Acute and transient psychotic disorders: precursors, epidemiology, course and outcome

Incidence of schizophrenia and other psychoses in England, 1950-2009: a systematic review and meta-analyses

BACKGROUND

We conducted a systematic review of incidence rates in England over a sixty-year period to determine the extent to which rates varied along accepted (age, sex) and less-accepted epidemiological gradients (ethnicity, migration and place of birth and upbringing, time).

OBJECTIVES

To determine variation in incidence of several psychotic disorders as above.

DATA SOURCES

Published and grey literature searches (MEDLINE, PSycINFO, EMBASE, CINAHL, ASSIA, HMIC), and identification of unpublished data through bibliographic searches and author communication.

STUDY ELIGIBILITY CRITERIA

Published 1950-2009; conducted wholly or partially in England; original data on incidence of non-organic adult-onset psychosis or one or more factor(s) pertaining to incidence.

PARTICIPANTS

People, 16-64 years, with first -onset psychosis, including non-affective psychoses, schizophrenia, bipolar disorder, psychotic depression and substance-induced psychosis.

STUDY APPRAISAL AND SYNTHESIS METHODS

Title, abstract and full-text review by two independent raters to identify suitable citations. Data were extracted to a standardized extraction form. Descriptive appraisals of variation in rates, including tables and forest plots, and where suitable, random-effects meta-analyses and meta-regressions to test specific hypotheses; rate heterogeneity was assessed by the I²-statistic.

RESULTS

83 citations met inclusion. Pooled incidence of all psychoses (N = 9) was 31.7 per 100,000 person-years (95%CI: 24.6-40.9), 23.2 (95%CI: 18.3-29.5) for non-affective psychoses (N = 8), 15.2 (95%CI: 11.9-19.5) for schizophrenia (N = 15) and 12.4 (95%CI: 9.0-17.1) for affective psychoses (N = 7). This masked rate heterogeneity (I²: 0.54-0.97), possibly explained by socio-environmental factors; our review confirmed (via meta-regression) the typical age-sex interaction in psychosis risk, including secondary peak onset in women after 45 years. Rates of most disorders were elevated in several ethnic minority groups compared with the white (British) population. For example, for schizophrenia: black Caribbean (pooled RR: 5.6; 95%CI: 3.4-9.2; N = 5), black African (pooled RR: 4.7; 95%CI: 3.3-6.8; N = 5) and South Asian groups in England (pooled RR: 2.4; 95%CI: 1.3-4.5; N = 3). We found no evidence to support an overall change in the incidence of psychotic disorder over time, though diagnostic shifts (away from schizophrenia) were reported.

LIMITATIONS

Incidence studies were predominantly cross-sectional, limiting causal inference. Heterogeneity, while evidencing important variation, suggested pooled estimates require interpretation alongside our descriptive systematic results.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Incidence of psychotic disorders varied markedly by age, sex, place and migration status/ethnicity. Stable incidence over time, together with a robust socio-environmental epidemiology, provides a platform for developing prediction models for health service planning.

Diagnostic stability over 2 years in patients with acute and transient psychotic disorders

OBJECTIVE

The nosological entity of acute and transient psychotic disorders (ATPD) as an independent diagnostic category has become a subject of controversial opinions. The present study aimed to follow-up the diagnostic stability of index episode of ATPD and to examine the influence of clinical and socio-demographic factors on the ATPD prognosis.

METHOD

A sample of 153 (60.1% females; mean age 27.8 ± 8.2) first-admitted patients with ATPD was followed over 2 years. The clinical manifestations, global functioning and quality of life were regularly evaluated during follow-up period.

RESULTS

At the end of follow-up, the overall stability rate of ATPD, excluding the cases not readmitted until last assessment, reached 34%. The diagnostic transition was observed in 35.9% of the patients, mostly to schizophrenia and schizoaffective disorders. There was a significant deterioration in several clinical and social indicators among the patients who developed schizophrenia, compared with those with stable ATPD, whereas no reliable predictors were found for diagnostic transition to schizophrenia, except younger age, unmarried status and period of the first hospitalization.

CONCLUSION

A sizeable proportion of the patients with initial diagnosis of ATPD is likely to represent early manifestations of schizophrenia-related disorders. In agreement with some previous observations, our study indicates a lack of strong rationale for separating ATPD from other psychotic disorders within the ICD-10 F2 category.

