Caregivers for Patients with Alzheimer’s Disease Benefit from Intervention

According to the National Institute of Mental Health, Alzheimer’s disease affects ~4.5 million people in the United States. For 75% of these patients, family members provide primary care, which has the potential to increase stress for the caregiver. Research has shown that caring for a family member can contribute to the caregiver’s development of mental health disorders.

Louis Burgio, PhD, of the Center of Mental Health and Aging at the University of Alabama, and colleagues studied the efficacy of a structured, multi-component care intervention on clinical depression and quality of life (QOL) for a diverse sample of dementia patient caregivers. They sought to assess whether intervention affected rates of institutional care placement for patients with Alzheimer’s disease or a related disorder. They studied 212 Hispanic, 219 white, and 211 African American in-home caregivers of a relative with dementia. Within each ethnic group, participants were randomized to receive either care intervention (12 one-on-one, in-home or telephone sessions with a certified interventionist over 6 months) or a less intensive intervention method (two brief “check-in” telephone calls during the study period). Caregivers receiving the longer intervention participated in five telephone support group sessions.

Treatment intervention focused on addressing five QOL concerns typically reported by caregivers: attention to personal health; burden and stress; depression; problem behavior from the care recipient (ie, feelings of hopelessness); and social support. Intervention techniques, including skills training, problem solving, and stress management, were tailored to the caregivers’ reported problem areas. After intervention, caregivers in both groups were assessed on all five concerns. Rates of institutional placement were also examined. Burgio and colleagues found that Hispanic and white caregivers in the intervention group experienced significant improvement in QOL than those who received limited intervention. African American spouse caregivers improved significantly, but African American participants caring for a non-spousal relative did not benefit significantly.

The authors were surprised by the “magnitude of positive impact we were able to achieve in improving the QOL of dementia caregivers, particularly among Hispanics and whites,” said corresponding author Richard Schulz, PhD.

They found that, for participants in the longer intervention group, African American caregivers showed the greatest improvement in the reduction of caregiver burden and improving self-care, white caregivers were affected most by social support, and Hispanic caregivers had reduced depressive symptoms and recipient problem behaviors. Caregivers also reported that the intervention helped them feel more confident about caring for their family member and improved their overall QOL. Rates of clinical depression were lower for caregivers who received the longer intervention (12.6%) than for caregivers who received the shorter intervention (22.7%) at 6 months. Regarding care recipients, caregiver intervention affected rates of institutional care placement for dementia patients, although not significantly. Intervention did not affect other health measures for dementia patients.

“Patient functional and cognitive status was not impacted by the intervention,” Dr. Schulz said. “However, the rates of patient institutionalization were lower in the intervention group versus the control group.”

Burgio and colleagues concluded that the structured intervention, shaped to individual caregiver need, can increase the QOL for caregivers of various ethnicities. They cited the 6-month study duration and the exclusion or combination of ethnic groups as limitations. The care intervention was developed based on findings from the study’s first phase, which identified the efficacy of various caregiver interventions.

Funding for this research was supported by the National Institute on Aging and the National Institute of Nursing Research. (Ann Intern Med. 2006;145:727-738.) —Carlos Perkins, Jr.

Researchers Find Few Differences in Effectiveness of FGAs and SGAs for Schizophrenia Patients

Originally developed in the 1950s, first-generation antipsychotics (FGAs), typical antipsychotics, became the standard treatment option of schizophrenia. During the 1990s, more expensive second-generation antipsychotics (SGAs), atypical antispychotics, were introduced. SGAs soon became the standard treatment option as they were thought to be safer and more effective than FGAs. New research from the United Kingdom is slowly disproving this theory.

Peter B. Jones, MD, PhD, from the University of Cambridge in England, and colleagues conducted a multicenter, randomized, controlled trial of 227 patients (118 randomly assigned to receive FGAs; 109 randomly assigned to receive SGAs). between 18–65 years of age diagnosed with schizophrenia, schizoaffective disorder, or delusional disorder according to Diagnostic Statistical Manual of Mental Disorders, Fourth Edition criteria. A change in each patient’s drug regimen was being considered due to drug ineffectiveness or harmful side effects. Each patient was assessed by the researchers to determine their individual therapies.

“This study was undertaken to test whether SGAs, as a class, led to clinically meaningful improvements in quality of life, over 1 year, compared to FGAs,” Dr. Jones said. “The design aimed to replicate routine clinical care, other than the randomization to class of drugs and the blind, independent rating of outcome”

Only 81% of patients were followed at baseline, 12 weeks, 26 weeks and 52 weeks using the Quality of Life Scale (QLS) as the primary outcome measure. The QLS is a 21-item, 45-minute semi-structured interview mainly used in psychopharmacologic treatment trials for schizophrenia. It is rated from 0–6 with various descriptive anchors and the higher the score, the more normal the patient’s functioning is. QLS scores are detailed in the Table. Contrary to expectation, the five point QLS benefit for SGA drugs was excluded with a high degree of confidence.



At a 1-year follow-up, Jones and colleagues interviewed 185 study participants (100 from the FGA arm and 85 from the SGA arm). A total of 39 patients (17%) either died (3 in each arm); were lost to follow-up (11); or withdrew (22). Jones and colleagues found that patients receiving FGAs had greater overall improvement in symptoms. However, the researchers did not reach a statistical significance (P=.24); thus leading them to believe that there is little to be gained by switching medications.

