Predictors of 10-year outcome of first-episode psychosis

Validating dimensions of psychosis symptomatology: Neural correlates and 20-year outcomes

Heterogeneity of psychosis presents significant challenges for classification. Between 2 and 12 symptom dimensions have been proposed, and consensus is lacking. The present study sought to identify uniquely informative models by comparing the validity of these alternatives. An epidemiologic cohort of 628 first-admission inpatients with psychosis was interviewed 6 times over 2 decades and completed an electrophysiological assessment of error processing at year 20. We first analyzed a comprehensive set of 49 symptoms rated by interviewers at baseline, progressively extracting from 1 to 12 factors. Next, we compared the ability of resulting factor solutions to (a) account for concurrent neural dysfunction and (b) predict 20-year role, social, residential, and global functioning, and life satisfaction. A four-factor model showed incremental validity with all outcomes, and more complex models did not improve explanatory power. The 4 dimensions-reality distortion, disorganization, inexpressivity, and apathy/asociality-were replicable in 5 follow-ups, internally consistent, stable across assessments, and showed strong discriminant validity. These results reaffirm the value of separating disorganization and reality distortion, are consistent with recent findings distinguishing inexpressivity and apathy/asociality, and suggest that these 4 dimensions are fundamental to understanding neural abnormalities and long-term outcomes in psychosis. (PsycINFO Database Record

Serum brain-derived neurotrophic factors in Taiwanese patients with drug-naïve first-episode schizophrenia: Effects of antipsychotics

OBJECTIVES

Brain-derived neurotrophic factors (BDNF) are known to be related to the psychopathology of schizophrenia. However, studies focussing on drug-naïve first-episode schizophrenia are still rare.

METHODS

Over a 5-year period, we investigated the serum BDNF levels in patients with first-episode drug-naïve schizophrenia and compared them to age- and sex-matched healthy controls. We also explored the association between antipsychotic doses, positive and negative syndrome scale (PANSS) scores, and serum BDNF levels before and after a 4-week antipsychotic treatment.

RESULTS

The baseline serum BDNF levels of 34 patients were significantly lower than those of the controls (df = 66, P = .001). Although the PANSS scores of 20 followed-up patients improved significantly after antipsychotic treatment, the elevation of the serum BDNF levels was not statistically significant (P = .386). In addition, Pearson's correlation test showed significant correlations between pre-treatment negative scale scores and percentage changes in BDNF (P = .002).

CONCLUSIONS

The peripheral BDNF levels in Taiwanese patients with drug-naïve first-episode schizophrenia, compared with healthy controls, did not elevate after antipsychotic treatment, and pre-treatment negative symptoms played a pivotal role in trajectories of serum BDNF levels. Large samples will be needed in future studies to verify these results.

Burden of illness of people with persistent symptoms of schizophrenia: A multinational cross-sectional study

BACKGROUND

Few studies have examined the impact of persistent symptoms of schizophrenia, especially with respect to patient-reported outcomes (PROs), carer burden and health economic impact.

AIMS

Analyse data relating to burden and severity of illness, functional impairment and quality of life for patients with persistent symptoms of schizophrenia.

METHODS

A cohort of stable outpatients with persistent symptoms of schizophrenia across seven countries were assessed in a multicentre, non-interventional, cross-sectional survey and retrospective medical record review using PRO questionnaires, clinical rating scales and carer questionnaires.

RESULTS

Overall, 1,421 patients and 687 carers were enrolled. Approximately two-thirds of patients had moderate/mild schizophrenia with more severe negative symptoms predominating. Patients showed impaired personal/social functioning and unsuitability for work correlated with various patient factors, most notably symptom-related assessments. Quality-of-life assessments showed 25% to ⩾30% of patients had problems with mobility, washing or dressing. Carer burden was also considerable, with carers having to devote an average of 20.5 hours per week and notable negative impact on quality-of-life measures. Healthcare resource utilisation for in-hospital, outpatient and other care provider visits was significant.

CONCLUSION

These results demonstrate the significant burden of schizophrenia for patients, carers and society and highlight the need for improved treatment approaches.

Duration of active psychosis and first-episode psychosis negative symptoms

AIM

Duration of untreated psychosis (DUP) has been associated with negative symptoms in several studies; however, longitudinal findings have been inconsistent. No previous study has accounted for active psychosis after presentation, although this could impact on outcomes in a manner similar to DUP.

METHODS

We measured Scale for the Assessment of Positive Symptoms at frequent intervals during the 12 months after initial presentation to determine the active psychosis duration for 230 individuals with first-episode psychosis. This duration was added to DUP prior to presentation to create a new variable, duration of active psychosis (DAP). Negative symptoms were divided into expressivity and motivation/pleasure domains as measured by Scale for the Assessment of Negative Symptoms (SANS). The relationship of DUP and DAP with negative symptoms at 24-month follow up was determined and confounders controlled for using regression analysis.

RESULTS

When DUP and DAP were compared as binary variables with long and short groups, 25.2% of individuals had differing category membership. DAP had a significant uncorrected association with both expressivity domain and motivation/pleasure domains at 24 months; however, relationship with DUP was not significant. DAP remained a significant predictor of 24-month expressivity domain after controlling for potential confounders.

CONCLUSIONS

Active psychosis after presentation is substantial, which is a limitation of DUP studies if active psychosis is considered as the key factor within DUP. DAP is a better predictor of negative symptoms than DUP at 2-year follow up, which suggests this concept requires further research.

Recovery style and stigma in psychosis: the healing power of integrating

INTRODUCTION

Persecutory delusions are a very common symptom in psychotic disorders and represent a considerable cost for both patients and for society. The way in which a person faces their psychotic disorder (i.e., recovery style) has impact on their recovery. The impact of coping style as a moderator in the course of their illness has not been studied sufficiently in persecutory delusions. In addition, internalised stigma is a common process in psychosis that not only might affect emotional distress, but might also shape recovery style. The goal of this study was to examine the moderator role of recovery style between internalised stigma and emotional distress in people with persecutory delusions.

METHODS

All 50 people with persecutory beliefs were assessed by the Recovery Style Questionnaire, the Beck Anxiety Inventory, Beck Depression Inventory, Second Edition, and Internalised Stigma of Mental Illness.

RESULTS

Moderation analysis showed that participants with a sealing-over recovery style had high levels of depression when they experienced internalised stigma and low levels of depression only when internalised stigma was low. However, participants with an integration recovery style presented similar levels of depression regardless of the level of their internalised stigma.

CONCLUSIONS

Findings suggest the moderator role of recovery style between internalised stigma and depression in people with persecutory delusions.

The impact of cognitive reserve in the outcome of first-episode psychoses: 2-year follow-up study

The concept of cognitive reserve (CR) suggests that the premorbid intelligence quotient (IQ), years of education and leisure activities provide more efficient cognitive networks and therefore allow a better management of some conditions associated to cognitive impairment. Fifty-two DSM-IV diagnosed FEP subjects were matched with 41 healthy controls by age, gender and parental socio-economic status. All subjects were assessed clinically, neuropsychologically and functionally at baseline and after a two-year follow-up. To assess CR at baseline, three proxies have been integrated: premorbid IQ, years of education-occupation and leisure activities. Higher CR was associated with better cognitive, functional and clinical outcomes at baseline. The CR proxy was able to predict working memory, attention, executive functioning, verbal memory and global composite cognitive score accounting for 48.9%, 19.1%, 16.9%, 10.8% and 14.9% respectively of the variance at two-year follow-up. CR was also significantly predictive of PANSS negative scale score (12.5%), FAST global score (13.4%) and GAF (13%) at two-year follow-up. In addition, CR behaved as a mediator of working memory (B=4.123) and executive function (B=3.298) at baseline and of working memory (B=5.034) at 2-year follow-up. An additional analysis was performed, in order to test whether this mediation could be attributed mainly to the premorbid IQ. We obtained that this measure was not enough by itself to explain this mediation. CR may contribute to neuropsychological and functional outcome. Specific programs addressed to improve cognition and functioning conducted at the early stages of the illness may be helpful in order to prevent cognitive and functional decline.

[Why and how to treat psychosis earlier?]

