Supervisor: dr. Sabar P Siregar, Sp.

KJ Adhitya Putra W Ana Fitria Lisa Rachmayanti Rifqi Ali Zaki Sisilia Anggraeni 01.208.5578 01.209.5834 01.208.5702 01.208.5765 01.208.5783

Clinical Clerkship Psychiatry RSJ Prof. dr. Soerojo Magelang Medical Faculty of UNISSULA 2013

Second generation of antipsychotic drug

Lower incidence of EPS (Extrapyramidal Side-Effect)

Strong affinity Serotonin 5HT2 receptors

Weak affinity Dopamine D2 receptors

Atypical Antipsychotic Drugs

Improvement in cognitive symptom

Increase in Dopamine and Acetthylcoline in Prefrontal Dorsolateral regions and Hippocampus

Guilera et al. Meta-analysis 18 studies (N=1808) Woodward et al. Meta-analysis

Atypical VS Typical psychotic drug Cognitive Functioning

Atypical mild improvement in the Global Cognitive Index (speed of processing and learning tasks) and moderately better in neuropsychological tests

Typical Psychotic Drug

Typical Psychotic Drug

Improvement in attention

Anticholinergic drug

Impair memory

CATIE (Clinical Antipsychotic Trials for Intervention Effectiveness) EUFEST (European First-Episode Schizophrenia Trial) CUTLASS (Cost Utility of The Latest Antipsychotic Drugs in Schizophrenia Study) TEOSS (Treatment of Early Onset Schizophrenia Spectrum Disorder)

Antipsychotic drugs minimum neurocognitive improvement Benefit in firstepisode psychosis symptom reduction Cognitive enhancement practice effect Controversial

Hempel et al. Meta Analysis of 8 studies (Effects of antipsychotic medication on facial affect recognition in schizophrenia) No substansial improvement after treatment with either typical or atypical antipsychotic drug

Facial affect recognition was not related to neuropsychological functioning

Deficits in emotion perception are not significantly improved with atypical antipsychotic medication

Aim Asses emotional and cognitive functioning in schizophrenia patients currently treated with conventional or atypical antipsychotic drugs

Objectives Determine the extent and nature of emotional and attentional deficits in these patients

AGE
Medication Type

SE X
Evaluate relationship deficit to:

Severity of psycho pathology

Education

Duration of illness

Current mood

Psychopathology SAN S SAP S

BDI
Beck Depression Inventory

Scale for

Scale for

The Assesment of Negative Symptom

The Assesment Positive Symptom

Inform Consent

Ethics Committee of The Lublin University

Typical Antipsychotic
Pherpenazine Perazine Fluphenazine Haloperidol

150 Participants

100 Schizophrenia inpatients

50 Controls

Atypical Antipsychotic
Olanzapine

Risperidone
Amisulpride Clozapine

39 Typical Antipsychotic

61 Atypical Antipsychotic

Quetiapine

Daily Dose Antipsychotic

Treatment: 4 weeks Age: 18-60 y.o. Admission: 1-16

CPZE (Equivalent) Typical Antipsychotic: 394 mg

Participants

Atypical Antipsychotic: 422 mg

SANS (Scale for The Assesment of Negative Symptom) SAPS (Scale for The Assesment for Positive Symptom)

Assesment

Exclusion Criteria

Inclusion Criteria

< 60 y.o. Completed BDI and instrument for self-rating of symptom of depression No history of psychiatric illness for participants in control group

Presence of Neurological Dissorder (Epilepsy, Dementia, etc) Habitual drug Alcohol abuse Difficulties with vision (poor acuity, lack of correction) Severe hearing problems Unable to complete the full set of tests Discharged before completing the experimental sessions

TEA (The Test of Everyday Attention)

SRMT (Short Recognition Memory Test for Faces)

FERT (Facial Expression Recognition Test) Reading The Mind in The Eyes (Eyes Test) BEES (Balanced Emotional Empathy Scale)

Based on ecologically plausible activities searching maps, looking through telephone directories, and listening to lottery number broadcasts. This test provides norm-referenced scores on tests that are sensitive to selective attention, sustained attention and attentional switching. For study purposes, 3 subtests were used:
Visual selective attention map search task. Subjects search a map for

2 minutes. Auditory selective attention elevator counting with distraction task. Subjects count how many times they hear a tone, while ignoring a distracting tone of a higher note. Sustained visual attention visual elevator task. Subjects count each elevator door, imagining that it represents a floor. Both accuracy and timing are assessed