Mortality and causes of death of acute and transient psychotic disorders

BACKGROUND

Little is known about mortality associated with acute transient psychoses. This paper examines mortality and causes of death of ICD-10 F23 'Acute and transient psychotic disorders' (ATPD).

METHOD

Data from all subjects aged over 15 years who were enrolled in 1996 in the Danish psychiatric register with a first-admission diagnosis of ATPD were linked to the national register of causes of death. The standardized mortality ratio (SMR) for overall mortality and specific categories were calculated.

RESULTS

Over the period 1996-2001, 87 (17.3%) of 503 patients with ATPD had died, accounting for a mortality rate of 35.3 per 1,000 person/years. The SMR for all causes (2.9), natural causes (2.5), and unnatural causes (9.2) were significantly increased. Suicide had the greatest SMR (30.9).

CONCLUSIONS

These findings argue for excess mortality of ATPD particularly from suicide.

Nonaffective acute psychoses: uncertainties on the way to DSM-V and ICD-11

Since the early 20th century, a group of nonaffective psychoses with acute onset and brief duration have been described in different countries under various names, including cycloid psychosis, bouffée délirante, and reactive psychosis. These psychoses share several characteristics, including benign course, greater prevalence in women than men and in developing countries than in industrialized countries, and high prevalence of premorbid psychological and physiologic stressors. However, the variations in names and minute details of symptomatology have overshadowed the basic similarities across these various descriptions. Confusion in classification persists in the two contemporary diagnostic systems, the DSM-IV and the ICD-10. We believe that most cases of these psychoses could be captured under a broad, unified category of nonaffective psychosis with acute onset and brief duration, and urge the authors of the upcoming revisions of the DSM and ICD to create such a category. A unified diagnostic category for these disorders would reduce unnecessary fragmentation in the diagnostic systems and assist in the progress of research on these rare conditions.

Evidence-based guidelines for the pharmacological treatment of schizophrenia: recommendations from the British Association for Psychopharmacology

These guidelines from the British Association for Psychopharmacology address the scope and targets of pharmacological treatment for schizophrenia. A consensus meeting, involving experts in schizophrenia and its treatment, reviewed key areas and considered the strength of evidence and clinical implications. The guidelines were drawn up after extensive feedback from the participants and interested parties, and cover the pharmacological management and treatment of schizophrenia across the various stages of the illness, including first-episode, relapse prevention, and illness that has proved refractory to standard treatment. The practice recommendations presented are based on the available evidence to date, and seek to clarify which interventions are of proven benefit. It is hoped that the recommendations will help to inform clinical decision making for practitioners, and perhaps also serve as a source of information for patients and carers. They are accompanied by a more detailed qualitative review of the available evidence. The strength of supporting evidence for each recommendation is rated.

McLean-Harvard International First-Episode Project: two-year stability of ICD-10 diagnoses in 500 first-episode psychotic disorder patients

OBJECTIVE

Because clinical and biologic research and optimal clinical practice require stability of diagnoses over time, we determined stability of ICD-10 psychotic disorder diagnoses and sought predictors of diagnostic instability.

METHOD

Patients from the McLean-Harvard International First-Episode Project, conducted from 1989 to 2003, who were hospitalized for first psychotic illnesses (N = 500) were diagnosed by ICD-10 criteria at baseline and 24 months, on the basis of extensive prospective assessments, to evaluate the longitudinal stability of specific categorical diagnoses and predictors of diagnostic change.

RESULTS

Diagnostic stability averaged 90.4%, ranking as follows: schizoaffective disorder (100.0%) > mania with psychosis (99.0%) > mixed affective episode (94.9%) > schizophrenia (94.6%) > delusional disorder (88.2%) > severe depressive episode with psychotic symptoms (85.2%) > acute psychosis with/without schizophrenia symptoms = unspecified psychosis (all 66.7%) >> acute schizophrenia-like psychosis (28.6%). Diagnoses changed by 24 months of follow-up to schizoaffective disorder (37.5%), bipolar disorder (25.0%), schizophrenia (16.7%), or unspecified nonorganic psychosis (8.3%), mainly through emerging affective features. By logistic regression, diagnostic change was associated with Schneiderian first-rank psychotic symptoms at intake > lack of premorbid substance use.

CONCLUSIONS

We found some psychotic disorder diagnoses to be more stable by ICD-10 than DSM-IV criteria in the same patients, with implications for revisions of both diagnostic systems.