Chronic psychosis, as for instance schizophrenia, usually begins in young adulthood and may cause severe disability. It causes a mean loss of life expectancy of 22 years. Actual models of psychosis do not trace the beginning of psychosis to the first franc psychotic episode only, but to earlier symptoms. In a classical health system only considering the first psychotic episode, the mean duration of untreated illness (DUI) can last several years. Yet this DUI has a direct impact on the prognosis of the disease. Actual international recommendations prescribe to early detect and treat at risk mental states of psychosis, thus reducing DUI. Such an attitude also helps the patient to integrate care in a moment where she/he is fully in condition to consent and to adhere. Generalist practitioners are crucial actors of early detection. We describe here simple and standardized tools helping early detection of high-risk mental states of psychosis in primary care and the appropriate attitude to do it properly. Numerous countries have developed early detection and treatment centers for psychosis. It has been established that such interventions clearly decrease the risk of transition towards chronic psychosis and improve the prognosis. These recent data about early detection and intervention in psychosis are a major step forward in psychiatry practice. It is now necessary to largely develop such actions in France.

[Duration of untreated psychosis: A state-of-the-art review and critical analysis]

INTRODUCTION

Prognosis of schizophrenia has not significantly improved despite extensive research. There is often a relatively long delay between onset of symptoms and treatment initiation. Lately, duration of untreated psychosis (DUP), the time between the onset of psychosis and initiation of treatment, has been one of the most studied variables in patients presenting for a first psychotic episode in order to evaluate the impact of early intervention on the prognosis of schizophrenia. In the literature, a variety of criteria have been used to define both transition to psychosis and initiation of treatment. Furthermore, the dating of both of these variables is usually retrospective, further complicating the measurement of DUP.

METHODS

We conducted a comprehensive review about DUP using Pubmed and Google Scholar databases up to January 2015 using the following keywords "schizophrenia", "duration of untreated psychosis", "duration of untreated illness" and "early intervention". Papers were included if they were published in French or English.

RESULTS

The mean DUP was found to be 2 years but it can vary according to multiple factors such as denial of illness by the patient and family, withdrawal and isolation from friends and relatives, diagnostic errors, paranoid views of the mental health treatment systems, or negative symptoms. Long DUP may also be a correlate of poor premorbid functioning or of an insidiously unfolding psychosis. Considerable discrepancies exist in the way that DUP is estimated in different studies. Although the clinical interview remains the most common way of measuring DUP, so far there is no evidence for favoring one method over another. Regardless of measurement method, a longer DUP is found to be associated with poorer outcome in schizophrenia in both the short and long-term across a number of domains: symptoms severity, remission rates, the risk of relapse, global functioning and quality of life. Its role in functional outcome appears to be mediated largely by negative symptoms, for which there is still no effective treatment. A recent meta-analysis has shown that shorter DUP is associated with less severe negative symptoms at short and long-term follow-up, especially when DUP is shorter than 9 months. The mechanism of the relationship between DUP and outcome is still undefined. A hypothesis is that the shorter the DUP, the more likely the intervention is being applied during the period in which neurobiological deficit processes in schizophrenia are most active.

DISCUSSION

A study of the duration of untreated illness (DUI), which is defined as the DUP and the prodromal phase, seems necessary because results of studies evaluating the effect of early detection and intervention in individuals with clinical high risk for psychosis are promising. A number of interventions such as omega 3 fatty acids and integrated psychosocial interventions seem to delay transition in the at-risk population. However, replication studies are lacking, and a great proportion of at high-risk individuals will spontaneously remit or develop diseases other than chronic psychosis, making us question the advantages and disadvantages of a treatment. Taking into consideration the high prevalence of comorbidities in individuals referred for clinical high-risk state and their effect on the individual's functioning, future interventions in the field need to address not only the preventative efficacy on psychosis transition but also their effectiveness in improving the functioning of this population and their effect on the outcome of schizophrenia when transition to psychosis has occurred.

CONCLUSION

Despite the huge advances in the field of schizophrenia, many questions remain unanswered and huge efforts are still necessary to understand the pathophysiology of this illness in order to improve its outcome.

Metacognition in first-episode psychosis and its association with positive and negative symptom profiles

There is growing evidence that metacognitive abilities which include the ability to synthesize knowledge regarding mental states in self and others and use this ability to solve problems are impaired in non-affective psychosis and associated with positive and negative symptom severity. We sought to (a) investigate the severity of metacognitive impairments in first-episode psychosis (FEP) compared to non-clinical controls and (b) explore associations with positive and negative symptom profiles. Ninety-seven people with FEP were compared to 101 control persons. Metacognition was assessed with interviews and the Metacognitive assessment scale-abbreviated. Four groups based on positive and negative symptoms were identified by cluster analysis and compared on metacognition, childhood adversities, duration of untreated psychosis and premorbid social and academic adjustment. Those with high levels of negative symptoms had poorer metacognitive abilities. Those with high positive and low negative symptoms did not have poorer metacognitive abilities than those with low positive and negative symptoms. None of the other predictors differed between the groups. The FEP group had poorer metacognitive abilities than the control group. Inclusion of metacognition in psychosis models may improve our understanding of negative symptoms, while previous findings of a relation with positive symptoms may have been confounded. Implications for current interventions are discussed.

Impact of dopamine supersensitivity psychosis in treatment-resistant schizophrenia: An analysis of multi-factors predicting long-term prognosis

BACKGROUND

Although a variety of factors are known to be significantly related to poor prognosis in schizophrenia, their interactions remain unclear. Dopamine supersensitivity psychosis (DSP) is a clinical concept related to long-term pharmacotherapy and could be one of the key factors contributing to the development of treatment-resistant schizophrenia (TRS). The present study aims to explore the effect of DSP on progression to TRS.

METHODS

Two-hundreds and sixty-five patients were classified into either a TRS or Non-TRS group based on retrospective survey and direct interview. The key factors related to prognosis, including the presence or absence of DSP episodes, were extracted, and each factor was compared between the two groups.

RESULTS

All parameters except for the duration of untreated psychosis (DUP) were significantly worse in the TRS group compared to the Non-TRS group. In particular, the TRS group presented with a significantly higher rate of DSP episodes than the Non-TRS group. Regression analysis supported the notion that DSP plays a pivotal role in the development of TRS. In addition, deficit syndrome was suggested to be a diagnostic subcategory of TRS.

CONCLUSIONS

Our data confirmed that the key predicting factors of poor prognosis which have been established would actually affect somehow the development of TRS. In addition, the occurrence of a DSP episode during pharmacotherapy was shown to promote treatment refractoriness.

Understanding the impact of persistent symptoms in schizophrenia: Cross-sectional findings from the Pattern study

BACKGROUND

The high societal burden of schizophrenia is largely caused by the persistence of symptoms and accompanying functional impairment. To date, no studies have specifically assessed the course of persistent symptoms or the individual contributions of positive and negative symptoms to patient functioning. The cross-sectional analysis of the Pattern study provides an international perspective of the burden of schizophrenia.

METHODS

Clinically stable outpatients from 140 study centers across eight countries (Argentina, Brazil, Canada, France, Germany, Italy, Spain and the United Kingdom) were assessed using clinical rating scales: Positive and Negative Syndrome Scale (PANSS), Clinical Global Impression-Schizophrenia (CGI-SCH) Scale and the Personal and Social Performance (PSP) Scale. Additional measures included patient-reported outcomes, patient socio-demographic variables, living situation, employment and resource use.

RESULTS

Overall, 1379 patients were assessed and analyzed and had similar sociodemographic characteristics across countries, with 61.6% having persistent positive and/or negative symptoms. Positive and negative symptoms had been persistent for a mean of 9.6 and 8.9 years (SD: 8.8 and 9.6), respectively. Approximately 86% of patients had a functional disability classified as greater than mild. Patients with a higher PANSS Negative Symptom Factor Score were more likely to have a poorer level of functioning.

CONCLUSIONS

This analysis examines individual contributions of persistent positive and negative symptoms on patient functioning in different countries. A high prevalence of patients with persistent symptoms and functional impairment was a consistent finding across countries. Longitudinal observations are necessary to assess how to improve persistent symptoms of schizophrenia and overall patient functioning.

