The association between early-onset schizophrenia with employment, income, education, and cohabitation status: nationwide study with 35 years of follow-up

The Importance of Suicide Risk Formulation in Schizophrenia

Suicide is a cause of early mortality in nearly 5% of patients with schizophrenia, and 25-50% of patients with schizophrenia attempt suicide in their lifetime. Evidence points to numerous individual, clinical, social, and psychological risk factors for suicide in patients with schizophrenia. Although recognizing suicidal risk factors in schizophrenia is extremely important in suicidal risk assessment, we have recently witnessed a change in suicide risk management that shifts the focus from suicide risk assessment to suicide risk formulation. Suicide risk formulation is dependent on the data gathered in the suicide risk assessment and assigns a level of suicide risk that is indispensable for the choice of treatment and the management of patients with a high suicidal risk. In this article, we extend the suicide risk formulation model to patients with schizophrenia. Suicide risk formulation results from four different areas that help clinicians collect as much information as possible for the management of suicidal risk. The four distinct judgments comprise risk status (the risk relating to the specific group to which the patient belongs), risk state (the risk for the person compared with his baseline or another reference point in the course of his life), available resources (on whom the person can count during a crisis) and foreseeable events (which can exacerbate the crisis). In schizophrenia, the suicide risk formulation model allows the clinician to evaluate in depth the clinical context of the patient, the patient's own history and patient-specific opportunities for better choosing and applying suicide prevention strategies.

Employment among people with schizophrenia or bipolar disorder: A population-based study using nationwide registers

OBJECTIVE

To assess the employment rate and the related background factors among people with schizophrenia or bipolar disorder.

METHODS

We identified all people in Sweden aged 18-64 years diagnosed with schizophrenia or bipolar disorder in nationwide registers in the years 2006-2013. The identified individuals were grouped by main activity or source of income. The association between background factors and employment was analyzed with generalized estimating equations (GEE).

RESULTS

Three years before the first psychosis or bipolar disorder diagnosis, 24% of the individuals with schizophrenia and 45% of the individuals with bipolar disorder were employed. However, the employment rate dropped around the time of the first diagnosis. Five years later, 10% of the individuals with schizophrenia and 34% of the individuals with bipolar disorder were employed. The most important factors associated with employment after diagnosis were a high level of education, older age at the first registered diagnosis, no substance use disorder, and a low number of previous hospitalizations. Marriage or cohabiting, higher level of education, and higher age at the first diagnosis were associated with an increased employment rate especially among people with schizophrenia, and substance use was associated with a lower employment rate, especially among people with bipolar disorder. Men with bipolar disorder had a higher employment rate than women.

CONCLUSION

The employment rate is low among people with schizophrenia and higher among people with bipolar disorder. The association of background characteristics with employment was mostly in the same direction both in schizophrenia and in bipolar disorder.

Trajectories of occupational and social functioning in people with recent-onset non-affective psychosis enrolled in specialized early intervention services across New York state

BACKGROUND

Despite the benefits of early intervention services for the initial stages of psychosis ongoing impairments in functioning are common.

AIMS

To identify 1-year trajectories of occupational and social functioning in individuals enrolled in OnTrackNY, a statewide program offering early intervention services for recent-onset psychosis in community settings.

METHOD

We included 937 persons with recent-onset psychosis enrolled at 19 programs across New York State. Demographic, social and clinical data was collected at program entry and at 3, 6, 9 and 12 months. We used growth mixture models to identify occupational and social functioning trajectories and examined the association between trajectory class, baseline factors and symptoms during 1-year follow-up.

RESULTS

Four distinct trajectory classes of occupational and social functioning were identified. The converging (58.0%) class had disparate levels of functioning at baseline (low occupational, higher social) which eventually converged. The other classes had high-stable (14.8%), moderate-stable (17.8%) and low-improving (9.4%) trajectories. Female gender, educational attainment and private insurance status were significantly associated with the trajectory characterized by higher functioning, while living alone, homelessness, a longer period from psychosis onset to program enrollment, a schizophrenia diagnosis and cannabis use at enrollment were associated with the poorest trajectory. The differences in severity of symptoms by trajectory class diminished over time.

CONCLUSIONS

Trajectories of occupational and social functioning showed substantial variation, but overall, remained stable or improved during 1-year follow-up. The relationship between symptoms and occupational and social functioning attenuated after the acute treatment phase.

