A relevant paradigm shift in the treatment of bipolar disorder started a few years ago; crucial findings on the usefulness of psychological interventions clearly support switching from an exclusively pharmacological therapeutic approach to a combined yet hierarchical model in which pharmacotherapy plays a central role, but psychological interventions may help cover the gap that exists between theoretical efficacy and “real world” effectiveness. Hereby we review the efficacy of several adjunctive psychotherapies in the maintenance treatment of bipolar patients.

A systematic review of the literature on the issue was performed, using MEDLINE and CURRENT CONTENTS databases. “Bipolar”, “Psychotherapy”, “Psychoeducation”, “Cognitive-behavioral” and “Relapse prevention” were entered as keywords.

Psychological treatments specifically designed for relapse prevention in bipolar affective disorder are useful tools in conjunction with mood stabilizers. Most of the psychotherapy studies recently published report positive results on maintenance as an add-on treatment, and efficacy on the treatment of depressive episodes. Interestingly, several groups from all over the world reported similar positive results and reached very similar conclusions; almost every intervention tested contains important psychoeducative elements including both compliance enhancement and early identification of prodromal signs — stressing the importance of life-style regularity — and exploring patients' health beliefs and illness-awareness.

The usefulness of psychotherapy for improving treatment adherence and clinical outcome of bipolar patients is nowadays unquestionable, and future treatment guidelines should promote its regular use amongst clinicians. As clinicians, it is our major duty, to offer the best treatment available to our patients and this includes both evidence-based psychoeducation programs and newer pharmacological agents.

While recent research points to the potential benefits of clinical intervention before the first episode of psychosis, the logistical feasibility of this is unclear.

To assess the feasibility of providing a clinical service for people with prodromal symptoms in an inner city area where engagement with mental health services is generally poor.

Following a period of liaison with local agencies to promote the service, referrals were assessed and managed in a primary care setting. Activity of the service was audited over 30 months.

People with prodromal symptoms were referred by a range of community agencies and seen at their local primary care physician practice. Over 30 months, 180 clients were referred; 58 (32.2%) met criteria for an at risk mental state, most of whom (67.2%) had attenuated psychotic symptoms. Almost 30% were excluded due to current or previous psychotic illness, of which two-thirds were in the first episode of psychosis. The socio-demographic composition of the 'at risk' group reflected that of the local population, with an over-representation of clients from an ethnic minority. Over 90% of suitable clients remained engaged with the service after 1 year.

It is feasible to provide a clinical service for people with prodromal symptoms in a deprived inner city area with a large ethnic minority population.

The present cross-sectional study examined the relationships of psychopathology, side effects, and sociodemographic factors with treatment outcomes in terms of patients' quality of life (QOL), functioning, and needs for care.

Sixty outpatients with chronic schizophrenia who had been treated with either clozapine or olanzapine for at least 6 months were investigated.

Most psychopathological symptoms as well as psychic side effects, weight gain, and female sex were associated with lower QOL, while cognitive symptoms correlated with better QOL. Female sex, cognitive symptoms, and parkinsonism negatively influenced occupational functioning, and negative symptoms determined a lesser likelihood of living independently. Age, education, depression/anxiety, negative symptoms, and psychic side effects were predictors of patients' needs for care.

Our results highlight the complex nature of patient outcomes in schizophrenia. They reemphasize the need of targeting effectiveness, i.e. both symptomatic improvement as well as drug safety, in such patients.

Cognitive dysfunction is increasingly considered to be the strongest clinical predictor of poor long-term outcome in schizophrenia. Associations have been found between the severity of cognitive deficits and social dysfunction, impairments in independent living, occupational limitations, and disturbances in quality of life (QOL).

In this cross-sectional study, the relationships of cognitive deficits and treatment outcomes in terms of QOL, needs, and psychosocial functioning were examined in 60 outpatients with schizophrenia who had a duration of illness over 2 years and had been treated with either clozapine or olanzapine for at least 6 months.

The present study suggests that cognitive functioning might be a predictor of work functioning/independent living outcome in stabilized patients with schizophrenia: deficits of visual memory and working memory were negatively associated with occupational functioning, and older patients lived independently and/or in a stable partnership more often. The patients' assessments of QOL and needs for care did not show any significant associations with cognitive functioning.

These findings suggest that cognitive functioning is a key determinant of work functioning/independent living for stable outpatients with schizophrenia.

Antipsychotic medications may reduce hostile and aggressive behavior in schizophrenia. This study compared the effectiveness of antipsychotics in the treatment of aggression.