Clinical predictors of therapeutic response to antipsychotics in schizophrenia

The search for clinical outcome predictors for schizophrenia is as old as the field of psychiatry. However, despite a wealth of large, longitudinal studies into prognostic factors, only very few clinically useful outcome predictors have been identified. The goal of future treatment is to either affect modifiable risk factors, or use nonmodifiable factors to parse patients into therapeutically meaningful subgroups. Most clinical outcome predictors are nonspecific and/or nonmodifiable. Nonmodifiable predictors for poor odds of remission include male sex, younger age at disease onset, poor premorbid adjustment, and severe baseline psychopathology. Modifiable risk factors for poor therapeutic outcomes that clinicians can act upon include longer duration of untreated illness, nonadherence to antipsychotics, comorbidities (especially substance-use disorders), lack of early antipsychotic response, and lack of improvement with non-clozapine antipsychotics, predicting clozapine response. It is hoped that this limited capacity for prediction will improve as pathophysiological understanding increases and/or new treatments for specific aspects of schizophrenia become available.

Future-directed thinking in first-episode psychosis

OBJECTIVES

This study employed the Future Thinking Task (MacLeod et al., 2005, Br. J. Clin. Psychol., 44, 495) to investigate whether future-directed thinking in first-episode psychosis is significantly different from that of matched controls, and to identify its correlates in this patient group.

DESIGN

Cross-sectional, mixed-model, case-control design.

METHOD

Participants were 30 patients with first-episode psychosis and 27 matched controls. The Future Thinking Task was used to assess future-directed thinking in both groups. Anxiety and depression were also measured as well as self-report measures of hopelessness, suicide ideation and a measure of negative symptoms.

RESULTS

Individuals with psychosis were impaired in future-directed thinking in both positive and negative domains, particularly with respect to the coming year. Increased self-reported hopelessness was associated with reduced positive future thinking and increased negative future thinking. Increased positive future thinking was also associated with reduced severity of negative symptoms, whilst negative future thinking was associated with suicide ideation.

CONCLUSIONS

Individuals with first-episode psychosis show a reduction in positive future thinking in line with that seen in other clinical groups, but this is accompanied by an unexpected reduction in negative future thinking. The findings suggest a general disengagement with the future in this group that may affect recovery and functioning.

PRACTITIONER POINTS

Individuals with first-episode psychosis may benefit from interventions to help them engage with their future, in particular in the mid-range, up to 1 year. The Future Thinking Task may be a helpful addition to the assessment of suicide risk in those with first-episode psychosis. Decreased positive future thinking was associated with increased severity of negative symptoms, indicating a potential new treatment angle for this resistant aspect of psychosis. The cross-sectional design of this study does not allow for conclusions about the causal relationship between psychosis and future-directed thinking. This study investigated future-directed thinking in individuals with a range of psychotic illnesses employing a trans-diagnostic approach; therefore, conclusions cannot be drawn about the nature of future-directed thinking in individual psychotic disorders.

Long-term trajectories of positive and negative symptoms in first episode psychosis: A 10year follow-up study in the OPUS cohort

OBJECTIVE

Knowledge about course of illness can help clinicians to develop effective interventions and improve treatment outcomes. The goal of this study was to construct positive and negative symptom trajectories based on structured clinical assessments collected over 10years within a cohort of people with first episode psychosis.

METHOD

A cohort of 496 people with first episode psychosis (ICD-10, F20-28) originally recruited for the OPUS study (1998-2000) and treated in community psychiatric services were rated on clinical symptoms at 5 different occasions across ten years. Psychopathology was assessed using the Scales for Assessment of Positive and Negative Symptoms. Symptom trajectories were constructed using Latent Class Analysis.

RESULTS

Five distinct trajectories were identified for positive symptoms (response - 47%, delayed response - 12%, relapse - 15%, non-response - 13% and episodic response - 13%). Four distinct trajectories were identified for negative symptoms (response - 28%, delayed response - 19%, relapse - 26% and non-response - 27%). Multivariable regression analysis of baseline characteristics identified that longer duration of untreated psychosis (OR 1.27-1.47, p<0.05) and substance abuse (OR 3.47-5.90, p<0.01) were associated with poorer positive symptom trajectories (higher levels of psychotic symptoms) while poor social functioning (OR 1.34-5.55, p<0.05), disorganized symptoms (OR 2.01-2.38, p<0.05) and schizophrenia diagnosis (OR 5.70-8.86, p<0.05) were associated with poorer negative symptom trajectories (higher levels of negative symptoms). A proportion of people displayed significant changes in symptoms several years after diagnosis.

CONCLUSIONS

Trajectories of illness for positive and negative symptoms were heterogeneous among people with first episode psychosis. Positive symptoms showed a general pattern of reduction and stabilization over time while negative symptoms typically showed less variation over the ten years. Results have implications for the focus, timing and length of interventions in first episode psychosis.

Stages of recovery in early psychosis: Associations with symptoms, function, and narrative development

OBJECTIVES

This study sought to explore the links between recovery stages, symptoms, function, and narrative development among individuals with a recent onset of psychosis.

DESIGN

A qualitative longitudinal study was conducted including quantitative data at baseline.

METHODS

Forty-seven participants were administered the Indiana Psychiatric Illness Interview three times over 9 months and content analysis was performed. Participants also completed the Social Functioning Scale, the Brief Psychiatric Rating Scale--Expanded, the California Verbal Learning Test, and the Trailing Making Test at baseline. Descriptive discriminant analysis was performed.

RESULTS

Results suggested that participants were mostly in the first two stages of recovery (moratorium, awareness) and that being in the awareness, rather than moratorium, stage was associated, to a different extent, with richer narrative development, better levels of psychosocial function, less negative and positive symptoms, and more years of education. Furthermore, recovery appeared to be a stable process over the assessment period.

CONCLUSIONS

Recovery is a complex concept including objective and subjective aspects. In the recovery path of persons recently diagnosed with psychosis, social engagement, narrative development, and occupational functioning seem to be particularly important aspects. This study is a first step, and future research is needed with larger and more diverse participant pools, and assessments conducted over longer periods of time.

PRACTITIONER POINTS

As greater level of social engagement was the most robust predictor of membership in the awareness versus moratorium stage, treatment of early psychosis should include interventions targeting social relations and social skills. As greater narrative development was the second most robust predictor, enhancing it via psychotherapy could be a pertinent clinical goal.

Decrease of functioning in remitted and non-remitted patients 16 years after a first-episode schizophrenia

In schizophrenia, a better level of functioning has been generally associated with symptomatic remission. However, this association has been supported by cross-sectional studies or by studies with a short follow-up period. Forty-eight patients with schizophrenia were evaluated by the Positive and Negative Symptoms Scale and the Social and Occupational Functioning Assessment Scale (SOFAS) at the first episode and after a mean period of 16 years. At follow-up, patients were defined as remitters (R) or non-remitters (NR) according to the Remission Schizophrenia Working Group criteria. R (n = 18; 37.5%) compared to NR showed at the first episode a lower illness severity and a better level of functioning. A functional decline was found in both groups at follow-up, even though NR showed a more than twofold reduction than R. Better SOFAS scores at follow-up were predicted by baseline SOFAS score and less severe negative symptoms at follow-up. Schizophrenia implies a functional decline over time, regardless of the symptomatic remission status with negative symptoms playing a major role.

Ten-Year Outcomes of First-Episode Psychoses in the MRC ÆSOP-10 Study

It has long been held that schizophrenia and other psychotic disorders have a predominately poor course and outcome. We have synthesized information on mortality, clinical and social outcomes from the ÆSOP-10 multicenter study, a 10-year follow-up of a large epidemiologically characterized cohort of 557 people with first-episode psychosis. Symptomatic remission and recovery were more common than previously believed. Distinguishing between symptom and social recovery is important given the disparity between these; even when symptomatic recovery occurs social inclusion may remain elusive. Multiple factors were associated with an increased risk of mortality, but unnatural death was reduced by 90% when there was full family involvement at first contact compared with those without family involvement. These results suggest that researchers, clinicians and those affected by psychosis should countenance a much more optimistic view of symptomatic outcome than was assumed when these conditions were first described.

