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Samoylova Daria Dmitrievna, Saratov State Medical University, PhD, assistant of professor, psychiatry, narcology, psychotherapy and clinical psychology department E-mail: ddkarelina@mail.ru Barylnik Yulia Borisovna, MD, head of psychiatry, narcology, psychotherapy and clinical psychology department E-mail: juljab@yandex.ru
Studying of psychorehabilitational potential in patients with schizophrenia at different stages of psychopharmacotherapy
Abstract: This article presents the results of changes in different spheres in patients with schizophrenia according to the pharmacotherapy variant. Based on the conducted research we can say that sertindole is the drug of choice for long-term outpatient treatment of patients with schizophrenia. Keywords: schizophrenia, psychorehabilitation, compliance-therapy, neuroleptics.
Introduction
Schizophrenia is the disease that is characterized by a variety of clinical manifestations, which may cause difficulties in selecting the most appropriate antipsychotic drug for each case [1].
At the same time the long-term course of the disease, the tendency to recurrence and chronicity, the relative efficacy of pharmacotherapy exacerbates the situation. As the result, individuals with schizophrenia exhibit some degree of social failure, limiting of functionality or permanent loss of it — approximately 40% of patients are disabled [5]. The social significance of the problem is also underlined by the predominance of indirect (social) costs associated with the «nonproduced» gross domestic product over direct (medical) costs: the ratio of indirect/direct costs in the majority of the disorders according to the cost analyzes of schizophrenia is 3-4:1. [6] At the same time schizophrenia occupies 26 th place in the list of these diseases. To 2020 schizophrenia is going to be on the 20-th position and the projected increase will amount to 17 million years lived in disability condition, i. e., 1.25% of total damage [8].
Currently there is no drug that could meet the needs of all patients. Each new antipsychotic may provide additional treatment options, in case when doctors are aimed to treating patients with schizophrenia not only for symptoms relief, but also to restore the proper level of social functioning [11].
According to the literature, the incidence of non-compliance by patients' regimen of antipsychotic
drugs varies between 11-80%. A very important factor is the fact that patients have trust relationships, as well as understanding and proper contact with the doctor who is interested to participate in the process of therapy to minimize the violation of prescribed medical advice. These circumstances make it necessary to create a so-called therapeutic alliance, the maintenance of which is an important indicator of medical professionalism and guarantee of the successful therapy [3]. R. Kemp et al. (2000) developed a method of compliance therapy for the treatment of patients with acute psychotic mixed state, aimed to improving the implementation of patient medical recommendations regarding pharmacotherapy. The benefits of compliance therapy consist in that fact that it is required 6-12 sessions of psychotherapy, it is practical and easy to implement the intervention in a real clinical setting. The emphasis on cooperation within the therapeutic interaction is consistent with the growing interest ofhealth workers in the observance of the patients' rights and understanding the need to increase the powers of mental health care users [9]. According to several studies the method of compliance therapy showed a fairly high efficacy in patients with schizophrenia by direct assessment. At the same time the further study of this intervention on the various factors of compliance for a more complete and comprehensive study of long-term treatment outcomes and a better understanding of mechanisms of action remains actual [3].
Nauroleptics remain the major class of psychotropic drugs using to treat schizophrenia. The effect of the
pioneer class of typical antipsychotics has been directed mainly to reduce the manifestations of positive symptoms. As for the negative symptoms, typical antipsychotics have a limited effect on thinking impoverishing, the social withdrawal and the lost emotional expressiveness. There are numerous side effects of neuroleptics such as somnolence, weight gain, orthostatic hypotension, constipation and dry mouth. In addition, conventional antipsychotics often cause extrapyramidal disorders. The current stage of the endogenic disorders treatment is characterized by the increasing amount of new psychotropic drugs that present certain advantages in the treatment of mental disorders. The appearance of the atypical neuroleptics, deprived of these side effects, was an important step in the schizophrenia treatment. In comparison with typical and atypical antipsychotics the second ones cause fewer side effects of the motor areas, which may contribute to better compliance with the therapeutic regimen, and increase the compliance and clinical efficacy [13]. EUFEST study (European First Episode Schizophrenia Trial) has confirmed the benefits of atypical antipsychotics (first of all, quetiap-ine and amisulpride) in the treatment of patients with schizophrenia. The coefficients of cancel and tolerability of these drugs were significantly better in the comparison with even the low doses of haloperidol [10].
