Предиктори на терапевтичния отговор при шизофренията // Predictors of therapeutic response in shizophrenia
| dc.contributor.author | Илиева, Ивайла Каменова // Ilieva, Ivayla Kamenova | |
| dc.date.accessioned | 2024-06-05T06:30:28Z | |
| dc.date.available | 2024-06-05T06:30:28Z | |
| dc.date.issued | 2023 | |
| dc.description.abstract | РЕЗЮМЕ Основания зu изследването: Шизофренията е хетерогенно заболяване с хроничен ход и е сред водещите причини за увреждания в света. Въпреки многобройните изследвания няма убедителни доказателства за предсказването на терапевтичния отговор в хетерогенната група. ЦЕЛ: Целта на изследването е да оцени влиянието на социодемографски фактори, анамнестични данни и клинични характеристики върху терапевтичния отговор при шизофрения. МЕТОДИ: Изследването е натуралистично, с едногодишно проспективно проследяване на 108 пациенти с диагноза Шизофрения и оценка на психопатология, агресия, функциониране, качество на живот. РЕЗУЛТАТИ: В хетерогенната извадка 89.8% са проспективно оценени след една година. Мъжкият пол е асоцииран с потежък ход на заболяването и по-често с рисково поведение като се потвърждава стратификацията на групата на млади мъже като високорискова категория. Установена е корелация между несъдействие към терапия и недоброволни хоспитализации като тези фактори са потенциални модифициращи фактори за терапевтичния ход поради асоциацията им с по-високи нива на агресия, клинично впечатление за тежестта и по-ниски нива на функциониране. Стационарното лечение е ефективно с намаляване на психопатология, негативна симптоматика и агресия след хоспитализация. Наблюдаване е повишаване на функционирането една година след прием (z=-8.01, р<.001,), въпреки че негативната симптоматика (z=-2.45. р=0.0 15) и агресивното поведение (z=-4.260, р<.001) са значимо повисоки в сравнение с периода на изписване. Регресионен модел установява недоброволна хоспитализация при постъпване като значим предиктор за по-висока агресия и по-ниско функциониране (р<.001 ). Продължителността на хоспитализация е повишена с ниско придържане към терапия (р=.022), докато лечение с атипични антиспихотици я намалява. Една година след приема, професионалната заетост е свързана със спад в психопатологията и негативните симптоми, както и с подобрение на функционирането и качеството на живота. Придържането към терапия е предиктор за по-ниска психопатология, по-малко агресия и по-добро функциониране. Използването на клозапин и наличието на хоспитализация в проспективния период са значими прогностични фактори за психопатология, по-ниско функциониране и тежест на болестта, докато необходнмостта от стационарното лечение е свързано с по-високи нива на агресия една година след това. Хроничен ход на болестта намалява шанса за подобрение в психопатология, докато анамнеза за агресия е негативен предиктор за промяна на психопатология и функциониране. Чрез качествено изследване, основните фактори, допринасящи за подобрението спрямо пациентите са "лечение" (35%) и "семейство" (34%). ЗАКЛЮЧЕНИЕ: Установени значими фактори за терапевтичния отговор като придържане към лечението и професионална ангажираност демонстрира неотложната нужда от континуитет между болнични и амбулаторни служби, както и ангажирането в комплексни психосоциални услуги допълнително към медикаментозната терапия. // SUMMARY BACKGROUND: Schizophrenia is a heterogenic disease with chronic course and is among the top-leading causes of disability in the world. In spite of the numerous studies in search of defining nosological boundaries, etiopathogenesis, clinical manifestation, and therapeutic response, there is, so far, no convincing evidence applicable to all patients with diagnosis of schizophrenia. In addition, heterogeneity of the disease is also found in its course as demonstrated in large follow-up studies. The many faces of the disorder determine lack of precise diagnostics sometimes implying the risk of iatrogenic use of unnecessary medication therapies and stigmatization, or, alternatively, may cause underestimation of the clinical picture and failure to apply efficacious therapeutic interventions. There is lack of convincing data on predictive factors for response to therapy and on division of the diverse group of schizophrenic patients according to the therapeutic response. PURPOSE: The aim of the study is to assess the influence of sociodemographic factors, anamnestic data, and clinical characteristics on the therapeutic response in schizophrenic patients and to objectify factors with prognostic value aiming to achieve better treatment response. The combination of these factors could be used to categorize relatively homogeneous groups of patients based on their response. Methods: This study has naturalistic, non-interventional design, and includes one-year prospective follow up with assessments at three time points: upon admission for inpatient treatment (T1), at discharge (T2), and one year later (T3). The study focuses on patients diagnosed with schizophrenia according to the ICD-10 (F20) and DSM – V, who have been admitted for inpatient treatment at the Clinic of Psychiatry at UMHAT “Alexandrovska” EAD, Sofia (N=108). The inclusion criteria were diagnosis of schizophrenia defined by the ICD-10 and DSM – V, admission for inpatient treatment, age above 18 years and informed consent for participation in the study and follow-up. Exclusion criteria were substance abuse, severe comorbid somatic illness, and lack of ability to obtain post-discharge contact. The sample consists of a heterogeneous group of patients, who are examined in a “naturalistic” order, with all potential candidates being assessed as they were consecutively admitted in the clinic. The clinical outcomes are measured in multidimensional approach. Psychopathology is assessed by the Positive and Negative Syndrome Scale (PANSS), negative symptoms – by the Scale for Assessment of Negative Symptoms (SANS), aggression – by the Modified Overt Aggression Scale (MOAS), clinical global impression for severity and improvement (CGI-S/I), functioning – by the Global Assessment of Functioning (GAF) scale, as well as subjective quality of life by World Health Organization Quality of Life Short Version Scale (WHOQOF– BREF). Statistical analyses are performed using descriptive methods, Student’s t-test, Wilcoxon Signed Ranks Test, Mann-Whitney U test, Chi-square test or Fisher’s exact test. Correlation analyses were conducted using Spearman and Pearson coefficients. Exploratory factor analysis with principal