Negative symptoms and functioning during the first year after a recent onset of schizophrenia and 8 years later

BACKGROUND

Understanding the longitudinal course of negative symptoms, especially in relationship to functioning, in the early phase of schizophrenia is crucial to developing intervention approaches. The course of negative symptoms and daily functioning was examined over a 1-year period following a recent onset of schizophrenia and at an 8-year follow-up point.

METHODS

The study included 149 recent-onset schizophrenia patients who had a mean age of 23.7 (SD=4.4)years and mean education of 12.9 (SD=2.2)years. Negative symptom (BPRS and SANS) and functional outcome (SCORS) assessments were conducted frequently by trained raters.

RESULTS

After antipsychotic medication stabilization, negative symptoms during the first outpatient year were moderately stable (BPRS ICC=0.64 and SANS ICC=0.66). Despite this overall moderate stability, 24% of patients experienced at least one period of negative symptoms exacerbation. Furthermore, entry level of negative symptoms was significantly associated with poor social functioning (r=-.34, p<.01) and work/school functioning (r=-.25, p<.05) at 12months, and with negative symptoms at the 8-year follow-up (r=.29, p<.05).

DISCUSSION

Early negative symptoms are fairly stable during the first outpatient year, are predictors of daily functioning at 12months, and predict negative symptoms 8years later. Despite the high levels of stability, negative symptoms did fluctuate in a subsample of patients. These findings suggest that negative symptoms may be an important early course target for intervention aimed at promoting recovery.

Which aspects of long-term outcome are predicted by positive and negative symptoms in early-onset psychosis? An exploratory eight-year follow-up study

BACKGROUND

Early-onset psychoses show substantial variability of diagnostic and functional outcome. Finding reliable prognostic factors may allow to allocate resources to those with the worst prognosis. The aim of the study was to gain new insights regarding the potential value of baseline negative and positive symptoms as predictors of outcome in psychoses of early onset.

METHOD

Sixty-three patients with early-onset schizophrenia spectrum psychosis hospitalized in an adolescent psychiatry unit were assessed with the Positive and Negative Syndrome Scale during the index admission. Associations with diagnosis, illness course and functional outcome were analysed in mean 8 years of follow-up (range 3.4-13.5 years).

RESULTS

The mean age at the index admission and the follow-up was 16.6 ± 1.2 and 24.5 ± 3.0 years, respectively. A significant majority of subjects continued psychiatric treatment (95%) and had been readmitted (71%). The mortality rate was 3% (suicide and accident). Negative symptoms were related to mental health service utilization during the follow-up. General severity of symptoms, specifically positive and cognitive factors were associated with the diagnosis of schizophrenia and inversely with diagnostic shift outside the schizophrenia spectrum at the catamnesis. Poor impulse control at baseline was associated with worse functional outcome. The drug-free subgroup with no occupational/educational activity compared with the drug-treated subjects showed lower levels of baseline negative symptomatology.

CONCLUSION

The study findings suggest that in patients with early-onset psychosis negative and positive symptoms show a differential prognostic value. Pharmacotherapy may attenuate the effect of symptoms on functional outcome. These hypotheses need to be tested in future studies using confirmatory approaches.

Reappraising the long-term course and outcome of psychotic disorders: the AESOP-10 study

BACKGROUND

Studies of the long-term course and outcome of psychoses tend to focus on cohorts of prevalent cases. Such studies bias samples towards those with poor outcomes, which may distort our understanding of prognosis. Long-term follow-up studies of epidemiologically robust first-episode samples are rare.

METHOD

AESOP-10 is a 10-year follow-up study of 557 individuals with a first episode of psychosis initially identified in two areas in the UK (South East London and Nottingham). Detailed information was collated on course and outcome in three domains (clinical, social and service use) from case records, informants and follow-up interviews.

RESULTS

At follow-up, of 532 incident cases identified, at baseline 37 (7%) had died, 29 (6%) had emigrated and eight (2%) were excluded. Of the remaining 458, 412 (90%) were traced and some information on follow-up was collated for 387 (85%). Most cases (265, 77%) experienced at least one period of sustained remission; at follow-up, 141 (46%) had been symptom free for at least 2 years. A majority (208, 72%) of cases had been employed for less than 25% of the follow-up period. The median number of hospital admissions, including at first presentation, was 2 [interquartile range (IQR) 1-4]; a majority (299, 88%) were admitted a least once and a minority (21, 6%) had 10 or more admissions. Overall, outcomes were worse for those with a non-affective diagnosis, for men and for those from South East London.

CONCLUSIONS

Sustained periods of symptom remission are usual following first presentation to mental health services for psychosis, including for those with a non-affective disorder; almost half recover.

Long-term follow-up of all-cause and unnatural death in young people with first-episode psychosis

OBJECTIVE

To determine mortality-related estimates and causes of death in young people with first-episode psychosis (FEP), and to identify baseline predictors of mortality.

METHOD

Mortality outcomes in 723 young people presenting to an early psychosis service were prospectively ascertained up to 20 years. Predictors of all-cause and unnatural death were investigated using survival techniques.

RESULTS

Forty-nine participants died by study end. Most deaths (n=41) occurred within 10 years of service entry. All-cause mortality was 5.5% at 10 years, rising to 8.0% after 20 years. Unnatural death rates at 10 and 20 years were 5.0% and 5.9%, respectively. Three risk factors consistently predicted all-cause mortality and unnatural deaths.

CONCLUSION

A substantial proportion of excess mortality was due to non-suicide unnatural death, and, later, natural deaths. This suggests that mental health services should expand their current focus on suicide to incorporate strategies to prevent accidental death and promote healthier lifestyles.

Duration of untreated psychosis as predictor of long-term outcome in schizophrenia: systematic review and meta-analysis

BACKGROUND

Duration of untreated psychosis (DUP) is one of the few potentially modifiable predictors of outcomes of schizophrenia. Long DUP as a predictor of poor short-term outcome has been addressed in previous meta-analyses, but the long-term effects of DUP remain unclear.

AIMS

To analyse the associations between DUP and long-term outcomes of schizophrenia.

METHOD

A systematic literature search was performed using seven electronic databases and manual searches. Random effects weighted meta-analysis with correlation coefficients was used to pool the results.

RESULTS

We identified 3493 unique publications, from which 33 samples met our predefined selection criteria. Long DUP correlated statistically significantly with poor general symptomatic outcome, more severe positive and negative symptoms, lesser likelihood of remission and poor social functioning and global outcome (correlations 0.13-0.18). Long DUP was not associated with employment, quality of life or hospital treatment.

CONCLUSIONS

The small but mostly consistent correlation between long DUP and poor outcome indicates that early intervention in psychosis may have at least subtle positive effects on the long-term course of illness.

Psychotic disorder caused by traumatic brain injury

Psychosis is a rare and severe sequela of traumatic brain injury (TBI). This article assists clinicians in differential diagnosis by providing literature-based guidance with regard to use of the Diagnostic and Statistical Manual for Mental Disorders 5 criteria for this condition. This article also describes potential relationships between TBI and the development of a psychosis within the conceptualization of psychosis as a neurobehavioral syndrome.

Prospective relationship between duration of untreated psychosis and 13-year clinical outcome: a first-episode psychosis study

BACKGROUND

The adverse effects of a long duration of untreated psychosis (DUP) have been explored in numerous short-term studies. These studies support the development of early interventions that reduce treatment delay and promote recovery. However, the enduring impact of DUP is largely unknown, partly due to the paucity of prospective long-term studies. Although the DUP-outcome relationship is commonly assumed to be linear, the threshold effect has not been adequately examined.

OBJECTIVE

To explore the relationship between DUP and long-term symptomatic remission.

METHODS

This was a prospective study of a cohort of 153 first-episode psychosis patients in Hong Kong at the 13-year follow-up. The patients were categorized into short (≤30days), medium (31-180days) and long (>180days) DUP groups.

RESULTS

The long-term outcome was ascertained in 73% of the patients. Nearly half of the patients (47%) fulfilled the criteria for symptomatic remission. The short DUP group experienced a significantly higher remission rate over the course of the illness. The odds of long-term symptomatic remission was significantly reduced in the medium DUP (by 89%) and long DUP (by 85%) groups compared with the short DUP group. Further analysis showed that DUP had a specific impact on negative symptom remission.

