Randomised controlled trials of conventional antipsychotic versus new atypical drugs, and new atypical drugs versus clozapine, in people with schizophrenia responding poorly to, or intolerant of, current drug treatment

OBJECTIVES

To determine the clinical and cost-effectiveness of different classes of antipsychotic drug treatment in people with schizophrenia responding inadequately to, or having unacceptable side-effects from, their current medication.

DESIGN

Two pragmatic, randomised controlled trials (RCTs) were undertaken. The first RCT (band 1) compared the class of older, inexpensive conventional drugs with the class of new atypical drugs in people with schizophrenic disorders, whose current antipsychotic drug treatment was being changed either because of inadequate clinical response or owing to side-effects. The second RCT (band 2) compared the new (non-clozapine) atypical drugs with clozapine in people whose medication was being changed because of poor clinical response to two or more antipsychotic drugs. Both RCTs were four-centre trials with concealed randomisation and three follow-up assessments over 1 year, blind to treatment.

SETTING

Adult mental health settings in England.

PARTICIPANTS

In total, 227 participants aged 18-65 years (40% of the planned sample) were randomised to band 1 and 136 (98% of the planned sample) to band 2.

INTERVENTIONS

Participants were randomised to a class of drug. The managing clinician selected the individual drug within that class, except for the clozapine arm in band 2. The new atypical drugs included risperidone, olanzapine, quetiapine and amisulpride. The conventional drugs included older drugs, including depot preparations. As in routine practice, clinicians and participants were aware of the identity of the prescribed drug, but clinicians were asked to keep their participating patient on the randomised medication for at least the first 12 weeks. If the medication needed to be changed, the clinician was asked to prescribe another drug within the same class, if possible.

MAIN OUTCOME MEASURES

The primary outcome was the Quality of Life Scale (QLS). Secondary clinical outcomes included symptoms [Positive and Negative Syndrome Scale (PANSS)], side-effects and participant satisfaction. Economic outcomes were costs of health and social care and a utility measure.

RESULTS

Recruitment to band 1 was less than anticipated (40%) and diminished over the trial. This appeared largely due to loss of perceived clinical equipoise (clinicians progressively becoming more convinced of the superiority of new atypicals). Good follow-up rates and a higher than expected correlation between QLS score at baseline and at follow-up meant that the sample as recruited had 75% power to detect a difference in QLS score of 5 points between the two treatment arms at 52 weeks. The recruitment to band 2 was approximately as planned. Follow-up assessments were completed at week 52 in 81% of band 1 and 87% of band 2 participants. Band 1 data showed that, on the QLS and symptom measures, those participants in the conventional arm tended towards greater improvements. This suggests that the failure to find the predicted advantage for new atypicals was not due to inadequate recruitment and statistical power in this sample. Participants reported no clear preference for either class of drug. There were no statistically significant differential outcomes for participants entering band 1 for reasons of treatment intolerance to those entering because of broadly defined treatment resistance. Net costs over the year varied widely, with a mean of 18,850 pounds sterling in the conventional drug group and 20,123 pounds sterling in the new atypical group, not a statistically significant difference. Of these costs, 2.1% and 3.8% were due to antipsychotic drug costs in the conventional and atypical group, respectively. There was a trend towards participants in the conventional drug group scoring more highly on the utility measure at 1 year. The results for band 2 showed an advantage for commencing clozapine in quality of life (QLS) at trend level (p = 0.08) and in symptoms (PANSS), which was statistically significant (p = 0.01), at 1 year. Clozapine showed approximately a 5-point advantage on PANSS total score and a trend towards having fewer total extrapyramidal side-effects. Participants reported at 12 weeks that their mental health was significantly better with clozapine than with new atypicals (p < 0.05). Net costs of care varied widely, but were higher than in band 1, with a mean of 33,800 pounds sterling in the clozapine group and 28,400 pounds sterling in the new atypical group. Of these costs, 4.0% and 3.3%, respectively, were due to antipsychotic drug costs. The increased costs in the clozapine group appeared to reflect the licensing requirement for inpatient admission for commencing the drug. There was a trend towards higher mean participant utility scores in the clozapine group.