A forced-choice recognition memory test. It consists of 25 unfamiliar grey-scale male faces, which are presented at a rate of 1 every 3 seconds (timed by stop watch). The subject is required to respond yes or no to each item, depending on whether the face is judged to be pleasant or not. Recognition memory is assessed immediately after the presentation of the stimuli using a 2-choice format, each stimulus item being paired with 1 distracter item. The number of correct choices for each subtest was recorded.

computerized task based on 25 facial expressions from a standardized series. Subjects view prototypical facial expressions of the 6 basic emotions (fear, disgust, anger, surprise, happiness, sadness) and neutral facial expressions. They judge the emotion displayed by each facial expression.

measure of adult metalizing. It assesses how well the subject can put themselves into the mind of another person and empathies with their mental state. Subjects see 36 photographs of the eye region of unknown faces, and choose which of 2 words best describes what the person in the photo is thinking or feeling
A

 The

full-length (30 item) BEES was used. When completing the scale, subjects were asked to state the extent to which they agreed or disagreed with 30 statements (examples: Unhappy movie endings haunt me for hours afterward; I cannot feel much sorrow for those who are responsible for their own misery) using a 9-point agreement-disagreement scale.

Post Hoc Turkey Test

SPSS
Pearson Correlation

ANCOVAs

Results
The Independent Samples Ttest Controls outperformed patients in all tests (p<0.001)

3 groups differed significantly Education (p<0.001) BDI (p<0.001)

Analysis of Variance (ANOVA)

Results
Atypical Antipsychotic Drugs
Less severely ill (lower mean scores on both SANS and SAPS) Less depressed (lower mean BDI score) Younger Lower numbers of admissions Shorter illness duration.

Typical Antipsychotic = Atypical Antipsychotic

Results
Post-hoc Turkey Multiple Comparison
Instrument TEA SRMT FERT Eyes Test BEES Sa/Sc Mean Difference 1.14 0.36 0.91 2.27 4.83 P 0.43 0.82 0.48 0.89 0.59

Not Significant

Results

Highly Significant

Results
Pearson Correlations
FERT SAPS SANS Admission Illness Duration Age Sc (p) 0.004 0.001 0.001 0.001 0.001 Sa (p) 0.03 0.01 0.003 0.003 0.002

Statistically significant in both typical and atypical antipsychotic

Results
Pearson Correlations
Eyes Test Admission Illness Duration P 0.01 0.002

Age

0.016

Statistically significant in typical antipsychotic

No significant correlaton in were found in atypical antipsychotic group

Results
Instrument Statistic Analysis Covariance BEES Pearson Correlation Atypical Antipsychotic BDI Education BDI SAPS SANS TEA Pearson Correlation Typical Antipsychotic Admission Duration of Illness Age Pearson Correlation Atypical Antipsychotic Admission Duration of Illness Education - BDI P 0.05

BEES - SANS

0.036
0.04 0.002 0.04 0.008 0.004 0.001 0.001 0.001 0.001 0.014 0.012

SMRT

Education

Control Group

Schizophrenia Patient

Difficulties in Schizophrenia

Recognizing emotions Empathizing with others and putting themselves into someone else shoes (theory of mind) Demonstrate deficits in understanding social instructions

Schizophrenia Deficits

Perception of emotions Scope of reading the state of mind of other people (theory of mind) The emotional empathy level Attention function

Schizophrenia patients did not show significant impairment in processing facial information.

Particular selective and sustained attention and switching attention

Neither the positive effect of atypical antipsychotics nor the negative influence of conventional antipsychotic drugs on emotional and attentional functions in schizophrenia

The type of the antipsychotic drug used in the study (typical versus atypical) seems not to have a substantial effect on improvement or deterioration in emotional and cognitive domains

Hempel et al, Herbener at al, Penn et al, Sergi et al Selva Vera et al No statistically significant in effect of antipsychotic No greater cognitive drugs on restoring enhancement over 2 years emotional functioning in in patient with atypical schizophrenia antipsychotic, compared to those treated with typical antipsichotic

Patients with a diagnosis of schizophrenia compared with healthy people demonstrated the following deficits:
Facial emotion perception, Empathy/theory of mind, Attention (visual selective attention/speed, and attentional

switching).

There was no difference between the performance of atypical and conventional treated patient groups, even when controlling for the prescription of atypical antipsychotic drugs to younger, less severely ill patients.