Great promises to improve the quality of patient's life are associated with the ability to reduce manifestations of atypical neuroleptics negative symptoms, including emotional deficiency, which would contribute to a certain degree of cognitive function normalization. Despite this, the implementation of atypical antipsychotic drugs is facing with some difficulties. They are connected with the fact that the expenses for their purchase are much greater than the cost of typical neuroleptics therapy [11]. The researchers found the differences in the subjective assessments of the life quality of patients with schizophrenia receiving conventional antipsychot-ics or atypical antipsychotics. In general, at the stage of drug remission the researchers marked the most consistently high subjective quality of life in the area of social and legal status (kernel module). The most consistently poor performance (poor quality of life) was found in patients with schizophrenia in the spiritual realm (specific unit) and the psychological sphere. At the same time, the given pharmacotherapy has the importance. Thus, the authors emphasize the significantly higher subjective indicators of life quality in sub spheres of «Mental quality of life» and «Peculiarities of sexual intercourse» in patients receiving atypical antipsychotics compared
with those receiving traditional pharmacy [12]. The numerous papers devoted to the study of the life quality of patients with schizophrenia demonstrate the dependence of subjective life quality of the many factors that can be combined into three main groups: psychosocial, medical and procedural factors. The impact of these factors on changes in individual indicators of the life quality of patients with schizophrenia may explain 12 to 36% of the variance [11].
By accumulated information, the new atypical antipsychotic sertindole may be considered as a meaningful alternative in the treatment of patients with schizophrenia [4].
The goal ofthe research was to conduct a comparative analysis ofpsychorehabilitational indicators of patients with schizophrenia, depending on the prescribed treatment.
Materials and methods: the study was conducted from 2015 at the psychiatry, narcology, psychotherapy and clinical psychology department of Saratov State Medical University n.a V. I. Razumovsky and in the Regional Clinical Psychiatric Hospital of St. Sophia.
The 105 patients with paranoid schizophrenia from 18 to 55 years (mean age 35,8 ± 1,4 years, 62 women, 43 men) were included in the study. Patients were randomly divided into three groups. The group 1 consisted of 35 patients who were appointed to treatment with sertin-dole, the 2nd group consisted of 35 patients treated with zuclopenthixol and the 3d one included 35 patients treated with clozapine. The rehabilitation approach was individual compliance therapy. All patients gave informed consent to participate in the study. There were 95% of patients fully completed the treatment (1 patient did not complete the study, due to a move to another city).
The study included the use ofoutpatient and inpatient cards and such psycho-diagnostic scales as the PANSS scale [16]; the scales for the assessment of cognitive functions (modified Hinting Task scale [14], the «Ekman's faces» scale [15]; the computerized Wechsler test [18]); the questionnaire for the assessment ofsocial functioning and life quality of the mentally ill patients [7]; the Moriscos-Green commitment treatment scale [17].
A survey of patients was carried out in five stages: admission to the hospital, before discharge from the hospital (2 months after the start of treatment) and 3, 6 months and one year after the discharge.
The variation-statistical method of the conducted research results was the use of «Statistica» 6.0 application package using descriptive statistics, correlation and analysis of variance. We used the parametric features of a normal distribution and non-parametric methods, regardless of the type of distribution. The differences were
considered statistically significant at 95, 99 and 99.9% probability thresholds.
The duration of the therapeutic course was 1 year. In order to detect the statistically significant differences in the study results the comparative analysis of 1 and 5 visits are represented on the graphs.
Results. According to the PANSS scale for the dynamics of psychopathology assessment the statistically significant changes (p<0,05) were observed in subscales P (gravity of positive symptoms) and G (general psycho-pathology symptoms).
By the end of sertindole treatment the decrease in the average severity of positive symptoms (subscale P) amounted from 23,4 ± 3,11 to 15,25 ± 4,77. In the zuclopenthixol and clozapine groups a decrease from the same period amounted from 19,08 ± 5,14 to 12,53 ± 3,48 and from 19,8 ± 3,97 to 14,92 ± 3,43 respectively. The differences were considered statistically significant at p <0,05.
