Difference Score: A "plus" difference indicates improvement from deteriorated behavior. In ad
pretreatment to posttreatment, and a "minus" difference indicates worsen dition to the terminations
ing.
*
Difference score significant at 0.05.
=
listed in Table 6, approxi
mately 3% of the high dose
measured by this factor (ie, slowed motor patients and 2% of the low dose patients
behavior, reduced general reactivity, and went home on trial visit, while another 4%
apathy). It was therefore surprising to find to 6% of the patients in each treatment group
that with younger, less hospitalized patients, were terminated for administrative reasons.
high dose actually reduced Retardation and Time of Early Termination.Of the 51
Apathy more than the other treatments (al high dose patients dropped from the study,
though the difference between high dose and 25% were terminated during the first eight
the other treatments was significant at only weeks, 45% during the second eight weeks,
the 0.1 level). At the other levels of age and and 30% during the last eight weeks. The
hospitalization, the results with high dose time pattern of dropouts for the placebo
were consistent with the literature; the high group was similar to that for the high dose
dose group showed a significant increase in group. Of the 82 placebo dropouts 24% oc
Retardation and Apathy and was the least curred during the first eight weeks, 56%
effective of the four treatments. during the second eight weeks, and 20%
Time of Improvement.Preliminary anal during the last eight weeks. The 31 low
ysis of the trends of clinical change over the dose dropouts were evenly distributed across
six-month treatment period indicated that the three eight-week periods. Time of ter
most high dose patients reached a plateau of mination was not related to sex, age, or
improvement by four months. Patients on length uf hospitalization in any of the three
low dose generally achieved maximum im treatment groups.
provement within two months, while the Side Effects.Table 7 presents the inci
greatest deterioration on placebo occurred dence of side effects judged to be moderate
provement in practical aspects of the pa routine treatmentDRI on either the global scales
tient's adjustment, namely those areas of or the important factors of Community
Adjustment Potential and Psychosocial Ade
behavior which most affect the patient's whether
the hospital and adjust in quacy. In light of this, it is doubtful
ability to leave
older
the community. Our results indicate that the clinical benefits of high dose with
younger, less hospitalized patients on high or longer hospitalized patients justify the
dose, in addition to showing generalized high risk of side effects. This is particularly
symptom reduction, also show significant true with older patients where the risk of
improvement in areas of social adjustment side effects greatest. is
known to be related to release. This im One interesting finding was that patients
provement is particularly meaningful since hospitalized under ten years had signifi-