Population Schizophrenia patients, age 18-60 years old, at the 4 weeks treatment, number of admisson: 1-16 Intervention Patients were received typical and atypical antipsychotic drugs Comparation Compared with control group Outcome Emotional and cognitive functioning in schizophrenia patients currently treated with conventional or atypical antipsychotic drugs

 The

Title of The Journal

: Yes : More than 12 words (14)

Describe the whole journal : Yes Intersting The Structure

The

Author and Institution

Appropriate with The Guidelines: Yes

 Abstrak

The Structure

Consist of 4 part Background, Material/Method, Results, Conclusion. There are key words. Informative : Yes Less than 250 words : Yes (211)
Background

Consist of two paragraph or part : No (9 paragraph) The first paragraph explain background of the

research : Yes The second paragraph explain hypothesis or objective : No (on paragraph 9) Less than one page : Yes

METHOD

Design, Place, and Time of The Research

Design Place

: Cross Sectional : Department of Psychiatry, Lublin University of Medical School, Lublin, Poland Time : Not Mentioned

The Population
Achieved Population: Schizophrenia patients, age 18-60 years

old, at the 4 weeks treatment, number of admisson: 1-16 in Department of Psychiatry, Lublin University of Medical School, Lublin, Poland Target Population: Population:Schizophrenia patients, age 1860 years old

Inclusion and Exclusion Criteria : Mentioned Sampling Technique : Not mentioned Calculation of Sampling : Not mentioned Detail of Observation, calculation, and intervention for application in other research/clinical : Not mentioned

 Blind

Method : No Reliable : Yes Definition of Technical Term : Partial Ethical Clereance

Ethics Committee of The Lublin University

Medical School
Inform Consent Inform consent was obtained from each

patients before enrollment

Analytic Computer Program ACNOVA Turkey PostHoc Pearson Correlation

Results
Characteristic

Subject Table : Included Characteristic Subject Before Intervention that was Compared with The Result : No Table Total Subject in Intervention : Was written Drop Out / Withdrawal : Was written] Accuracy of Numeric Data : Trusted Accuracy and Compability of Analytic Computer Program : Trusted Include The Result of The Analysis, Degree of Freedom and P Value : Included

Discussion

All of Relevan Thing are Discussed : Yes Not Repeated : Yes The Limitation : Was written The Previous Research : Included The Relation of Result and Clinical Process : Yes Side Effect : Yes Addition of The Research : No Data Statistic Analysis that Addition : Not written

Literarture The Structure : Appropiate with guidelines Appropiatewith Any Citation : Yes

A. General Description Design : Cross Sectional Population and Sample

Achieved Population: Schizophrenia patients, age 18-60 years

old, at the 4 weeks treatment, number of admisson: 1-16 in Department of Psychiatry, Lublin University of Medical School, Lublin, Poland Target Population: Population:Schizophrenia patients, age 18-60 years old

Sampling Technique : Not mentioned Variable

Dependent Variable : Conventional and Atypical Drugs Independent Variable : Attentional and Emotional Fucntioning in

Schizophrenia Patient

Subjective : Included

B. Internal Validity (Non-causal Relationship) 1. Was The Result Influenced by Bias? On Subject Selection
Prevalence Bias (Neyman Bias)

Cant be assesed (no prevalence data) Admission Rate Bias (Berksons Fallacy) No Bias. There is data of number admission Non-Response Bias Cant be assesed (no data) Membership Bias Cant be assesed (no data) Procedure Selection Bias Cant be assesed (no data)

On measurement & observation

Procedure bias There is no bias Recall bias The bias was not found in this research. This bias only match for case-control study Insensitive measurement There is no bias, because the instrument score have standart spesification Detection bias (change of the value) There is no bias, because the instrument score have standart spesification Compliance bias There is no data

o o o

o
o

2. Was the result influenced by opportunity factor? No 3. Was the observation influenced by confounding factor? No

C. Internal validity (causal relationship)

1. Was the time relationship right? Yes, the dependent variable preceded the independent variable 2. Was the association strong? Yes, because the P value present low value 3. Had it relationship with the dosage? Yes 4. Was the result consistent in this research? Yes 5. Was the result have coherency with the fact on the society? Yes 6. Was the result same with other research? Yes 7. Was the result biologically plausible? Yes

D. External Validity

1. Can the result be applicated on the subject of this research? Yes 2. Can the result be applicated on achieved population? Yes, it can
3. Can the result be applicated on target population? Yes, it can