CONCLUSION

The findings support the threshold theory that DUP longer than 30days adversely impacts the long-term outcome. The present study is one of the few studies that confirmed the enduring impact of DUP on long-term outcomes based on well-defined criteria and adequate statistical adjustment.

Trajectories of antipsychotic response in drug-naive schizophrenia patients: results from the 6-month ESPASS follow-up study

OBJECTIVE

The aim of this study was to explore any heterogeneity in the 6-month clinical response in patients with antipsychotic drug-naive schizophrenia and to determine predictors of that outcome.

METHOD

467 patients with antipsychotic drug-naive schizophrenia were included in France nationwide and followed up over 6 months. To identify trajectories of clinical response, a latent class growth analysis (LCGA) was performed using the Clinical Global Impression-Severity (CGI-S) scores at baseline, 1, 3, and 6 months. Regression models were used to identify predictors of trajectory membership.

RESULTS

Five trajectory groups were identified: a rapid response group (n = 45), a gradual response group (n = 204), patients remaining mildly ill (n = 133), patients remaining very ill (n = 23), and a group with unsustained clinical response (n = 62). Predictors of the 6-month clinical response were baseline CGI-S score (odds ratio: 3.1; 95% confidence interval, 2.1-4.4) and negative symptoms (OR, 1.5; 95% CI, 1.2-1.9). The sole predictor of rapid response as compared to gradual response was employment (OR, 2.5; 95% CI, 1.2-4.9).

CONCLUSION

Clinical response in patients with schizophrenia 6 months after a first-ever antipsychotic drug initiation is heterogeneous. Therapeutic strategies in first episode should take account of symptom severity and early clinical response, to maximize the chances of recovery.

Clinical outcomes of long-acting risperidone in recent versus long-term diagnosed Belgian schizophrenic patients: results from electronic Schizophrenia Treatment Adherence Registry (e-STAR) and Trial for the Initiation and Maintenance Of REmission in Schizophrenia with risperidone (TIMORES)

AIM

Potential differences in psychiatric clinical outcomes and hospitalization rates before and after the initiation of long-acting risperidone among recently and long-term diagnosed schizophrenia patients were studied.

METHODS

Data from two observational studies (Trial for the Initiation and Maintenance Of REmission in Schizophrenia with risperidone (TIMORES) and electronic Schizophrenia Treatment Adherence Registry (e-STAR)) were categorized by the recency of their diagnose and compared in several post hoc analyses. Clinical Global Impression of illness Severity (CGI-S) and Global Assessment of Functioning (GAF) scores, as well as symptoms of clinical deterioration (including hospitalization data) at baseline, 12-month (for TIMORES and e-STAR) and 24-month (for e-STAR) follow-up were analysed. Other outcome measures included discontinuation rate, employment status and remission attainment.

RESULTS

Statistically significantly differences between recent and long-term diagnosed schizophrenic patients at 12- and 24-month follow-up were found for CGI-S (between P < 0.01 and P ≤ 0.001) and GAF (P < 0.05) scores. Other differences between both schizophrenic patient groups were found for measures of clinical deterioration, employment status and full symptomatic remission rates at 1 year. Although no consistent difference was found between recent and long-term patient groups for hospitalization parameters, the difference in length of full hospitalization days was statistically significantly different (P < 0.01) between e-STAR 'Early' and 'Late' patient groups at both 12- and 24-month endpoints: the mean change from baseline was significantly greater for e-STAR 'Early' at 12 months, but greater for e-STAR 'Late' at 24 months.

CONCLUSIONS

The findings of the post hoc analyses support the significance of pharmacological interventions, such as long-acting risperidone, in addressing discontinuity issues, especially in recently diagnosed patients.

Short-term functional outcome and premorbid adjustment in clinical high-risk patients. Results of the EPOS project

PURPOSE

In patients with schizophrenia, premorbid psychosocial adjustment is an important predictor of functional outcome. We studied functional outcome in young clinical high-risk (CHR) patients and how this was predicted by their childhood to adolescence premorbid adjustment.

METHODS

In all, 245 young help-seeking CHR patients were assessed with the Premorbid Adjustment Scale, the Structured Interview for Prodromal Syndromes (SIPS) and the Schizophrenia Proneness Instrument (SPI-A). The SIPS assesses positive, negative, disorganised, general symptoms, and the Global Assessment of Functioning (GAF), the SPI-A self-experienced basic symptoms; they were carried out at baseline, at 9-month and 18-month follow-up. Transitions to psychosis were identified. In the hierarchical linear model, associations between premorbid adjustment, background data, symptoms, transitions to psychosis and GAF scores were analysed.

RESULTS

During the 18-month follow-up, GAF scores improved significantly, and the proportion of patients with poor functioning decreased from 74% to 37%. Poor premorbid adjustment, single marital status, poor work status, and symptoms were associated with low baseline GAF scores. Low GAF scores were predicted by poor premorbid adjustment, negative, positive and basic symptoms, and poor baseline work status. The association between premorbid adjustment and follow-up GAF scores remained significant, even when baseline GAF and transition to psychosis were included in the model.

CONCLUSION

A great majority of help-seeking CHR patients suffer from deficits in their functioning. In CHR patients, premorbid psychosocial adjustment, baseline positive, negative, basic symptoms and poor working/schooling situation predict poor short-term functional outcome. These aspects should be taken into account when acute intervention and long-term rehabilitation for improving outcome in CHR patients are carried out.

Apathy, poor verbal memory and male gender predict lower psychosocial functioning one year after the first treatment of psychosis

BACKGROUND

Apathy is a negative symptom associated with poor psychosocial functioning in schizophrenia but has not been sufficiently studied as predictor of poor functioning in first episode psychosis (FEP).

OBJECTIVE

The main aim of the current study was to evaluate if apathy predicts poor functioning after 1 year in FEP patients in the context of other clinical variables with influence on outcome.

METHOD

Sixty-four FEP patients completed an extensive clinical and neuro-psychological test battery at baseline and 1-year follow-up. Symptoms were assessed with the Positive and Negative Syndrome scale (PANSS), apathy with the shortened Apathy Evaluation Scale (AES-C-12) and psychosocial functioning with the functioning score from the split version of the Global Assessment of Functioning scale (GAF-F).

RESULTS

High levels of apathy, poor verbal memory and being male were the baseline variables that best predicted poor functioning at 1-year follow-up, explaining 34% of the variance in GAF-F. When PANSS negative factor was included in the analysis, the significance of AES-C-12 diminished.

CONCLUSION

These findings points to a robust role for apathy among the negative symptoms in the development of persisting psychosocial dysfunction in FEP and supports the current effort in targeting motivation to improve functioning.

Predictors of recovery in first episode psychosis: the OPUS cohort at 10 year follow-up

BACKGROUND

Recovery, the optimal goal in treatment, is the attainment of both symptomatic and functional remission over a sustained period of time. Identification of factors that promote recovery can help develop interventions that facilitate good outcomes for people with first episode psychosis.

AIM

To examine long-term outcomes within a cohort of people with first episode psychosis in relation to symptom remission, functioning and recovery, 10 years after diagnosis.

METHOD

The study had a prospective design. Participants from the OPUS trial (1998-2000) (n=496) completed a series of interviews and questionnaires to measure current levels of psychopathology and social/vocational functioning, ten years after diagnosis. Predictors of recovery were identified using socio-demographic and clinical characteristics collected at baseline.

RESULTS

A total of 304 participants were interviewed, giving a follow-up rate of 61%. A total of 42 people (14%) met the criteria for symptomatic and psychosocial recovery at 10 years. A multivariable binary logistic regression analysis indicated that baseline predictors accounted for 22% of the variance of full recovery. Lower severity of negative symptoms at baseline (Odds Ratio (OR) 0.53, 95% confidence interval CI 0.36-0.78, p<0.001) and earlier age of diagnosis (OR 0.92, 95% CI 0.86-0.99, p<0.05) predicted better rates of recovery at 10 years.