Schizophrenia and Epigenetic Aging Biomarkers: Increased Mortality, Reduced Cancer Risk, and Unique Clozapine Effects

BACKGROUND

Schizophrenia (SZ) is associated with increased all-cause mortality, smoking, and age-associated proteins, yet multiple previous studies found no association between SZ and biological age using Horvath's epigenetic clock, a well-established aging biomarker based on DNA methylation. However, numerous epigenetic clocks that may capture distinct aspects of aging have been developed. This study tested the hypothesis that altered aging in SZ manifests in these other clocks.

METHODS

We performed a comprehensive analysis of 14 epigenetic clocks categorized according to what they were trained to predict: chronological age, mortality, mitotic divisions, or telomere length. To understand the etiology of biological age differences, we also examined DNA methylation predictors of smoking, alcohol, body mass index, serum proteins, and cell proportions. We independently analyzed 3 publicly available multiethnic DNA methylation data sets from whole blood, a total of 567 SZ cases and 594 nonpsychiatric controls.

RESULTS

All data sets showed accelerations in SZ for the 3 mortality clocks up to 5 years, driven by smoking and elevated levels of 6 age-associated proteins. The 2 mitotic clocks were decelerated in SZ related to antitumor natural killer and CD8T cells, which may help explain conflicting reports about low cancer rates in epidemiological studies of SZ. One cohort with available medication data showed that clozapine is associated with male-specific decelerations up to 7 years in multiple chronological age clocks.

CONCLUSIONS

Our study demonstrates the utility of studying the various epigenetic clocks in tandem and highlights potential mechanisms by which mental illness influences long-term outcomes, including cancer and early mortality.

Association of Mental Disorder in Childhood and Adolescence With Subsequent Educational Achievement

IMPORTANCE

Onset of mental disorders during childhood or adolescence has been associated with underperformance in school and impairment in social and occupational life in adulthood, which has important implications for the affected individuals and society.

OBJECTIVE

To compare the educational achievements at the final examination of compulsory schooling in Denmark between individuals with and those without a mental disorder.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study was conducted in Denmark and obtained data from the Danish Civil Registration System and other nationwide registers. The 2 cohorts studied were (1) all children who were born in Denmark between January 1, 1988, and July 1, 1999, and were alive at age 17 years (n = 629 622) and (2) all children who took the final examination at the end of ninth grade in both Danish and mathematics subjects between January 1, 2002, and December 31, 2016 (n = 542 500). Data analysis was conducted from March 1, 2018, to March 1, 2019.

EXPOSURES

Clinical diagnosis by a psychiatrist of any mental disorder or 1 of 29 specific mental disorders before age 16 years.

MAIN OUTCOMES AND MEASURES

Taking the final examination at the end of ninth grade and mean examination grades standardized as z scores with differences measured in SDs (standardized mean grade difference).

RESULTS

Of the total study population (n = 629 622; 306 209 female and 323 413 male), 523 312 individuals (83%) took the final examination before 17 years of age and 38 001 (6%) had a mental disorder before that age. Among the 542 500 individuals (274 332 female and 268 168 male), the mean (SD) age was 16.1 (0.33) years for the females and 16.2 (0.34) years for the males. Among the 15 843 female and 22 158 male students with a mental disorder, a lower proportion took the final examination (0.52; 95% CI, 0.52-0.53) compared with individuals without a mental disorder (0.88; 95% CI, 0.88-0.88). Mental disorders affected the grades of male individuals (standardized mean grade difference, -0.30; 95% CI, -0.32 to -0.28) more than the grades of their female peers (standardized mean grade difference, -0.24; 95% CI, -0.25 to -0.22) when compared with same-sex individuals without mental disorders. Most specific mental disorders were associated with statistically significantly lower mean grades, with intellectual disability associated with the lowest grade in female and male students (standardized mean grade difference, -1.07 [95% CI, -1.23 to -0.91] and -1.03 [95% CI, -1.17 to -0.89]; P = .76 for sex differences in the mean grades). Female and male students with anorexia nervosa achieved statistically significantly higher grades on the final examination (standardized mean grade difference, 0.38 [95% CI, 0.32-0.44] and 0.31 [95% CI, 0.11-0.52]; P = .54 for sex differences in the mean grades) compared with their peers without this disorder. For those with anxiety, attachment, attention-deficit/hyperactivity, and other developmental disorders, female individuals attained relatively lower standardized mean grades compared with their male counterparts.

CONCLUSIONS AND RELEVANCE

Results of this study suggest that, in Denmark, almost all mental disorders in childhood or adolescence may be associated with a lower likelihood of taking the final examination at the end of ninth grade; those with specific disorders tended to achieve lower mean grades on the examination; and female, compared with male, individuals with certain mental disorders appeared to have relatively more impairment. These findings appear to emphasize the need to provide educational support to young people with mental disorders.

