| Visit | CGI-S | CGI-G | PANSS Positive | PANSS Negative | PANSS total | Clinical correlates |
|---|---|---|---|---|---|---|
| Baseline | 4 | 5 | 24 | 21 | 94 | —- |
| Week 2 | 3 | 2 | N/A | N/A | N/A | Positive, negative symptoms much improved |
| Week 12 | 3 | 2 | 11 | 16 | 56 | Mr. F’s understanding about his illness, life, socioeconomic issues much improved |
| Week 76 | 3 | 2 | 11 | 18 | 56 | Activity level increased; starts doing yard work to supplement disability income |
| Week 88 | 3 | 2 | 12 | 14 | 52 | Volunteers as courier at local hospital; continues to do yard work |
| Week 226 | 2 | 2 | 9 | 12 | 42 | Starts steady work as a janitor and security aid |
| Week 284 | 2 | 2 | 9 | 14 | 45 | Concerned about losing Social Security benefits, since he is working 40 hours a week. |
| Week 328 | 3 | 1 | 11 | 15 | 52 | Discharged from hospital after psychotic relapse. Looking for apartment. |
| Week 384 (Final visit) | 3 | 1 | 9 | 12 | 45 | Father died the previous week. Mr. F accepted his father’s passing well. Open-label study terminated. Patient continued on aripiprazole, 20 mg/d. |
What the scores mean
Clinical Global Impression-Severity of Illness (CGI-S)—Scores range from 1 to 7, with 1 meaning normal (normal, minimal, mild, moderate, moderately severe, severe, among the most extreme).
Clinical Global Impression-Global Improvement (CGI-G)—Scores range from 1 to 7, with 1 meaning very much improved (very much improved, much improved, improved, unchanged, little worse, much worse, very much worse).
Positive and Negative Syndrome Scale (PANSS) Positive—consists of 7 items (delusions, conceptual disorganization, hallucinatory behavior, excitement, grandiosity, suspiciousness/persecution, hostility); scores range from 7 to 49 and decrease as patients improve.
PANSS Negative—consists of 7 items (blunted affect, emotional withdrawal, poor rapport, passive pathetic withdrawal, difficulty in abstract thinking, lack of spontaneity and flow of conversation, stereotyped thinking); scores range from 7 to 49 and decrease as patients improve.
PANSS General—consists of 16 items (somatic concern, anxiety, guilt feelings, tension, mannerism and posturing, depression, motor retardation, uncooperativeness, unusual thought content, disorientation, poor attention, lack of judgment and insight, disturbance of volition, poor impulse control, preoccupation, active social avoidance). Scores range from 16 to 112 and decrease as patients improve.
CONTINUED TREATMENT: A new trial
Mr. F participated in a 4-week, double-blind, placebo-controlled trial of aripiprazole, 2, 10, or 30 mg/d, versus haloperidol, 10 mg/d.
One month later, he entered a second aripiprazole trial: a 4-day, open-label study starting at 5 mg/d with titration to 20 mg/d. In the interval between the two trials, Mr. F was prescribed thiothixene, 10 mg/d, and benztropine, 2 mg at bedtime.
During the 4-day trial, he complained of insomnia and was given chloral hydrate, 500 to 1,000 mg at bedtime. He also complained of anxiety and was started on lorazepam, 2 mg bid.
After completing the open-label aripiprazole trial, Mr. F exhibited no behavioral problems and complied with ward routine. He was discharged after 17 days, at which time he denied auditory or visual hallucinations. His thinking seemed clear and his insight improved. His Global Assessment of Functioning (GAF) score at discharge was 55, suggesting moderate symptoms and difficulty in social and occupational functioning.
For the next 5 1/2 years, Mr. F was maintained on aripiprazole, 20 mg/d, as part of the same ongoing open-label trial. During that period he also took lorazepam, 1 mg bid prn; oxazepam, 15 mg bid; or clonazepam, 0.5 mg bid, for anxiety.
Mr. F. exhibited significant sustained improvement as measured with the Positive and Negative Symptom Scale (PANSS), Clinical Global Impression scale (CGI), and GAF (Table). His TD remained mild throughout the trial, as determined through AIMS scores. He also reported no EPS, akathisia, or other adverse events.
About 18 months after starting aripiprazole, Mr. F resumed working part time. In September 2001, he stopped receiving disability benefits and started supporting himself again.
FOLLOW-UP: ‘The voices were ugly’
In December 2001, after 6 years without hospitalization, Mr. F was back in the psychiatric ward. One week before admission, he reported that he had been having panic attacks because “the voices were ugly.” He only slept 4 to 5 hours per night.
He then revealed that he had stopped taking aripiprazole for 2 weeks because he had no longer felt ill. He was still taking his lorazepam, however.
Mr. F appeared mildly anxious upon presentation and his affect was blunted. On examination, his thought processes were linear; he was once again hearing voices and experiencing delusions of telepathic control.
The patient was placed back on aripiprazole, 20 mg/d. His behavior on the ward improved dramatically, and the frequency and severity of his delusions and auditory hallucinations decreased gradually.
At discharge, Mr. F’s insight was good, his delusions had disappeared, and auditory hallucinations were rare. He was instructed to continue the aripiprazole and was prescribed clonazepam, 0.5 mg bid, for his anxiety and trazodone, 50 mg at bed-time, to help his sleep.
Since then, Mr. F has lived on his own, is working steadily, and has not required hospitalization. He stopped taking trazodone soon after discharge, but continues taking aripiprazole and clonazepam as prescribed. His hygiene is good, and he is making amends with family members. He attends church every Sunday—free of the messianic delusions that once tormented him. He also stopped abusing alcohol on his own in 1995 and has remained abstinent since.