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\title{Retrospective Study Evaluating the Management of Psychotic Disorders at Behavioral Medicine Dept -SQUH}
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\begin{document}

             \author[1]{Dr. Amr  Guenedi}

             \author[2]{Dr. Yousif  Obeid}

             \affil[1]{  Sultan Qaboos University}

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\date{\small \em Received: 10 December 2013 Accepted: 1 January 2014 Published: 15 January 2014}

\maketitle


\begin{abstract}
        


undreds of millions of people worldwide are affected by mental, behavioral, neurological and substance abuse disorders. For example, estimates made by WHO in 2002 showed that 154 million people globally suffer from depression and 25 million people from schizophrenia. (1) This exerts tremendous social, medical and financial burden. Early intervention and effective management can easily reduce this burden significantly. One other main disorders encountered and constitute real challenge are the psychotic disorders. They constitute 3 to 4 % of all mental disorders (1). They have gained special interest due to its possible chronic course and hence its long term economic and social impact. Cost-effective treatments exist for most disorders and, if correctly applied, could enable most of those affected to become functioning members of society.

\end{abstract}


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\let\tabcellsep& 	 	 		 
\section[{Introduction}]{Introduction}\par
undreds of millions of people worldwide are affected by mental, behavioral, neurological and substance abuse disorders. For example, estimates made by WHO in 2002 showed that 154 million people globally suffer from depression and 25 million people from schizophrenia. \hyperref[b0]{(1)} This exerts tremendous social, medical and financial burden. Early intervention and effective management can easily reduce this burden significantly. One other main disorders encountered and constitute real challenge are the psychotic disorders. They constitute 3 to 4 \% of all mental disorders \hyperref[b0]{(1)}. They have gained special interest due to its possible chronic course and hence its long term economic and social impact. Cost-effective treatments exist for most disorders and, if correctly applied, could enable most of those affected to become functioning members of society. 
\section[{II.}]{II.} 
\section[{Objective of our Study}]{Objective of our Study}\par
To evaluate our current management of inpatient psychotic disorders at SQUH-Behavioral medicine department. 
\section[{III.}]{III.} 
\section[{Method}]{Method}\par
? Data were collected from inpatients computer notes for patients diagnosed with psychotic disorders using the DSM IV criteria \hyperref[b2]{(3)}. No consent was needed since this is a retrospective study and no intervention is done. Patients were chosen according to an inclusion criteria which includes the following: a) inclusion criteria\par
? Age group between 18-65 years old.\par
? Patients admitted to our psychiatric ward.\par
? Patients who were followed up for at least 3 months after being discharged from hospital.  
\section[{Results}]{Results}\par
According to the collected criteria, the number of patients included in the study was 121 patients. They were 54 males (44.63 \%) versus 67 females (55.37 \%). The highest age distribution (57 \%) was between 20-29 years old. 22.3\% were between 30 and 39 years old. 9.1\% between 40 and 49, 8.3\% between 16 and 19, and 3.3 \% over 50 years old (Figure \hyperref[fig_0]{1}). As per diagnosis it was found the patients with mania were (41.3 \%) , Schizoaffective cases were 19.8\% positive schizophrenia were 14\% ,Unipolar depression with psychotic features were 11.6 \% , and those with bipolar depression with psychotic features were 7.5 \%. Patients with either mixed affective states (2.5\%) or other psychosis (4\%) constituted the least percentage among the study group( table \hyperref[tab_1]{1}). The average length of stay as per diagnosis reflects the following: 13 days for patients diagnosed as having bipolar depression with psychotic features , 12 days for patients with either a positive schizophrenia or a manic episode, 11 days for pts with the diagnosis of unipolar depression with psychotic features ( Figure  {\ref 2}). Figure  {\ref 2} Reviewing our archives and the follow up notes on each visit to the outpatient clinic, we found that 87.61 \% of selected patients remained symptom free at least three months after being discharged from hospital. The percentage of patients who relapsed within 3 months after discharge was 12.39 \%.9 (Figure  {\ref 3}). Figure  {\ref 3} The highest rate of relapse (22.2\%) was among patients diagnosed with bipolar depression with psychotic features, followed by those with Unipolar depression with psychotic features (21.4\%), schizoaffective disorder (16.6\%), positive schizophrenia (11.76\%) and finally patients with mania who relapsed within 3 months after discharge were (6 \%) of the total percentage of those who relapsed (12.39\%).Figure  {\ref 4}. 
\section[{Figure 4}]{Figure 4}\par
These findings led us to review the antipsychotics we usually prescribe for our patients. We found that three antipsychotics are frequently used: Haloperidol, Risperidone, \& Olanzapine. We compared these three medications as regard the field of efficacy.\par
Figure \hyperref[fig_1]{5} shows that Haloperidol was the drug prescribed for 37.5 \% of those patients diagnosed as having the positive syndrome of schizophrenia and who remained symptom free for at least three months after discharge, compared to 31.2\% for Olanzapine, and 6.3 \% for Risperidone. According to our findings for such patients, addition of a mood stabilizer or of an antidepressant or both had no remarkable effects.  Figure  {\ref 6} shows that Olanzapine added to a mood stabilizer was the drug prescribed for 45 \% of those patients diagnosed as having a schizoaffective disorder and who remained symptom free for at least three months after discharge, compared to 25\% for Olanzapine as a monotherapy, and 15 \% for Haloperidol combined to a mood stabilizer.
\begin{quote}
Figure 6\end{quote}
\par
Figure  {\ref 7} shows that again Olanzapine added to a mood stabilizer was the drug prescribed for 36.17 \% of those patients diagnosed as having a manic episode and who remained symptom free for at least three months after discharge, compared to 27.65\% for a combination of Haloperidol and a mood stabilizer, and 12.7 \% for Risperidone combined to a mood stabilizer. These findings emphasize that mood stabilizers are an essential component in the treatment of acute manic episodes.\par
Figure  {\ref 7} Figure  {\ref 8} shows that Olanzapine added to a mood stabilizer was the drug prescribed for 44.4 \% of those patients diagnosed as having a bipolar depressive disorder with psychotic features and who remained symptom free for at least three months after discharge, compared to 33.3\% for Haloperidol combined to a mood stabilizer. And 11.1 \% for Risperidone combined to a mood stabilizer.
\begin{quote}
Figure 8\end{quote}
\par
Figure  {\ref 9} shows that Risperidone added to a mood stabilizer and to an antidepressant was the drug prescribed for 33.3 \% of those patients diagnosed as having a unipolar depressive disorder with psychotic features and who remained symptom free for at least three months after discharge, compared to 16.6 \% for Risperidone added to antidepressant, 16.6\% for Risperidone added to a mood stabilizer, and again 16.  
\section[{Discussion}]{Discussion}\par
From the results mentioned above two main findings are to be brought to attention. The first point is the average length of stay as denoted by 11.8days. This is considered to be of great significance if compared with other studies (eg 13 days in the study run by Boronow J) (2). The second point is the low relapse rate in the first 3 months as reflected by the 13\% figure, again below much of the reported figures. This is considered to be of great importance since it reflects both short and long term success in management.\par
Comparing different antipsychotics under study it was found that Haloperidol seems to be the drug of choice in cases of positive schizophrenia. Olanzapine added to a mood stabilizer seems to be the combination of choice in cases of mania, schizoaffective disorders \& bipolar depression with psychotic features. Risperidone added to a mood stabilizer and to an antidepressant was found to be the combination of choice in cases of unipolar depression with psychotic features. 
\section[{VI.}]{VI.} 
\section[{Declaration of Interest}]{Declaration of Interest}\par
The present study was not supported by any pharmaceutical company. \begin{figure}[htbp]
\noindent\textbf{1}\includegraphics[]{image-2.png}
\caption{\label{fig_0}Figure 1 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{5}\includegraphics[]{image-3.png}
\caption{\label{fig_1}Figure 5}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{}\includegraphics[]{image-4.png}
\caption{\label{fig_2}}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{1} \par 
\begin{longtable}{P{0.7452464788732395\textwidth}P{0.10475352112676056\textwidth}}
\multicolumn{2}{l}{Table 1 showing percentage of diagnosed cases}\\
Disorder\tabcellsep Percentage\\
\tabcellsep (\%)\\
Mania\tabcellsep 41.3\\
Schizoaffective\tabcellsep 19.8\\
Schizophrenia (Positive symptoms)\tabcellsep 14\\
Unipolar depression with psychotic\tabcellsep 11.6\\
features\tabcellsep \\
Bipolar depression with psychotic\tabcellsep 7.5\\
features\tabcellsep \\
Mixed affective state\tabcellsep 2.5\\
Others e.g. Epileptic induced psychosis\tabcellsep 4\end{longtable} \par
 