CONCLUSIONS

For band 1, there is no disadvantage in terms of quality of life and symptoms, or associated costs of care, over 1 year in commencing conventional antipsychotic drugs rather than new atypical drugs. Conventional drugs were associated with non-significantly better outcomes and lower costs. Drug costs represented a small proportion of the overall costs of care (<5%). For band 2, there is a statistically significant advantage in terms of symptoms but not quality of life over 1 year in commencing clozapine rather than new atypical drugs, but with increased associated costs of care. The results suggest that conventional antipsychotic drugs, which are substantially cheaper, still have a place in the treatment of patients unresponsive to, or intolerant of, current medication. Further analyses of this data set are planned and further research is recommended into areas such as current antipsychotic treatment guidance, valid measures of utility in serious mental illness, low-dose 'conventional' treatment in first episode schizophrenia, QLS validity and determinants of QLS score in schizophrenia, and into the possible financial and other mechanisms of rewarding clinician participation in trials.

Grey matter correlates of minor physical anomalies in the AeSOP first-episode psychosis study

BACKGROUND

Minor physical anomalies are more prevalent among people with psychosis. This supports a neurodevelopmental aetiology for psychotic disorders, since these anomalies and the brain are both ectodermally derived. However, little is understood about the brain regions implicated in this association.

AIMS

To examine the relationship between minor physical anomalies and grey matter structure in a sample of patients with first-episode psychosis.

METHOD

Sixty patients underwent assessment of minor physical anomalies with the Lane scale. High-resolution magnetic resonance images and voxel-based methods of image analysis were used to investigate brain structure in these patients.

RESULTS

The total anomalies score was associated with a grey matter reduction in the prefrontal cortex and precuneus and with a grey matter excess in the basal ganglia, thalamus and lingual gyrus.

CONCLUSIONS

Minor physical anomalies in a sample of patients with first-episode psychosis are associated with regional grey matter changes. These regional changes may be important in the pathogenesis of psychotic disorder.

Cognitive reserve in neuropsychiatry

BACKGROUND

The idea that superior cognitive function acts as a protective factor against dementia and the consequences of head injury is well established. Here we suggest the hypothesis that cognitive reserve is also important in neuropsychiatric disorders including schizophrenia, bipolar disorder and depression.

METHOD

We review the history of passive and active models of reserve, and apply the concept to neuropsychiatric disorders. Schizophrenia is used as an exemplar because the effects of premorbid IQ and cognitive function in this disorder have been extensively studied.

RESULTS

Cognitive reserve may impact on neuropsychiatric disorders in three ways: by affecting the risk for developing the disorder, in the expression of symptoms within disorders, and in patients' functional outcome. Cognitive failure below a certain threshold may alone, or in combination with common psychiatric symptoms, produce neuropsychiatric syndromes.

CONCLUSIONS

Consideration of cognitive reserve may considerably improve our understanding of individual differences in the causes and consequences of neuropsychiatric disorders. For these reasons, the concept of cognitive reserve should be incorporated in future studies of neuropsychiatric disorder. It may be possible to enhance cognitive reserve through pharmacological or non-pharmacological means, such as education, neurocognitive activation or other treatment programmes.

Infant motor development is associated with adult cognitive categorisation in a longitudinal birth cohort study

BACKGROUND

The relationship between the age of reaching infant developmental milestones and later intellectual function within the normal population remains unresolved. We hypothesised that the age of learning to stand in infancy would be associated with adult executive function and that the association would be apparent throughout the range of abilities, rather than confined to extremes.

METHODS

The Northern Finland 1966 Birth Cohort is based upon 12,058 live-born children in a geographic and temporally defined population. Information on age at learning to stand without support was obtained at one year. At age 33-35 a random sample of 104 subjects underwent a neuropsychological test battery including tests of executive function (cognitive categorisation), visuo-spatial memory, verbal learning and visual object learning. We investigated associations between developmental data and adult neuropsychological test scores.