CONCLUSION

Results of this study indicated that negative symptoms could play a central role in the process of recovery from schizophrenia. A challenge for clinicians and researchers is to understand the mechanisms behind negative symptoms and develop interventions that can prevent or ameliorate these symptoms in order to promote recovery.

Onset Pattern and Long-Term Prognosis in Schizophrenia: 10-Year Longitudinal Follow-Up Study

BACKGROUND

Although the duration of untreated psychosis (DUP) plays an important role in the short-term prognosis of patients with schizophrenia, their long-term prognosis generally is not determined by DUP alone. It is important to explore how other clinical factors in the early stage are related to DUP and consequent disease courses.

METHODS

A total of 664 patients with untreated psychosis were surveyed for this study. At the first examination, we divided them into the severe positive symptoms cases (SC) or the less severe cases (NonSC) and compared the prognosis among the two groups after a 10-year follow-up. In all, 113 patients in the SC group and 43 patients in the NonSC group were follow-up completers.

RESULTS

Whereas DUP was not different between the two groups, patients with nonacute onset in both groups had significantly longer DUP than those in patients with acute onset. For all clinical measures, there was no difference in prognosis between the two groups or among the four groups classified by mode of onset (MoO) and initial severity of positive symptoms. However, the degree of improvement of global assessment of functioning (GAF) was significantly smaller in the NonSC-nonacute group than in the SC-acute and SC-nonacute groups.

CONCLUSIONS

These results suggest that neither DUP nor MoO alone necessarily affects the initial severity of positive symptoms. Moreover, it is possible that patients with low impetus of positive symptoms onset within long DUP experience profound pathologic processes. Therefore, the current study results indicated that long DUP and nonacute onset were related to poor long-term prognosis, regardless of initial positive symptoms.

Mechanisms Underlying Auditory Hallucinations-Understanding Perception without Stimulus

Auditory verbal hallucinations (AVH) are a common phenomenon, occurring in the “healthy” population as well as in several mental illnesses, most notably schizophrenia. Current thinking supports a spectrum conceptualisation of AVH: several neurocognitive hypotheses of AVH have been proposed, including the “feed-forward” model of failure to provide appropriate information to somatosensory cortices so that stimuli appear unbidden, and an “aberrant memory model” implicating deficient memory processes. Neuroimaging and connectivity studies are in broad agreement with these with a general dysconnectivity between frontotemporal regions involved in language, memory and salience properties. Disappointingly many AVH remain resistant to standard treatments and persist for many years. There is a need to develop novel therapies to augment existing pharmacological and psychological therapies: transcranial magnetic stimulation has emerged as a potential treatment, though more recent clinical data has been less encouraging. Our understanding of AVH remains incomplete though much progress has been made in recent years. We herein provide a broad overview and review of this.

Basic treatment principles for psychotic disorders in patients with epilepsy

In patients with epilepsy, coexisting psychoses, either interictal (IIP) or postictal (PIP), are associated with serious disturbance in psychosocial function and well-being, and often require the care of a specialist. Unfortunately, evidence-based treatment systems for psychosis in patients with epilepsy have not yet been established. This article aims to propose concise and practical treatment procedures for IIP and PIP based on currently available data and international consensus statements, and primarily targeting nonpsychiatrist epileptologists who are often the first to be involved in the management of these complex patients. Accurate and early diagnosis of IIP and PIP and their staging in terms of acuity and severity form the essential first step in management. It is important to suspect the presence of psychosis whenever patients manifest unusual behavior. Knowledge of psychopathology and both individual and epilepsy-related vulnerabilities relevant to IIP and PIP facilitate early diagnosis. Treatment for IIP involves (1) obtaining consent to psychiatric treatment from the patient, whenever possible, (2) optimization of antiepileptic drugs, and (3) initiation of antipsychotic pharmacotherapy in line with symptom severity and severity of behavioral and functional disturbance. Basic psychosocial interventions will help reinforce adherence to treatment and should be made available. Due consideration must be given to patients' ability to provide informed consent to treatment in the short term, with the issue being revisited regularly over time. Given the often prolonged and recurrent nature of IIP, treatment frequently needs to be long-term. Treatment of PIP consists of two aspects, that is, acute protective measures and preventive procedures in repetitive episodes. Protective measures prioritize the management of risk in the early stages, and may involve sedation with or without the use of antipsychotic drugs, and the judicious application of local mental health legislation if appropriate. As for preventative procedures, optimizing seizure control by adjusting antiepileptic drugs or by surgical treatment is necessary.

Depressive symptoms in first episode psychosis: a one-year follow-up study

BACKGROUND

Depressive symptoms are common in patients with first episode psychosis (FEP) and have serious consequences for them. The main aims of this study were to examine the course of depression in FEP patients and explore whether any patient characteristics at baseline predicts depressive symptoms after one year.

METHOD

A total of 198 FEP patients with schizophrenia spectrum disorders were assessed for depressive symptoms with Calgary Depression Scale for Schizophrenia (CDSS) at baseline and 127 were followed for one year. A CDSS score [greater than or equal to] 6 was used as a cut-off score for depression.

RESULTS

Approximately 50% of the patients were depressed (CDSS[greater than or equal to]6) at baseline. At follow-up approximately 35% had depression. The course of depressive symptoms varied, 26% was depressed at both baseline and follow-up, 9% became depressed during the follow-up, 22% remitted from depression during the 12 months and 43% was neither depressed at baseline nor at follow-up. Poor childhood social functioning, long duration of untreated psychosis (DUP) and depressive symptoms at baseline predicted depression at 12 months follow-up.

CONCLUSION

Depressive symptoms are frequent in the first year after onset of psychosis. Patients with poor social functioning in childhood, long DUP and depressive symptoms at baseline are more prone to have depressive symptoms after one year. These patients should be identified and proper treatment provided.

Early detection, early symptom progression and symptomatic remission after ten years in a first episode of psychosis study

BACKGROUND

Poor symptom outcome remains a challenge in psychosis: At least 50% of first-episode patients continue to have positive and/or negative symptoms after ten years.

OBJECTIVE

To investigate rates, early predictors and early symptom progression of long-term non-remitted psychosis in an early detection study.

METHODS

Symptomatic remission according to new international criteria was assessed in 174 patients at ten-year follow-up. Remitted and non-remitted patients were compared on early symptom progression, and logistic regression was applied to predict non-remission.

RESULTS

At ten years, 50% of patients were in symptomatic remission. Non-remission was predicted by positive symptoms at inclusion and during the first year of treatment. Of individual symptoms only hallucinations were significantly predictive of ten-year non-remission. Early symptom differences were not reflected by differences in treatment.

CONCLUSIONS

Long-term symptomatic non-remission is associated with early positive symptoms. More assertive intervention may be needed in patients who do not respond robustly in the first year of treatment, whether or not they have been detected "early".

Comparison of first-episode and chronic patients diagnosed with schizophrenia: symptoms and childhood trauma

AIM

There has been considerable interest in identifying and addressing the specific needs of early-episode patients diagnosed with schizophrenia in the hope that by addressing such needs early, chronic disabilities can be avoided.

METHODS

One hundred twenty-eight early-episode and 571 chronic patients were compared on socio-demographic characteristics, clinical symptoms and history of childhood trauma. Symptoms were measured with the Positive and Negative Syndrome Scale (PANSS), and trauma with the short version of the Childhood Trauma Questionnaire.

RESULTS

First-episode patients scored 9.3% higher than chronic patients on the PANSS positive symptom scale and 16.3% lower on the negative symptom scale. More first episode patients reported childhood sexual abuse (P = 0.033); however, fewer reported childhood emotional neglect (P = 0.01). Childhood trauma was associated with positive symptoms, specifically with hallucinations in first-episode patients (r = 0.174; P = 0.049). Moreover, fewer parents of first episode patients were living alone (P = 0.008). On multiple logistic regression, the first-episode patients were younger (odds ratio = 0.92), had higher PANSS positive symptom scores (odds ratio 1.04) and lower negative symptom scores (odds ratio 0.948 recalculate).

CONCLUSIONS

More positive symptoms, fewer negative symptoms, less isolated parents and greater risk of childhood sexual abuse might warrant attention in first episode schizophrenia and perhaps should be a focus for the development of targeted interventions.

