No abstract

Treatment of cognitive impairments is feasible in both early-course and chronic schizophrenia, but the clinical meaningfulness and generalization to functioning appear to be more substantial when delivered early. Cognitive remediation should be considered a tool for early intervention in schizophrenia.

Clozapine is an atypical antipsychotic medication with proven efficacy in the management of refractory schizophrenia. It is also recommended for patients who do not tolerate the extrapyramidal adverse effects of traditional antipsychotic medications. However, the therapeutic promise of clozapine has been limited by a higher incidence of agranulocytosis. Currently, plasma clozapine concentrations are not routinely used in clinical management. Therapeutic effects are monitored empirically during a 6 to 8 week titration period in which the dosage is raised to 300 to 450 mg/day. Clozapine nevertheless fulfils a number of criteria which make it a candidate for therapeutic monitoring. These include an identifiable therapeutic range, an unpredictable dose-concentration relationship between patients, a potential for clinically relevant pharmacokinetic interaction with other drugs and a high probability of patient noncompliance. The therapeutic threshold plasma concentration appears to be about 400 micrograms/L. Concentrations above 1000 micrograms/L increase the risk of adverse effects on the central nervous system (confusion, delirium and generalised seizures). There is no evidence to link increased concentrations of clozapine or its metabolite to the development of agranulocytosis. We conclude that therapeutic drug monitoring can play a useful role in the clinical management of patients treated with clozapine. The clinician is advised to primarily use clinical judgement during dosage escalation, but intermittent monitoring is recommended to quickly optimise a therapeutic dosage for each patient. At steady state, occasional measurements could be made when clinical signs indicate possible toxicity or lack of effect (possibly caused by a lack of compliance or drug interaction). Long term monitoring would, in our view, not be necessary.

Clinically stabilised patients with schizophrenia can provide accurate health state descriptions and assign them utilities with a fair degree of reliability and validity. Utility evaluations based on patients' self-appraisals can be seen as potential tools in outcome studies and clinical trials involving patients with schizophrenia, but the methodology requires further refinement to accommodate the limitations imposed by the patients' disturbed mental status.

The patterns of use of psychiatric emergency services in Saskatoon, Saskatchewan were studied. A total of 576 patients who had received psychiatric emergency care from any of the four major health care facilities in Saskatoon during a three month period were included in the study. Visits for psychiatric emergency services during the study period represented 2.32% of the total number of visits to emergency facilities. Most patients with psychiatric emergencies went to hospitals with psychiatric units. The characteristics of patients served by the four facilities and those who visited the psychiatric emergency services on more than one occasion during the study period are reported. The implications of these findings for health care planning are discussed.