RESULTS

There was a significant linear relationship between age of learning to stand and adult categorisation: the earlier the attainment of the milestone, the better was the categorisation. No such relationships were observed between infant neurodevelopment and adult cognition in other neuropsychological domains.

CONCLUSION

Even within the normal range of development, early development in the gross motor domain is associated with better adult executive function (in tests of categorisation). Investigation of the determinants and sequelae of normal neural development will facilitate research into a variety of neurodevelopmental disorders.

Infant motor development and adult cognitive functions in schizophrenia

BACKGROUND

Childhood neuromotor dysfunction is a risk factor for schizophrenia, a disorder in which cognitive deficits are prominent. The relationship between early neurodevelopment and adult cognition in schizophrenia remains unclear.

METHODS

We examined the associations between infant motor development and adult cognitive functions in schizophrenia (n = 61) and the general population (n = 104) in a sample drawn from the The Northern Finland 1966 Birth Cohort. Data on ages of learning to stand and walk with or without support were obtained at age 12 months by health visitor assessment. Neurocognitive measures at age 33-35 included executive function, verbal and visual episodic memory, and visuo-spatial working memory.

RESULTS

The schizophrenia group achieved neuromotor milestones later and performed significantly worse than the control group on all measures of cognition. In pooled analyses there were associations between infant motor development and adult cognition in the domains of executive function, verbal learning and visuospatial working memory, but not in visual object learning. The pattern of associations between development and cognition was similar in schizophrenia and the general population.

CONCLUSIONS

These findings are consistent with the hypothesis that in schizophrenia mild infant motor developmental delay and adult cognitive deficits (at least in some domains) are age dependent manifestations of the same underlying neural process. Thus, they may be better considered as part of a single longitudinal syndrome.

Incidence and distribution of first-episode mania by age: results from a 35-year study

BACKGROUND

Few epidemiological studies have investigated incidence by age or age at onset distributions for mania or bipolar disorder. The current study aimed to determine these in a defined area in south-east London, over a 35-year period.

METHOD

All cases of first-episode mania presenting to psychiatric services in Camberwell, south-east London, between 1965 and 1999 were identified. Incidence rates by age, using 5-year age-at-onset bands, were estimated and the structure of the age-at-onset distribution for first-episode mania was investigated using finite mixture distributions (admixture analysis).

RESULTS

The incidence of DSM-IV bipolar I disorder (BP I), first manic episode peaked in early adult life (16.38/100,000 population per year in the 21-25 years band) with a much smaller peak in mid-life. A two-component normal mixture distribution fitted age at onset better than either a single normal distribution or a three-component mixture, implying the existence of early and later onset subgroups. The early onset group had a stronger family history of bipolar disorder, and showed more acute, severe and atypical symptoms during their first manic episode.

CONCLUSIONS

The incidence of mania peaks in early adult life but there is clear evidence of early and later onset subgroups which may represent different forms of disorder.

Effectiveness of antipsychotic treatment for schizophrenia: 6-month results of the Pan-European Schizophrenia Outpatient Health Outcomes (SOHO) study

OBJECTIVE

To present the 6-month outcomes associated with antipsychotic treatment of patients participating in the Schizophrenia Outpatient Health Outcomes (SOHO) study.

METHOD

SOHO is a 3-year, prospective, observational study of the health outcomes associated with antipsychotic treatment in 10 European countries. The study included over 10,000 out-patients who were initiating or changing their antipsychotic medication.

RESULTS

Clinical Global Impression (CGI)-severity and quality of life (QOL) scores improved in all treatment cohorts. There was a higher response in the CGI-overall symptoms and in the CGI-schizophrenia positive, negative, cognitive and depressive symptom scales in the olanzapine (Olz) and clozapine (Cloz) cohorts compared with other treatment cohorts. Changes were associated with an improvement in QOL.

CONCLUSION

Patients starting Olz and Cloz tend to have better outcomes at 6 months than patients who start other antipsychotics in actual out-patient clinical practice. The results should be interpreted conservatively because of the non-randomized study design.