Association between the duration of untreated psychosis and short- and long-term outcome in schizophrenia within the Northern Finland 1966 Birth Cohort

BACKGROUND

Long duration of untreated psychosis (DUP) may relate to poor outcome in schizophrenia. However, the associations between DUP and outcomes, particularly in later course of illness, remain unclear. Our aim was to explore the associations between DUP and short- and long-term outcomes in schizophrenia.

METHODS

Data was collected for subjects with schizophrenia (n=89) in the population-based Northern Finland 1966 Birth Cohort. DUP was obtained from medical records, and its associations with short- (under 2years) and long-term clinical and social outcomes were assessed extending to 20years after the onset of the illness.

RESULTS

Longer DUP predicted longer length of first hospitalisation and increased the risk of rehospitalisation during the first two years. Longer DUP associated with decreased probability of disability pension, smaller amount of time spent in hospital, and higher proportion of time at work during the first 10years of the follow-up.

CONCLUSIONS

Regarding early outcome, long DUP may be a modest marker and proxy measure of a more severe clinical phenotype. The divergent results of earlier studies and the association between long DUP and better long-term outcome in our study, indicate that the length of DUP does not necessarily predict poor outcome in long-term follow-up. This may also be due to methodical difficulties, e.g. insufficient power and residual confounding linked to long follow-up studies.

Prospective relationship of duration of untreated psychosis to psychopathology and functional outcome over 12 years

BACKGROUND

The duration of untreated psychosis is well recognised as an independent predictor of symptomatic and functional outcome in the short term and has facilitated the development of worldwide early intervention programmes. However, the extent and mechanisms by which it might influence prognosis beyond a decade remain poorly understood.

METHODS

The authors examined the relationship between duration of untreated psychosis and outcome 12years after a first episode of psychosis and assessed whether its relationship with function is affected by symptoms in a prospective, 12-year follow-up of an epidemiologically-based inception cohort.

RESULTS

Longer duration of untreated psychosis predicted poorer remission status, more severe positive and negative symptoms, and greater impairment in general functioning, social functioning and quality of life at 12years on standardised measures, independent of other factors at baseline. It was not associated with gainful employment, for which education was the only predictor, or independent living, for which age was the only predictor. The relationship between duration of untreated psychosis and functional outcome was mediated by concurrent psychopathology, particularly negative symptoms.

CONCLUSIONS

These results provide qualified support for the potential long-term benefit of reduction in the duration of untreated psychosis in terms of improvement in symptoms and functional outcome. Its failure to predict real-life outcomes such as independent living and gainful employment could reflect the importance of pre-existing socio-cultural factors such as individual opportunity. The relationship between duration of untreated psychosis and negative symptoms was largely responsible for its effect on function, suggesting a possible long-term protective mechanism against disability.

Do all schizophrenia patients need antipsychotic treatment continuously throughout their lifetime? A 20-year longitudinal study

BACKGROUND

The prevailing standard of care in the field involves background assumptions about the importance of prolonged use of antipsychotic medications for all schizophrenia (SZ) patients. However, do all SZ patients need antipsychotics indefinitely? Are there factors that help to identify which SZ patients can enter into prolonged periods of recovery without antipsychotics? This 20-year longitudinal research studied these issues.

METHOD

A total of 139 early young psychotic patients from the Chicago Follow-up Study, including 70 patients with SZ syndromes and 69 with mood disorders, were assessed, prospectively, at the acute phase and then followed up six times over the next 20 years. Patients were assessed with standardized instruments for major symptoms, psychosocial functioning, personality, attitudinal variables, neurocognition and treatment.

RESULTS

At each follow-up, 30-40% of SZ patients were no longer on antipsychotics. Starting at the 4.5-year follow-ups and continuing thereafter, SZ patients not on antipsychotics for prolonged periods were significantly less likely to be psychotic and experienced more periods of recovery; they also had more favorable risk and protective factors. SZ patients off antipsychotics for prolonged periods did not relapse more frequently.

CONCLUSIONS

The data indicate that not all SZ patients need treatment with antipsychotics continuously throughout their lives. SZ patients not on antipsychotics for prolonged periods are a self-selected group with better internal resources associated with greater resiliency. They have better prognostic factors, better pre-morbid developmental achievements, less vulnerability to anxiety, better neurocognitive skills, less vulnerability to psychosis and experience more periods of recovery.

Does duration of untreated psychosis predict very long term outcome of schizophrenic disorders? results of a retrospective study

BACKGROUND

Studies performed to assess the relevance of duration of untreated psychosis (DUP) as a predictor of long-term outcome (i.e. follow-ups of ten years or more) are somewhat limited. The aim of this study was to evaluate the potential association between DUP and very long-term outcome (16-33 yrs) of schizophrenia by means of a retrospective design.

METHODS

Retrospective data obtained from clinical records were collected regarding DUP and outcome variables (number of hospitalizations; number of attempted suicides; course of illness; GAF scores at last observation) for a cohort of 80 outpatients (52 Males, 28 Females, mean age 51.0+/-11.58 years) affected by schizophrenia according to DSMIVTR attending a university community mental health centre.

RESULTS

Mean duration of follow up was 25.2 +/- 8.68 years; mean duration of untreated psychosis was 49.00 months (range 1-312 mo), with no significant difference according to gender. Patients with a shorter DUP (=/< 1 year) displayed more frequent "favourable" courses of illness (28.9% vs 8.6%) (p = 0.025), more frequent cases with limited (=/< 3) number of hospital admissions (85.7% vs 62.1%) (p = 0.047) and a better functioning (mean GAF score = 50.32+/-16.49 vs 40.26+/-9.60, p = 0.002); regression analyses confirmed that shorter DUP independently predicted a more positive outcome in terms of number of hospital admissions, course of illness, functioning (GAF scores).

CONCLUSION

A shorter DUP appears to act as a significant predictor of better outcome in schizophrenia even in the very long-term.

Social functioning in early psychosis: are all the domains predicted by the same variables?

AIM

The study aims to determine the predictive value of negative symptoms, depression, short-term verbal learning and gender on three areas of social functioning--social life, vocational functioning and independent living skills--in a sample of 88 individuals with early psychosis.

METHODS

Participants were recruited from early psychosis intervention programmes and community mental health clinics in British Columbia, Canada, and completed the following measures: client's assessment of strengths, interests, and goals, brief psychiatric rating scale, Beck depression inventory and California verbal learning task.

RESULTS

Multiple linear regressions revealed that: more negative symptoms and higher depression predicted a less active social life; more negative symptoms and poorer short-term verbal learning ability predicted lower vocational functioning; and more negative symptoms and male gender predicted lower independent living skills.

CONCLUSION

Results suggest that negative symptoms are predictive of all three areas of functioning but that specific variables add significant unique variance to individual areas of social functioning. Although a global social functioning score can be considered useful, greater precision can be gained by the use of domain-specific measures.

Flat affect and social functioning: a 10 year follow-up study of first episode psychosis patients

BACKGROUND

Affective flattening has been described as enduring, but long term follow-up studies of first episode psychosis patients are lacking.

OBJECTIVE

The aim of this study was to follow the symptom development of flat affect (FA), over a 10 year follow-up period, with focus on prevalence, predictors and outcome factors including social functioning.

METHODS

Three-hundred-and-one patients with FEP were included at baseline, 186 participated in the 10 year follow-up. These were followed on PANSS item N1 (FA) from baseline through 5 follow-up assessments over 10 years. Patients were grouped as having never-present, improving, deteriorating, fluctuating or enduring FA. The groups were compared on baseline variables, variables at 10 year follow-up, and social functioning throughout the follow-up period.

RESULTS

Twenty nine percent never displayed FA, 66% had improving, deteriorating or fluctuating FA, while 5% of patients had enduring FA. Premorbid social function predicted enduring FA. The patients with enduring, fluctuating and deteriorating FA did poorer on all outcome variables, including remission and recovery rates. The enduring FA group did significantly poorer in social functioning over the 10 year period.