The average point of the productive symptoms (P) changes in the three patients groups at time of therapy completion, compared with baseline is illustrated at Fig. 1.
Fig. 1. The variety of indicators through P subscale (PANSS) according to treatment variant
Subscale G is a general psychopathology scale for evaluating the severity of other mental disorders on the following 16 criteria: somatization, anxiety, guilt, inner tension mannerisms movements and postures, depression, motor retardation, negativism, unusual content of thinking, disorientation, decreased attention, impaired judgment and critics, volitional disorders, reduced control impulses, autization, active social isolation [16].
By the end of the treatment the average decline in the
severity of general psychopathology symptoms through subscale G in the group of patients treated with sertindole amounted from 56,15 ± 5,31 to 36,9 ± 10,18. In the group of zuclopenthixol and clozapine -the decrease amounted from 46,78 ± 12,68 to 35,11 ± 8,49 and from 44,75 ± 6,46 to 41,33 ± 8,09 respectively (p<0,05).
The changes in the average point through subscale G in the studied group of patients by the end of the therapy, compared with baseline depicted at Fig. 2.
Fig. 2. The variety of indicators through G subscale (PANSS) according to treatment variant Thus, according to the conducted study results During the sertindole therapy there was the im-
there was almost equal reduction of psychoproductive provement in cognitive function compared with other symptoms on both subscales in all treatment groups. groups up to visit 5. This improvement is concerned
first of all in the scale of social intelligence Hinting ± 1,18 to 7,97 ± 0,17 in the zuclopenthixol group
Task. The average point through «The hint understanding» at the end of sertindole therapy improved from 5,75 ± 1,18 to 7,1 ± 0,17. Whereas the same point in the comparison groups changed from 7,25
and from 7,79 ± 0,59 to 7,92 ± 0,41 in the clozapine group. The differences were considered statistically significant at p <0,05. These changes are illustrated at Figure 3.
Fig. 3. The variety of indicators through «The hint understanding» (Hinting Task) according to treatment variant
In addition to improving of the «The hint under-standing» through the Hinting Task scale the increase of the indicator «Social knowledge» was also marked in the group of patients treated with sertindole — from 3,81 ± 0,52 to 4,00 ± 0 at visit 1 and visit 5 respectively (Fig. 4). In the comparison with other groups, the in-
crease of this indicator in the sertindole group was the highest. This is confirmed by the following results: the observed change in the parameter «Social knowledge» in the zuclopenthixol group was from 3,96 ± 0,2 to 4,0, in clozapine group — from 3,81 ± 0,81 to 4,0 ± 0,37 at the first and last stages of observation (p <0,05).
Fig. 4. The variety of indicators through «Social knowledge» (Hinting Task) according to treatment variant
By the end ofthe treatment the emotional intelligence changes were also noted. In the sertindole group this indicator has improved as much as possible. It's value was 4,94 ± 1,62 at visit 1 and 5,21 ± 1,40 at the end of treatment. The average change of emotional intelligence based on
the «Ekman's faces» scale in zuclopenthixol group made up from 4.14 ± 1.62 to 1.4 ± 4.64. In the clozapine group some decrease of this parameter from 3.63 ± 0,92 to 3.5 ± 0.78 was observed at visits 1 and 5. The differences were considered statistically significant at p <0,05 (Figure 5).
visi I1 visit. 5
Fig. 5. The variety of indicators through «Ekman's faces» scale according to treatment variant
The increase of all indicators through the Wechsler scale was also noted to visit 5 in the group of sertindole patients. The average score ofnonverbal intelligence in this group increased from 18,75 ± 15,26 to 20,81 ± 15,7 because of improving of the «encryption» indicator (from 18,89 ± 20,42 to 20,28 ± 20.84) and the «missing pieces» (from 6,47 ± 4,3 to 7,11 ± 4,54) at p<0,05. The following changes were noted in the comparison groups: in zuclopenthixol group the nonverbal intelligence increased from 7,4 ± 4,27 to 7,8 ± 5,66, whereas clozapine group noted a slight decline in this indicator from 15, 0 ± 12,27 to 11,54 ± 11,29 to the end of therapy (p <0,05).