Disorder resistivity of solid neutron-star matter

Lower limits are found for the disorder electrical resistivity of solid neutron-star matter in the neutron-drip region which is amorphous and heterogeneous in nuclear charge. This temperature-independent resistivity, large compared with that produced by phonon scattering, has direct consequences for theories of neutron-star magnetic field generation and evolution.

Serum lipids in schizophrenia and other functional psychoses: a general population northern Finland 1966 birth cohort survey

OBJECTIVE

To compare fasting serum lipid concentrations of subjects with schizophrenia with a comparison group.

METHOD

The study sample consists of 5654 members of the northern Finland 1966 birth cohort who participated in the field study with blood samples after overnight fasting and clinical examination in 1997-98. Total cholesterol (TC), high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, triglycerides (TG) and glucose were analyzed. Analysis of variance were used for comparing differences in lipids means between diagnostic categories.

RESULTS

Mean fasting TC in subjects with schizophrenia was 20 mg/dl higher than in the comparison group. TC and TG levels in the group of other psychoses resembled the schizophrenia group.

CONCLUSION

Blood lipid levels in subjects with schizophrenia and other functional psychoses were high. As these persons are at special risk for hyperlipidemia their lipid levels should be regularly monitored, and cholesterol lowering diet, as well as medication, should be considered.

The Clinical Global Impression-Schizophrenia scale: a simple instrument to measure the diversity of symptoms present in schizophrenia

OBJECTIVE

To describe the development and validation of the Clinical Global Impression-Schizophrenia (CGI-SCH) scale, designed to assess positive, negative, depressive and cognitive symptoms in schizophrenia.

METHOD

The CGI-SCH scale was adapted from the CGI scale. Concurrent validity and sensitivity to change were assessed by comparison with the Positive and Negative Symptom Severity (PANSS) and Global Assessment of Functioning (GAF) scales. To evaluate inter-rater reliability, all patients were assessed by two clinicians.

RESULTS

Symptoms were assessed in 114 patients. Correlation coefficients between the CGI-SCH and the GAF and PANSS scores were high (most above 0.75), and were highest for positive and negative symptoms. Reliability was substantial (intraclass correlation coefficient, ICC > 0.70) in all but one dimension (depressive dimension, ICC = 0.64).

CONCLUSION

The CGI-SCH scale is a valid, reliable instrument to evaluate severity and treatment response in schizophrenia. Given its simplicity, brevity and clinical face validity, the scale is appropriate for use in observational studies and routine clinical practice.

The European Schizophrenia Outpatient Health Outcomes Study: baseline findings across country and treatment

OBJECTIVE

To describe the baseline findings and study population of the Schizophrenia Outpatient Health Outcomes (SOHO) Study.

METHOD

The SOHO study is an ongoing, large, prospective, long-term observational study of schizophrenia treatment in 10 European countries. The study population consists of out-patients who initiate therapy or change to a new antipsychotic.

RESULTS

A total of 1096 investigators enrolled 10 972 patients. Approximately 60% of patients were men and the mean age was 40 years. Patients treated with clozapine and more than one antipsychotic are more severely ill, patients receiving depot medications have a history of non-compliance, and patients receiving their first antipsychotic for schizophrenia are most likely to receive an atypical agent.

CONCLUSION

The SOHO study population appears to represent European out-patients with schizophrenia in whom a treatment decision is required. Baseline findings reflect European clinical practice with respect to patients treated with individual antipsychotics.

The European Schizophrenia Outpatient Health Outcomes (SOHO) study: rationale, methods and recruitment

OBJECTIVE

The objective of the European Schizophrenia Outpatient Health Outcomes (SOHO) study is to understand the comparative costs and outcomes of antipsychotic drug treatment, with specific focus on olanzapine. The study will also provide a large database for research into the treatment and outcome of schizophrenia. The role of observational studies in the assessment of the effectiveness of antipsychotic agents is reviewed, and the rationale, design and recruitment issues surrounding the SOHO study are presented.