Naming psychosis: the Hong Kong experience

AIM

Schizophrenia translates in Chinese as 'Mind Split Disease' which is heavily stigmatizing. The narrow conceptualization for schizophrenia alone was insufficient, in the context of early detection and intervention for psychosis. The need for an effective Chinese translation for psychotic disorders was imminent upon the launch of the Early Assessment Service for Young People with Psychosis in Hong Kong, where public awareness strategies had to be built upon effective communication of the disorder.

METHODS

'Si Jue Shi Tiao', the new term for psychosis, described 'thought and perceptual dysregulation'. This new terminology and concept was strategically introduced to the local community.

RESULTS

The term 'Si Jue Shi Tiao' was taken up well locally and had demonstrated interactions within the Chinese and East Asian communities. The public has taken in the broader concept of psychosis, in contrary to the previous concept of schizophrenia per se.

CONCLUSIONS

In Hong Kong, the restrictive view of perceiving psychotic disorders as schizophrenia was broadened upon the introduction of a more embracing, less stigmatizing term 'Si Jue Shi Tiao'. Effective establishment of this term to the local vocabulary allowed a basis for communication as well as public education work. Further evaluation is necessary to determine the effectiveness of the naming and to guide further public awareness strategies.

Who needs antipsychotic medication in the earliest stages of psychosis? A reconsideration of benefits, risks, neurobiology and ethics in the era of early intervention

In recent years, early intervention services have attempted to identify people with a first episode of psychosis as early as possible, reducing the duration of untreated psychosis and changing the timing of delivery of interventions. The logic of early intervention is based partly on accessing people in a more treatment responsive stage of illness in which psychosocial damage is less extensive, and partly on remediating a putatively active process of neuroprogression that leads to pathophysiological, symptomatic and structural changes, hence improving symptomatic and functional outcomes. However, as in other areas of health care, earlier identification of new patients may mean that different treatment approaches are indicated. The corollary of early detection is that the sequence and complexion of treatment strategies for first episode psychosis has been revaluated. Examples include the minimal effective dosage of antipsychotic medication and the content of psychosocial interventions. With the substantial reductions of DUP now seen in many early psychosis services, based on clinical staging and stepped care principles, it is even possible that the immediate introduction of antipsychotic medication may not be necessary for all first episode psychosis cases, but that potentially safer interventions, which may be more acceptable to many patients, such as comprehensive psychosocial intervention, may constitute effective treatment at least for a subgroup of patients. In this paper, we review this theoretical background and describe a randomised controlled trial currently underway at the Early Psychosis Prevention and Intervention Centre (EPPIC) in Melbourne designed to test outcomes for first episode psychosis patients in response to two different treatments: intensive psychosocial intervention plus antipsychotic medication versus intensive psychosocial intervention plus placebo. This is a theoretically and pragmatically novel study in that it will provide evidence as to whether intensive psychosocial intervention alone is sufficient for a subgroup of first episode psychosis patients in a specialised early intervention service, and provide a test of the heuristic clinical staging model. By experimentally manipulating duration of untreated psychosis, the study will also provide a methodologically strong test of the effect of delaying the introduction of antipsychotic medication, as well as helping to disentangle the effects of antipsychotic medications and the putative neurobiological processes associated with brain changes and symptom profiles in the early phase of psychotic disorders. The study has been carefully crafted to satisfy critical ethical demands in this challenging research domain.

Appraising evidence for intervention effectiveness in early psychosis: conceptual framework and review of evaluation approaches

The literature that is relevant to evaluation of treatment effectiveness is large, scattered and difficult to assemble for appraisal. This scoping review first develops a conceptual framework to help organize the field, and second, uses the framework to appraise early psychosis intervention (EPI) studies. Literature searches were used to identify representative study designs, which were then sorted according to evaluation approach. The groupings provided a conceptual framework upon which a map of the field could be drawn. Key words were cross-checked against definitions in dictionaries of scientific terms and the National Library of Medicine Medical Subject Headings (MeSH) browser. Using the final list of key words as search terms, the EPI evaluation literature was appraised. Experimental studies could be grouped into two classes: efficacy and effectiveness randomized controlled trials. Non-experimental studies could be subgrouped into at least four overlapping categories: clinical epidemiological; health service evaluations; quality assurance studies; and, quasi-experimental assessments of treatment effects. Applying this framework to appraise EPI studies indicated promising evidence for the effectiveness of EPI irrespective of study design type, and a clearer picture of where future evaluation efforts should be focused. Reliance on clinical trials alone will restrict the type of information that can inform clinical practice. There is convergent evidence for the benefits of specialized EPI service functions across a range of study designs. Greater investment in health services research and quality assurance approaches in evaluating EPI effectiveness should be made, which will involve scaling up of study sizes and development of an EPI programme fidelity rating template. The degree of complexity of the evaluation field suggests that greater focus on research methodology in the training of Australasian psychiatrists is urgently needed.