Individual Health Budgets in Mental Health: Results of Its Implementation in the Friuli Venezia Giulia Region, Italy

Background: Individual Health Budget (IHB) is an intervention for recovery in mental health services, providing personalized care for subjects with severe disorders and complex needs. Little is known on its effectiveness and on the criteria for its delivery. Methods: A total of 67 IHB beneficiaries and 61 comparators were recruited among service users of the Mental Health Department of the Trieste Healthcare Agency, Italy. Data included sociodemographic and clinical variables, type of IHB, and Health of the Nation Outcome Scale (HoNOS) scores. Results: A comparison between groups showed significant differences in several socioeconomic and clinical characteristics. Multivariate logistic regression showed that IHB was positively associated to the 20–49 age group, single status, unemployment, low family support, cohabitation with relatives or friends, diagnosis of personality disorder, and a higher number of hospitalizations. The IHB group was at a higher risk of severe problems related to aggressive or agitated behaviors (OR = 1.4), hallucinations and delusions (OR = 1.5), and impairment in everyday life activities (OR = 2.1). Conclusions: IHB was used in patients with severe clinical and social problems. More resources, however, may be aimed at the working and social axes. More research is needed to better assess clinical and social outcomes of IHB and to adjust their intensity in a longitudinal perspective in order to enhance cost-effectiveness.

Association Between Childhood Green Space, Genetic Liability, and the Incidence of Schizophrenia

Childhood exposure to green space has previously been associated with lower risk of developing schizophrenia later in life. It is unclear whether this association is mediated by genetic liability or whether the 2 risk factors work additively. Here, we investigate possible gene-environment associations with the hazard ratio (HR) of schizophrenia by combining (1) an estimate of childhood exposure to residential-level green space based on the normalized difference vegetation index (NDVI) from Landsat satellite images, with (2) genetic liability estimates based on polygenic risk scores for 19 746 genotyped individuals from the Danish iPSYCH sample. We used information from the Danish registers of health, residential address, and socioeconomic status to adjust HR estimates for established confounders, ie, parents' socioeconomic status, and family history of mental illness. The adjusted HRs show that growing up surrounded by the highest compared to the lowest decile of NDVI was associated with a 0.52-fold (95% confidence interval [CI]: 0.40 to 0.66) lower schizophrenia risk, and children with the highest polygenic risk score had a 1.24-fold (95% CI: 1.18 to 1.30) higher schizophrenia risk. We found that NDVI explained 1.45% (95% CI: 1.07 to 1.90) of the variance on the liability scale, while polygenic risk score for schizophrenia explained 1.01% (95% CI: 0.77 to 1.46). Together they explained 2.40% (95% CI: 1.99 to 3.07) with no indication of a gene-environment interaction (P = .29). Our results suggest that risk of schizophrenia is associated additively with green space exposure and genetic liability, and provide no support for an environment-gene interaction between NDVI and schizophrenia.

Employment-Related Factors of Forensic Psychiatric Outpatients with Psychotic Disorders

PURPOSE

Employment is important for forensic psychiatric patients with psychotic disorders, in terms of reduction in symptoms, improving the quality of life, and preventing re-offenses. However, few detailed studies on employment status in such patients exist. We aimed to determine the employment rate among forensic psychiatric outpatients with psychotic disorders and identify the factors associated with employment.

PATIENTS AND METHODS

The study population comprised 406 patients with psychotic disorders who completed a forensic outpatient treatment order, were aged <65 years at discharge from a forensic psychiatric ward and provided written informed consent. Psychotic disorders were defined as psychiatric disorders classified into F2 in the International Statistical Classification of Diseases and Related Health Problems, 10th edition. Demographic data were collected from the medical records of the inpatient treatment period. Prognostic data during the outpatient treatment order period was provided by the reintegration coordinators responsible for coordinating the patients' social environment during this period. Exploratory univariate and multivariable logistic regression analyses identified the factors associated with employment.

RESULTS

The mean age at discharge was 44.4±10.8 years. The mean follow-up period was 2.69±1.01 years. There were 4.6 times more men (n=334) than women (n=72). During the outpatient treatment order period, 56 of 406 participants achieved employment (13.8%). Participants who committed serious crime, including homicide, arson, robbery, and sexual assault, had a lower employment rate compared to participants who committed bodily injury crimes (multivariable odds ratio, 0.421; 95% confidence interval, 0.220-0.807). History of substance use and living with family after discharge from a forensic psychiatric ward positively contributed to employment.

CONCLUSION

The employment rate among forensic psychiatric outpatients with psychotic disorders was low and was similar to that reported in previous studies on general psychiatric patients with schizophrenia. Furthermore, serious criminal behavior negatively impacted employment.