METHOD

SOHO is a 3-year, prospective, observational study of the health outcomes associated with antipsychotic treatment in Europe.

RESULTS

Over 10 000 patients have been recruited from 10 countries. Baseline evaluation included measures of clinical status, social functioning, quality of life, service use and pharmacological treatment. Patients will be followed for 3 years.

CONCLUSION

The SOHO study will complement randomized controlled trial findings on the treatment of schizophrenia and will address relevant clinical and policy research questions.

IQ in childhood psychiatric attendees predicts outcome of later schizophrenia at 21 year follow-up

OBJECTIVE

Preschizophrenic children who merit psychiatric referral are claimed to have a particularly malevolent illness when the psychosis develops later. The 21 years outcome of a sample of such children was investigated.

METHOD

Fifty-one children who attended psychiatric services, and were later diagnosed as having schizophrenia, were followed up a mean of 21 years later. Baseline childhood demographic, clinical and putative aetiological characteristics were identified from the case notes. Follow-up assessment evaluated clinical symptoms, social functioning and service utilization. The predictive value of baseline factors on outcome was examined.

RESULTS

Outcome was poor, and seven (14%) of the subjects were deceased. Childhood IQ was strongly predictive of social outcome (F=5.1, P=0.01) and service utilization (F=5.2, P=0.01), but not clinical symptoms. No other factors predicted outcome.

CONCLUSION

Low childhood IQ had an unfavourable impact on social outcome and service utilization once schizophrenia developed.

Early developmental milestones in adult schizophrenia and other psychoses. A 31-year follow-up of the Northern Finland 1966 Birth Cohort

Delayed childhood development may precede adult psychoses. We tested this hypothesis in a large, general population birth cohort (n=12058) followed to age 31 years. The ages at which individuals learned to stand, walk, speak, and became potty-trained (bowel control) and dry (bladder control), were recorded at a 1-year examination. Psychiatric outcome was ascertained through linkage to a national hospital discharge register. Cumulative incidence of DSM-III-R schizophrenia, other psychoses and non-psychotic disorders were stratified according to the timing of milestones and compared within the cohort using internal standardization. 100 cases of DSM-III-R schizophrenia, 55 other psychoses, and 315 non-psychotic disorders were identified. The ages at learning to stand, walk and become potty-trained were each related to subsequent incidence of schizophrenia and other psychoses. Compared with the whole cohort, earlier milestones reduced, and later milestones increased, the risk in a linear manner. These developmental effects were not seen for non-psychotic outcomes. The findings support hypotheses regarding psychosis as having a developmental dimension with precursors apparent in early life.

Neuroticism as a risk factor for schizophrenia

BACKGROUND

Neuroticism has been shown to increase the risk of depression whereas extraversion is associated with a reduction of risk. These personality traits play a central role in aetiological theories of affective disorder but their role in schizophrenia is unclear. In this study, the risk for schizophrenia associated with neuroticism and extraversion was examined and quantified.

METHODS

Neuroticism and extraversion rated at the age of 16 years were examined in relation to adult schizophrenia in a national birth cohort of 5362 individuals.

RESULTS

Neuroticism increased the risk of later schizophrenia independent of the level of affective symptoms in adult life (odds ratio over three levels: 1.93, 95% CI 1.09-3.43), whereas extraversion reduced the risk (OR: 044, 95% CI 0.23-0.84).

CONCLUSIONS

Depression and schizophrenia may share personality risk-increasing and risk-reducing factors. Coping styles associated with particular personality traits may determine whether isolated symptoms progress to full-blown illness.

Juvenile and early adulthood smoking and adult educational achievements--a 31-year follow-up of the Northern Finland 1966 Birth Cohort

AIMS

To investigate the association between juvenile and early adult cigarette smoking and educational achievements up to the age of 31 years.

METHODS

As a part of the follow-up of the North Finland 1966 Birth Cohort (n = 10542) from 1966 to 1997, smoking was assessed at the ages of 14 and 31 by postal questionnaires. The highest level of educational attainment was obtained from the National Education Registry of Statistics Finland up to the age of 31 years.