\caption{\label{tab_1}Table 1 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{} \par 
\begin{longtable}{P{0.028406169665809767\textwidth}P{0.3299485861182519\textwidth}P{0.49164524421593836\textwidth}}
\tabcellsep \tabcellsep Remission versus Relapse Remission versus Relapse\\
\tabcellsep \tabcellsep stay symptom free for at stay symptom free for at least 3 months least 3 months relapse within 3 months relapse within 3 months\\
\tabcellsep 90.00\% 90.00\%\tabcellsep \\
\tabcellsep 80.00\% 80.00\%\tabcellsep \\
\tabcellsep 50.00\% 50.00\% 60.00\% 70.00\% 60.00\% 70.00\%\tabcellsep 87.61\% 87.61\%\\
\tabcellsep 40.00\% 40.00\%\tabcellsep \\
\tabcellsep 20.00\% 30.00\% 20.00\% 30.00\%\tabcellsep 12.39\% 12.39\%\\
\tabcellsep 10.00\% 10.00\%\tabcellsep \\
2014\tabcellsep 0.00\% 0.00\%\tabcellsep \% of pts \% of pts\\
Year\tabcellsep \tabcellsep \\
( ) A\tabcellsep \tabcellsep \end{longtable} \par
 
\caption{\label{tab_2}}\end{figure}
 			\footnote{© 2014 Global Journals Inc. (US)} 		 		\backmatter  			  				\begin{bibitemlist}{1}
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\end{document}