The average score of verbal intelligence by the end of the treatment in the sertindole group improved from
35,94 ± 11,14 to 39,36 ± 10,85. In the zuclopenthixol and clozapine groups there were a slight decline in this indicator — from 32,15 ± 9,22 to 31,45 ± 9,62 and from 40,7 ± 9,26 to 35,87 ± 10,82 respectively (p <0.05).
While carrying out a computerized version of the Wechsler intelligence test, the average score in the sertindole group increased from 54,69 ± 22,4 to 60,22 ± 23,0. In the zuclopenthixol and clozapine groups there was a decrease in this indicator from 39,2 ± 10,36 to 38,65 ± 12,04 and from 55,7 ± 14,7 to 47,42 ± 13,52 to the end of treatment respectively (p<0,05). The comparable changes in the general intelligence results of a computerized version of the Wechsler test are shown at Figure 6.
Fig. 6. The comparable changes in general intelligence results of the computerized Wechsler test The patients in sertindole group had better ± 1,1б) and clozapine (2,05 ± 0,38) groups at p <0,05 compliance (3,83 ± 0,42) than zuclopenthixol (3,17 (Figure 7).
Fig. 7. The comparative compliance results in the research groups
Fig. 8. The dynamics of well-being in the research groups during the study
The highest increase ofgeneral well-being was noted in the sertindole group by the end of the therapy (from 2,78 ± 1,02 to 3,16 ± 0,74 in average). In the zuclopenthixol group the positive dynamics of this indicator was also noted (2,25 ± 0,55 ± 0.44 and 2.75 respectively). While in the clozapine group the general well-being indicator to the end of treatment remained without dynamics (2,67 ± 0,76). The differences were considered statistically significant at p<0,05 (Figure 8).
In addition to the well-being the improve of disability index (2,39 ± 1,29 and 3,39 ± 0,73 respectively during the study) was statistically marked in the sertindole group. In other research groups of zuclopenthixol and clozapine this score has changed from 3,55 ± 1,1 to 3,3 ± 1,12 and from 1,63 ± 0,49 to 1,62 ± 0,49 respectively. The dynamics shows it's decline by the end of the therapy (p<0,05) (Figure 9).
Fig. 9. The dynamics of disability index in the research groups during the study
Conclusions: According to the study results the stable reduction of psychoproductive symptoms in all groups of patients treated with study medication was noted. Sertindole was the most effective drug, which improved cognitive profile of the patients. The compliance indicator in the sertindole group was the highest. The criterias of life quality (general well-being and disability index), according to the questionnaire for the assessment of social functioning and life quality
for mentally ill patients were higher in the sertindole group.
Based on these results we can conclude that at nearly equal improvement in PANSS scale in all three research groups there is the maximum effectiveness of the cognitive scales indicators, compliance, life quality and social functioning in the sertindole group. Thus, we can say that sertindole is the drug of choice for the long-term outpatient treatment of schizophrenia patients.
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Khayitov Ilkhom, assistant, department of Surgical disease for GP Tashkent Medical Academy E-mail: ilhom.med79@mail.ru
Experimental modeling hernia of anterior abdominal wall with abdomino-visceral obesity
Abstract: Improve the results of treatment of patients with postoperative ventral hernias, and based on the study of changes in the anterior abdominal wall of the experimental method of modeling To achieve this goal the first objective of the study was to develop an adequate experimental model of postoperative ventral hernias.
Keywords: experimental method of modeling of abdominal hernia, abdominoplasty, abdominal-visceral obesity.
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age. Scientists provides interesting facts, that the incidence of metabolic syndrome, depending on the membership of a particular ethnic group. [2, 263-270] In our study, patients with postoperative ventral hernias and who had belly droops more common in urban areas.
At the present time we are faced with an epidemic of obesity in the world. Early diagnosis of metabolic syndrome — is primarily prevention ofclinical manifestations oftype 2 diabetes and atherosclerotic vascular disease. [3, 62-67] In many cases, the disease is detected during the clinical manifestation, as the disease is often asymptomatic, and in the early period revealed only methods Other laboratory diagnostics. [4, 460-468] Currently, most doctors and scientists do not consider abdominal obesity as a specific form of the disease, in spite of the large number of works, there are many controversial issues. On this