RESULTS

Adult smoking (at age 31) and prolonged smoking (at ages 14 and 31) were both associated with an approximately two- to sixfold, adjusted odds for educational underachievement. Smoking only at age 14 showed none of these associations.

CONCLUSION

These results are unlikely to be causal, but may be explained by other characteristics associated with smoking such as personality or lifestyle factors, as well as the effect of knowledge related to smoking gained during higher education.

Predictors of later schizophrenia and affective psychosis among attendees at a child psychiatry department

BACKGROUND

Schizophrenia has been linked with psychological problems in childhood but there is little information on precursors of affective psychosis.

AIMS

To compare childhood psychological antecedents of adult schizophrenia and affective psychosis.

METHOD

Childhood item sheets, which give standardised information on signs and symptoms of mental illness in the year preceding assessment are completed for all attendees at the children's department of the Maudsley and Bethlem Royal Hospital. We examined item sheet data on individuals with an adult diagnosis of schizophrenia (n=59) or affective psychosis (n=27) and a comparison group with no adult mental illness (n=86) (all had attended the department).

RESULTS

Abnormal suspiciousness or sensitivity and relationship difficulties with peers are associated with later schizophrenia. In contrast, affective psychosis is associated with childhood hysterical symptoms and disturbances in eating.

CONCLUSIONS

Childhood psychological precursors for schizophrenia and affective psychosis differ and do not simply reflect non-specific psychiatric disturbance in adolescence.

Developmental precursors and biological markers for schizophrenia and affective disorders: specificity and public health implications

Schizophrenia's developmental dimension includes causes being active early in life. Precursors are manifest before psychosis begins, and there is an emerging public health agenda including prediction and prevention. We discuss the specificity of some developmental precursors to schizophrenia as an outcome, with particular reference to longitudinal birth cohort studies. Underlying structural brain abnormalities are considered. Differences from controls are found in schizophrenia and, to a lesser extent, before affective disorder on many measures. This apparent lack of specificity may not be the case in neurobiological terms, as underlying mechanisms may be different; parsimony suggests not. This same lack of specificity may be an advantage in public health terms, raising the possibility of strategies to predict and prevent a range of psychiatric disorders, not just schizophrenia.

In vitro activity of a novel antimycobacterial compound, N-octanesulfonylacetamide, and its effects on lipid and mycolic acid synthesis

beta-Sulfonyl carboxamides have been proposed to serve as transition-state analogues of the beta-ketoacyl synthase reaction involved in fatty acid elongation. We tested the efficacy of N-octanesulfonylacetamide (OSA) as an inhibitor of fatty acid and mycolic acid biosynthesis in mycobacteria. Using the BACTEC radiometric growth system, we observed that OSA inhibits the growth of several species of slow-growing mycobacteria, including Mycobacterium tuberculosis (H37Rv and clinical isolates), the Mycobacterium avium complex (MAC), Mycobacterium bovis BCG, Mycobacterium kansasii, and others. Nearly all species and strains tested, including isoniazid and multidrug resistant isolates of M. tuberculosis, were susceptible to OSA, with MICs ranging from 6.25 to 12.5 microg/ml. Only three clinical isolates of M. tuberculosis (CSU93, OT2724, and 401296), MAC, and Mycobacterium paratuberculosis required an OSA MIC higher than 25.0 microg/ml. Rapid-growing mycobacterial species, such as Mycobacterium smegmatis, Mycobacterium fortuitum, and others, were not susceptible at concentrations of up to 100 microg/ml. A 2-dimensional thin-layer chromatography system showed that OSA treatment resulted in a significant decrease in all species of mycolic acids present in BCG. In contrast, mycolic acids in M. smegmatis were relatively unaffected following exposure to OSA. Other lipids, including polar and nonpolar extractable classes, were unchanged following exposure to OSA in both BCG and M. smegmatis. Transmission electron microscopy of OSA-treated BCG cells revealed a disruption in cell wall synthesis and incomplete septum formation. Our results indicate that OSA inhibits the growth of several species of mycobacteria, including both isoniazid-resistant and multidrug resistant strains of M. tuberculosis. This inhibition may be the result of OSA-mediated effects on mycolic acid synthesis in slow-growing mycobacteria or inhibition via an undescribed mechanism. Our results indicate that OSA may serve as a promising lead compound for future antituberculous drug development.