“The results do not suggest that FGAs are superior to SGAs; merely that the expected advantage of the latter drugs could not be found,” Dr. Jones said. “Benefits of SGAs were not apparent in other domains, including patient preference and side effects. Clinicians can do well with either class of drugs in this group of patients, so long as they prescribe carefully aiming for low tolerance of side effects. The results cannot be generalized to first episode patients nor to newer drugs. Further research is necessary in order to explore these findings.”

Funding for this research was provided by the United Kingdom National Health Service Health. (Arch Gen Psychiatry. 2006;63:1079-1087.) —Christopher Naccari

Multi-pronged Treatment Helpful in Smoking Cessation in Psychosis Patients

Researchers from the University of Newcastle in Australia, led by Amanda Baker, PhD, suggest that nicotine replacement therapy combined with motivational interviewing/cognitive behavioral therapy (CBT) aides in smoking cessation intervention among psychosis patients. There are high rates of smoking among psychotic disorder sufferers and few trials have studied the efficacy of smoking cessation treatments in these individuals.

Smokers with a psychotic disorder were separated into two groups: routine-care comparison (n=152) or an individually tailored smoking cessation program consisting of eight sessions (n=147). The latter involved nicotine-replacement therapy, motivational interviews, and CBT. Baker and colleagues used abstinence rates, smoking reduction, and changes in psychosis symptoms and functioning as outcome measures. Approximately 57% of patients received a diagnosis of either schizophrenia or schizoaffective disorder. Less than half of the patients in the intervention group completed all eight treatment sessions and 25% of those subjects attended <5 sessions.

Baker and colleagues found no overall abstinence rate differences between those receiving treatment and those receiving routine care. More smokers who completed all treatment sessions stopped smoking during follow-up (point-prevalence rates: 3 months, 30% vs 6%; 6 months, 18.6% vs 4%; and 12 months, 18.6% vs 6.6%). Smokers who completed all treatment sessions were also more likely to have achieved continuous abstinence at 3 months (21.4% vs 4%). A significant dose-response relationship between treatment-session attendance and smoking-reduction status was found: 50% of the participants who completed the intervention program achieved a >50% reduction in daily cigarette consumption across the follow-ups compared with <20% of the comparison subjects. There was no evidence of a link to deterioration in symptoms or functioning.

Baker and colleagues believe there is a benefit to a multi-pronged treatment approach to smoking cessation among individuals with a psychotic disorder. For individuals who do not respond to the current treatment options there is a need for increased study in order to devise more efficacious therapeutic interventions. (Am J Psychiatry. 2006;163:1934-1942.) —José R. Ralat

Asymmetrical Brain Activity a Potential Marker for Alcoholism

Research has found that asymmetry of electrical activity in the brain, as measured via electroencephalograms (EEGs), may be a marker for various mental health disorders. Studies have shown that patients with past history of depression have lower levels of electrical activity in the front left brain region than the front right, a condition known as EEG asymmetry.

Elizabeth Hayden, PhD, of the University of Western Ontario in Canada, and colleagues studied resting brain activity in the anterior and posterior cortical brain regions of 193 males with alcoholism and 108 with no history of psychopathology. They evaluated the difference between patients with alcoholism to alcoholic patients with a lifetime history of comorbid disorders, including major depressive disorder (MDD) and antisocial personality disorder, which are commonly present in alcoholic patients. They sought to investigate if EEG asymmetry is related to alcoholism, if comorbid conditions are related to EEG asymmetry, beyond possible effects of alcohol dependence, and provide brain activity data instead of self-reports to assess emotionality in alcoholism.

“Anterior cortical asymmetry is thought to index emotional traits related to vulnerability to psychopathology,” Dr. Hayden said. “Literature indicates that individuals with depression show a pattern of frontal cortical asymmetry reflecting decreased left, relative to right, hemispheric activity. We predicted that alcohol-dependent participants would show a similar pattern of anterior cortical asymmetry.”

When compared to non-alcoholic patients, alcoholic patients had lower electrical activity in left frontal brain areas than right frontal areas. A deficiency in the left frontal cortex may help explain the development of alcoholism beyond self-report measures used by prior studies.

“The relationship between left and right anterior cortical activity is thought to reflect brain systems that regulate responses to rewards and potential punishment,” Dr. Hayden said. “The fact that alcohol dependent participants show an imbalance in activity in these regions suggests that these systems are dysregulated in alcohol dependence. Taken as a whole, these findings suggest that abnormal responses to reward may be important in the pathogenesis of this disorder, at least for some dependent individuals.”

EEG asymmetry rates in alcoholic patients with comorbid antisocial personality disorder were not significantly different from those without the disorder. Alcoholic patients with a lifetime history of MDD showed less EEG asymmetry in anterior regions than patients without MDD.

“We had expected that this group would show the most pronounced pattern of asymmetry of all the groups,” Dr. Hayden said. “One reason for this is that we looked only at males for the comorbidity analyses of EEG, while the literature looking at frontal asymmetry in depression has focused largely on females. Given that some research shows major sex differences on patterns of frontal EEG asymmetry, this might explain the unexpected results.”

Hayden and colleagues concluded that alcoholics exhibit frontal EEG asymmetry similar to patients with mental health disorders. They believe the results are most relevant for understanding markers of alcoholism risk and suggest that frontal asymmetry may be genetically based, citing research involving preschool-age children and brain activity patterns. They believe the relation between EEG asymmetry and various mental health disorders should be studied further, as well as whether asymmetry is an inherited trait.

Funding for this research was supported by National Institute on Alcohol Abuse and Alcoholism, the National Institute on Drug Abuse, and National Institutes of Health. (Alcohol Clin Exp Res. 2006;30:1986-1991.) —Carlos Perkins, Jr.