components, varimax rotation, and Kaiser normalization was applied. Additionally, multiple stepwise and logistic regression were used for quantitatively assessing the factor influence on therapeutic response. ETHICS: The study protocol was approved by the ethics committee of the Medical University of Sofia. All participants gave written informed consent prior to their inclusion in the study and their anonymity was guaranteed. RESULTS: The study is original research, conducted within the real clinical practice among a heterogeneous group of patients with schizophrenia. It presents the clinical picture in a cross- sectional manner as well as the course of the illness over one-year follow-up. The sample consists of 108 patients with mean age of 39 (SD±12.7), and 89.8 % (N=97) of them were prospectively assessed after one year. It is demonstrated that there is a high proportion of patients without social stability - a significant number are unemployed (87%), receive disability pension due to their illness (50,9%) and a proportion of 13,9% lack any social support. A considerable portion of patient also have physical comorbidities (44%), family history of psychiatric disease (52%) and risky behavior, including records of aggression (54%), self-harm (36%) and involuntary admissions (44%). The male gender is with more severe course and more frequently with risky behavior. Younger age is associated with higher levels of aggression (rs= -0.246, p=0.01), while functioning improves with age (rs=.303, p=0.001). These findings, combined with the history of past aggression as a predictor for future aggression, confirm the stratification of the group of young male patients as a high-risk category. A correlation has been established between non-adherence to treatment and involuntary admission. Adherence to therapy and the element of coercion for treatment have been identified as protentional variables (modifying factors) for the therapeutic course, due to their association with higher levels of aggression, clinical impression of severity and lower levels of functioning. All symptom dimensions in the 5-factor model – positive, negative, disorganized, manic, and depressive, measured by PANSS, as well as the negative symptoms (objectified by SANS) and aggression (objectified by MOAS) rates, are significantly lower after inpatient treatment. There is an improvement in functioning one year after admission (z=-8.01, p<.001,), although both negative symptoms (z=-2,45, p=0.015) and aggressive behavior (z=-4.260, p<.001) are significantly higher as compared to discharge. In addition to the positive change in clinical measures after inpatient treatment, as a marker for effectiveness is the improvement of compliance rates (from 15,7% to 48,1%). From the multiple regression, at T1, involuntary admission is a significant predictor for higher aggression and lower functioning (p<.001). The duration of hospitalization is longer with lower compliance (p=.022), and the treatment with atypical antipsychotics decreases the hospital stay (p=.021). One year after admission, employment serves as a positive predictive factor as it is significantly associated with drop of psychopathology (p=.001) and negative symptoms (p<.001), and with improvement of functioning (p<.001). Good compliance is predictor for lower psychopathology (p=.015), less aggression and higher functioning (p<.001). Professional engagement is identified as well as an important protective factor for subjective quality of life. From the conducted regression model, several predictors have been identified as significant for the values of clinical measurements one year after inpatient treatment. Use of clozapine and prior hospitalization during the studies prospective period serve as negative prognostic factors for psychopathology, lower functioning, clinical impressions of severity, while the presence of hospitalizations by itself is associated with higher levels of aggression at T3. From the clinical characteristics, a longer duration of illness if predictive of a reduced likelihood of improvement in functioning and clinical impression of improvement. Meanwhile, a progressive or chronic course mediates a decreased chance of improvement in psychopathology and the clinical impression o improvement. Another established factor is a history of aggression, which is negative predictor for changes in psychopathology and functioning. Considering the patient perspective, in addition to the collected objective information, qualitative research was performed. The responses for the main factors, contributing to the improvement of the patient, vary significantly but by their grouping two answers stand out – “medications/treatment” (35%) and “family” (34%). LIMITATIONS: A limitation of the current study can be noted as a methodological constraint, which is the collection of the sample from one treatment facility and the relatively small sample size, rendering the sample non-representative. However, the sample may serve as representative for a more severe course of schizophrenia in patients. Furthermore, the nature of the observational study could contribute to a bias toward more negative outcomes in the study sample. CONCLUSION: The inpatient treatment is efficacious in terms of psychopathology and aggression, and is linked to better functioning. The naturalistic design of the study shows depletion of the positive effects of treatment in terms of negative symptoms and aggression probably due to incomplete medication compliance, which is a poor prognostic factor for functioning Another protective factor for improved functioning and subjective quality of life is the professional engagement. This demonstrates the imperative need of continuity in mental health care and better psychoeducation after discharge, as well as engagement in complex psychosocial services in addition to medication treatment. | |
| dc.identifier.uri | http://hdl.handle.net/10861/2139 | |
| dc.language.iso | other | |
| dc.publisher | Медицински университет - София // Medical University - Sofia | |
| dc.subject | психиатрия; психични разстройства; шизофрения – фармакотерапия; прогноза // psychiatry; mental disorders; schizophrenia - drug therapy; prognosis | |
| dc.title | Предиктори на терапевтичния отговор при шизофренията // Predictors of therapeutic response in shizophrenia | |
| dc.title.alternative | Predictors of therapeutic response in shizophrenia | |
| dc.type | Thesis |
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