The Intercontinental Schizophrenia Outpatient Health Outcomes (IC-SOHO) study compares the effectiveness of antipsychotic treatments in practice setting. Schizophrenia outpatients who initiated or changed to a new antipsychotic are followed in this non-interventional, prospective observational study for up to 3 years, with 6-months data now available on the entire cohort (N = 7655). The presence or absence of verbal or physical hostility/aggression was assessed retrospectively for the period of 6 months before enrollment, and prospectively in the period of 6 months after enrollment (the study treatment period). At baseline, patients in five monotherapy treatment groups (combined N = 3135) were prescribed one of the treatments: clozapine, olanzapine, quetiapine, risperidone, or haloperidol, and had complete data.

Hostile/aggressive behavior was reduced during the treatment period. Olanzapine and risperidone were significantly superior to haloperidol and to clozapine in this respect. These results remained essentially unchanged when adjusting for baseline imbalances in age, gender, age of onset, and substance abuse.

As monotherapy, both olanzapine and risperidone were superior to haloperidol and clozapine in reducing aggression. The relative lack of effectiveness of clozapine may be specific to this study population.

A high proportion (42.4%) of outpatients attending a psychiatric hospital appears to harbor expectations of secondary gain and hide this from their psychiatrists. This study investigated whether the prevalence of expectations of secondary gain could be replicated in a different sample, namely, a general hospital outpatient clinic attended by patients with less severe mental disorders, and whether patients hid these expectations from the psychiatrists they consulted.

The study was performed at a Dutch psychiatric outpatient department of a general hospital. In a prospective cohort, expectation of secondary gain was assessed by directly asking the patients via questionnaires whether they expected gaining specific ‘benefits’ from being in therapy.

Of 99 patients, 41 (41.4%) expected secondary gain while being in therapy. In contrast, only nine patients (9.5%) told their diagnosing psychiatrist of these expectations.

The present finding of a large proportion of patients expecting secondary gain is consistent with the results of an earlier study. Again, in most cases the diagnosing psychiatrists were unaware of their patients’ expectations. Thus many patients have hidden expectations of what therapy will do for them, in terms of material or non-material benefits other than getting better. Earlier empirical studies have shown that harboring expectations of benefits other than therapeutic benefits may be detrimental to therapeutic success.

Evidence indicates that classical antipsychotics may aggravate non-malignant and malignant catatonia (MC). Atypical antipsychotics are less likely to cause movement disorders than classical antipsychotics and they are being frequently prescribed in disorders that can be associated with catatonia. Therefore, the important question that arises is whether atypical antipsychotics have a role to play in the treatment of catatonia.

A Medline search was performed to locate papers on the use of atypical antipsychotics in catatonia published between 1970 and 31st December 2004.

The literature on the use of atypical antipsychotics in catatonia consists of case reports and retrospective studies. In most cases of non-MC a reduction of the catatonic symptoms is reported upon treatment with atypical antipsychotics. Cases of MC relate mainly to the neuroleptic malignant syndrome (NMS), which is considered as an iatrogenic stuporous variant of MC caused by antipsychotics.

There are indications that atypical antipsychotics may be useful in non-MC. As a consequence, one should not only focus on the possible extrapyramidal and autonomic side effects of these drugs, but also on the possible beneficial effects on certain brain functions and on the catatonic symptomatology. However, randomized controlled trials are needed to evaluate the effect of these drugs, and caution is advisable, since cases of NMS have been linked to treatment with atypical antipsychotics. There is no evidence to prescribe atypical antipsychotics in MC.

In this cross-sectional study we compared alcohol-dependent smokers and non-alcohol-dependent smokers with respect to intensity of nicotine dependence, craving conditions, sleep disturbances, comorbidity with major depression, reasons for smoking, accompanying somatic diseases and patients' prolonged abstinence from smoking during the 3 years preceding the study.

Fifty-one alcohol-dependent smokers and 327 non-alcohol-dependent smokers diagnosed as ICD-10 and DSM-IV-nicotine dependent, were investigated by means of the Fagerström Test for Nicotine Dependence, the Lübeck Craving-Recurrence Risk Questionnaire and the Lesch Alcohol Dependence Typology (both adapted to smoking).

The intensity of nicotine dependence was more enhanced in alcohol-dependent smokers compared to non-alcohol-dependent smokers. Several variables of all factors of craving (“depressive mood”, “stimulation”, “relaxation”, “socially triggered tension”) were significantly increased in alcohol-dependent patients (P < 0.05). Alcohol-dependent smokers showed depressive symptoms and sleep disturbances, whilst non-alcohol-dependent individuals mainly smoked for stress release and weight control.

Our study demonstrates that the intensity of nicotine dependence, several conditions of craving for nicotine, sleep disturbances and symptoms of depression appear to be enhanced in alcohol-dependent smokers compared with non-alcohol-dependent smokers.

It is hoped that the factors of craving and reasons for smoking identified in this study will contribute to a better understanding of smoking temptation in alcohol-dependent smokers and non-alcohol-dependent smokers in future.