Neuroticism, life events and mental health: evidence for person-environment correlation

BACKGROUND

There is some evidence that genetic effects on the likelihood of experiencing stressful life events (SLEs) are mediated by heritable traits such as cognitive ability (CA) and neuroticism (N).

AIMS

To examine whether the association between CA, N and mental ill-health is driven in part by a predisposition to experience depressogenic SLEs.

METHOD

Childhood measures of N and CA were available in a birth cohort of 5362 individuals. At ages 36 and 43 years, mental state and occurrence of SLEs in the previous year were assessed. Using a path-analytic approach, models with and without a hypothesised influence of N and CA on the occurrence of SLEs were compared.

RESULTS

The fit of the model with childhood N having a direct influence on SLEs was good with chi 2 = 5.72, d.f. = 4, P = 0.22 at age 36 years and chi 2 = 3.50, d.f. = 5, P = 0.62 at age 43. The fit of the model was significantly worse without this path at both ages (36 years: chi 2 = 42.5, d.f. = 1, P < 0.001; 43 years chi 2 = 15.3, d.f. = 1, P < 0.001). No consistent differences were seen in comparisons of models with CA.

CONCLUSIONS

The results are congruent with the suggestion that genetic effects on SLEs are mediated by personal characteristics. Part of the well-established association between N and minor psychiatric disorder may be mediated by an indirect effect of N on the likelihood of experiencing SLEs.

Educational consequences of mental disorders treated in hospital. A 31-year follow-up of the Northern Finland 1966 Birth Cohort

BACKGROUND

Mental disorders often begin during the formative years of education. They may disrupt education and lead to social underachievement.

METHODS

We examined the impact of mental disorders treated in hospital (ages 16-29) on educational attainment up to 31 years in the Northern Finland 1966 Birth Cohort (N = 10581). People discharged due to mental illness were grouped by DSM-III-R diagnoses (of schizophrenia, other psychoses and non-psychotic disorders) and were compared with those having no such hospital treatment. Associations between diagnoses and educational outcome (completion of basic level, upper secondary or tertiary education) were analysed stratified by age at onset (early onset < 22 years v. later), and adjusted for confounding by perinatal risk, early motor development, maternal education, family structure, parental social class, and school achievement using prospective data from earlier assessments and logistic regression analysis.

RESULTS

Twelve per cent of the comparison group completed basic level education, 62% upper secondary, and 26% tertiary education. People with early onset disorder tended to stagnate in the basic level. Early onset schizophrenia and all non-psychotic cases had 3- to 6-fold adjusted odds for this outcome. Many with early onset schizophrenia completed secondary education, but none completed the tertiary level. Hospitalization for non-psychotic disorder increased the risk of underachievement in tertiary education for those with early onset.

CONCLUSIONS

Mental disorder treated in hospital truncates education. Failure to complete higher education may contribute to the 'social exclusion' of the mentally ill through reduced opportunities in later occupational life and failure to accumulate social capital.

The functional anatomy of auditory hallucinations in schizophrenia

We used continuous whole brain functional magnetic resonance imaging (fMRI) with a 3-T magnet to map the cerebral activation associated with auditory hallucinations in four subjects with schizophrenia. The subjects experienced episodes of hallucination whilst in the scanner so that periods of hallucination could be compared with periods of rest in the same individuals. Group analysis demonstrated shared areas of activation in right and left superior temporal gyri, left inferior parietal cortex and left middle frontal gyrus. When the data were examined on an individual basis, the temporal cortex and prefrontal cortex areas were activated during episodes of hallucination in all four subjects. These findings support the theory that auditory hallucination reflects abnormal activation of normal auditory pathways.