CONCLUSIONS

FA is expressed at some point of time in the majority of FEP patients in a 10 year follow-up period, and appears more fluctuant than expected from the relevant literature. FA is associated with poorer outcome after 10 years, and enduring FA to poorer social function at all points of assessment.

Jeune, urbain… mais psychotique : l’importance du travail de proximité

La psychose débutante non traitée occasionne beaucoup de souffrance et son impact se répercute à divers degrés sur le fonctionnement de la personne atteinte. Lorsqu’elle survient dans un milieu de centre-ville, un défi supplémentaire s’impose puisque plusieurs jeunes vivent dans des conditions précaires, instables et sont désaffiliés. Il faut adapter l’organisation des soins pour éviter un retard dans l’identification et le traitement de la psychose. Cet article présente différentes pistes de solution en décrivant la Clinique JAP du CHUM, clinique d’intervention précoce pour la psychose, qui offre des services intégrés visant à optimiser l’évolution. Pour favoriser l’adhésion au traitement, il importe d’offrir un climat accueillant et convivial, d’avoir un cadre d’intervention flexible et de faire preuve d’un espoir optimiste mais réaliste. Des interventions intensives offertes par une équipe interdisciplinaire spécialisée, en collaboration avec les différents acteurs communautaires, doivent être mises en place de façon proactive afin d’abréger le délai du traitement et d’éviter des conséquences désastreuses de la psychose.

Practical guidelines on the use of paliperidone palmitate in schizophrenia

OBJECTIVE

Paliperidone palmitate is an atypical long-acting injectable (LAI) antipsychotic that has been approved for use in the US, EU, Australia and numerous other countries for acute and maintenance therapy of schizophrenia. LAI antipsychotics are often viewed as a 'last-resort' treatment for difficult-to-treat patients, however this article considers their role more broadly in the management of partial or non-adherence in schizophrenia.

METHOD

A search of MedLine, CTR and PsychInfo was conducted to identify relevant publications and clinical trials (search term 'paliperidone palmitate', up to December 2010). The findings were discussed in a number of teleconferences and the manuscript was finalized with a face-to-face meeting of the authors group.

MAIN FINDINGS

Relapse prevention in schizophrenia requires a comprehensive approach to treatment, which includes antipsychotic medication and psychosocial measures as well as family and/or carer involvement. Good symptom control and the interconnected issue of treatment adherence are arguably the most crucial factors for success. Carer and patient feedback should be carefully considered. Negotiation about commencing LAI therapy done early in course of disease is easier than many clinicians believe, although it is not often attempted in practice. Paliperidone palmitate is useful in both the acute and maintenance phases of treatment.

COMMENTARY

A case-based approach is presented to suggest various opportunities where use of paliperidone palmitate could be considered within the disease course of schizophrenia.

CONCLUSIONS

Paliperidone palmitate offers some advantages in terms of tolerability, simplicity of treatment initiation and long duration between injections. The consensus of the authors is that rather than reserving paliperidone palmitate for use in difficult-to-treat or refractory patients, it could be used to promote adherence and prevent relapse earlier in the course of the illness.

Apathy in first episode psychosis patients: a ten year longitudinal follow-up study

BACKGROUND

Apathy is a common symptom in first episode psychosis (FEP), and is associated with poor functioning. Prevalence and correlates of apathy 10 years after the first psychotic episode remain unexplored.

OBJECTIVE

The aims of the study were twofold: 1) to examine prevalence and predictors of apathy at 10 years, and 2) to examine the relationship between apathy at 10 years and concurrent symptoms, functioning and outcome, including subjective quality of life.

METHODS

Three-hundred-and-one patients with FEP were included at baseline, 186 participated in the 10 year follow-up. Of these, 178 patients completed the Apathy Evaluation Scale (AES-S-Apathy). Patients were classified as having apathy (AES-S-Apathy≥27) or not. The relationship between apathy and baseline variables (Demographics, Diagnosis, Duration of Untreated Psychosis), measures of symptomatology (Positive and Negative Syndrome Scale, Calgary Depression Scale for Schizophrenia), functioning (Global Assessment of Functioning Scale, Strauss Carpenter Level of Functioning Scale) and subjective quality of life (Lehman's Quality of Life Interview) were estimated through correlation analyses and blockwise multiple hierarchical regression analysis.

RESULTS

Nearly 30% of patients met the threshold for being apathetic at follow-up. No baseline variables predicted apathy significantly at 10 years. Apathy was found to contribute independently to functioning and subjective quality of life, even when controlling for other significant correlates.

CONCLUSIONS

Apathy is a common symptom in a FEP cohort 10 years after illness debut, and its presence relates to impaired functioning and poorer subjective quality of life.

Evaluation of secondary school teachers' knowledge about psychosis: a contribution to early detection

AIMS

We sought to evaluate secondary school teachers' knowledge about psychosis and their level of interest in this topic given the key role they may be able to play in the early detection of psychosis.

METHODS

A questionnaire survey of 268 secondary school teachers from eight secondary schools within the Azienda Sanitaria Locale Rome/E and Rome/A catchment areas (two of the five city health districts) in Rome. Teachers were asked to complete the Italian version Esperienza e Conoscenza delle Difficoltò Sociali ed Emotive dei Giovani of the Knowledge and Experience of Social Emotional Difficulties among Young people self-report questionnaire that investigates the diagnosis, age of onset, aetiology, prognosis and treatment of psychosis. They were also asked about their experience with pupils with possible psychosis.

RESULTS

Most of teachers were able to recognize psychotic symptoms from a case vignette. Approximately 25% of the teachers had experienced a pupil with possible symptoms of psychosis. However, teachers displayed little awareness of psychiatric community services available for young people.

CONCLUSIONS

Our study shows that teachers may play an important role in early detection and psychosis prevention strategies. The teachers also displayed a keen interest in gaining a deeper knowledge of early psychotic signs and in cooperating closely with a mental health specialist to obtain guidance and support when faced with serious mentally ill pupils.

The role of treatment delay in predicting 5-year outcomes in an early intervention program

BACKGROUND

Past research on the relationship between treatment delay and outcomes for first-episode psychosis has primarily focused on the role of duration of untreated psychosis (DUP) in predicting symptomatic outcomes up to 2 years. In the current study we examine the influence of both DUP and duration of untreated illness (DUI) on symptoms and functioning at 5 years follow-up while controlling for other early characteristics.

METHOD

A total of 132 patients with first-episode psychosis and treated in an early intervention program were prospectively followed up for 5 years. Outcomes assessed included positive and negative symptoms, overall functioning, weeks on disability pension and weeks of full-time competitive employment.

RESULTS

While DUP showed a significant correlation with level of positive symptoms at follow-up, this was not independent of pre-morbid social adjustment. DUI emerged as a more robust independent predictor of negative symptoms, social and occupational functioning and use of a disability pension.

CONCLUSIONS

Delay between onset of non-specific symptoms and treatment may be a more important influence on long-term functioning for first-episode patients than DUP. This suggests the possible value of treating such signs and symptoms as early as possible regardless of the effectiveness of such interventions in reducing likelihood or severity of psychotic symptoms.

Duration of untreated illness in schizophrenia is not associated with 5-year brain volume change

OBJECTIVES

Evidence for an association between duration of untreated illness (DUI) with clinical and functional outcome or brain volume (change) in schizophrenia patients is inconclusive. We aimed to investigate the relationship between DUI, outcome and brain volume at illness onset or brain volume change during the first five years of the illness in first-episode patients.

METHODS

Magnetic resonance images were acquired at baseline (T0) and after 5-year (T5) of 57 schizophrenia patients. Correlations were calculated in patients between brain volume (change), DUI and outcome variables.

RESULTS

We found no significant correlation between DUI and brain volume (change) in schizophrenia patients. A longer DUI was significantly correlated with higher PANSS scores at T0 and T5, and with higher scores on the Camberwell Assessment of Need scale at T5. Baseline volume of the cerebrum and lateral ventricles, and cerebellum volume (change) were associated with PANSS scores at T0 and T5.

CONCLUSION

Although clinical outcome is associated with both brain volume (change) and DUI, we found no evidence for a relationship between DUI and brain volume (change). DUI and baseline brain volume or 5-year brain volume (change) seem to explain different parts of the variation in clinical outcome.