Predictors of schizophrenia in patients with a first episode of psychosis

Early identification of schizophrenia in patients with a first episode of psychosis (FEP) may help to avoid inappropriate treatment and may enhance long-term outcome by addressing issues such as family network, treatment adherence and functional and symptomatic outcome. It was the aim of the study to determine baseline variables that significantly predicted a diagnosis of schizophrenia in patients with FEP. The sample consisted of 133 FEP patients hospitalized for at least 6 weeks, in whom a DSM-IV diagnosis was confirmed after 1 year follow-up. Patients were divided into two groups, those with a diagnosis of schizophrenia (Schizophrenia group, n=63; 47.8%), and those with other psychosis, who were grouped under Non-Schizophrenic Psychosis (NSP, n=70; 52.2%). Sociodemographic (marital status, educational level) and clinical variables were recorded for each patient. Substance use (alcohol, cannabis and cocaine) did not statistically differ between the two groups. Absence of characteristics defined as criteria for good prognosis, lack of > or = 20% improvement in the total Positive and Negative Syndrome Scale score at 6 weeks, and a poor premorbid adjustment as determined by the Premorbid Adjustment Scale score significantly predicted the presence of schizophrenia. The regression model including these three variables achieved a predictive value of 76.3%, with a sensitivity of 74.6% and a specificity of 77.9%.

Five-year stability of ICD-10 diagnoses among Chinese patients presented with first-episode psychosis in Hong Kong

BACKGROUND

Diagnostic stability is one measure of predictive validity for psychiatric syndromes. It is an under-studied area in functional psychosis despite its clinical and research implications. We aimed at evaluating the stability of ICD-10 diagnoses in a sample of young people with first-episode psychosis.

METHOD

One hundred and sixty-six Hong Kong Chinese enrolled in a regional first-episode psychosis treatment program were studied. Subjects' baseline and final 5-year consensus diagnoses were established via systematic medical records' review to determine diagnostic stability and to identify predictors of diagnostic shift towards schizophrenia spectrum.

RESULTS

The overall diagnostic consistency was 80.7%. Bipolar affective disorder and schizophrenia were the most stable diagnostic categories over 5 years with prospective consistency of 100% and 95.8% respectively. The least stable baseline diagnoses were unspecified non-organic psychosis, acute and transient psychotic disorders and delusional disorder. Around one-fifth (19.3%) of subjects had diagnostic revision in 5 years. The predominant pattern of diagnostic shift was towards schizophrenia spectrum disorder. Family history of psychosis and longer duration of untreated psychosis were associated with diagnostic transition towards schizophrenia spectrum.

CONCLUSIONS

Schizophrenia and bipolar affective disorder were diagnostically stable and could be reliably classified at intake in a Chinese first-episode psychosis sample using the ICD-10 criteria. Diagnostic instability in the least prevalent categories of functional psychosis highlights the limitations of current taxonomies and calls for ongoing revision of diagnostic criteria. In the absence of biological marker, longitudinal validation across consecutive episodes is necessary for accurate diagnostic ascertainment.

Acute and transient psychotic disorders (ICD-10 F23): a review from a European perspective

The tenth revision of the International Classification of Mental and Behavioural Disorders (ICD-10) introduced the category F23 'Acute and transient psychotic disorders' (ATPD) to incorporate clinical concepts such as the French bouffée délirante, cycloid psychosis (Germany), and the Scandinavian reactive and schizophreniform psychoses. The aim of this paper is to review the literature on ATPD and to examine how it has been differentiated from the other categories of F2 group 'schizophrenia and related disorders'. Papers published between 1993 and 2007 were found through searches in Medline, PsychInfo and Google Scholar. Further references were identified from book chapters and comprehensive reviews of the topic. ATPD is reported as being prevalent in females and as having onset in early-middle adulthood. Although follow-up studies suggest that its outcome is more favourable than other disorders in the F2 group, ATPD tends to recur and half of cases convert mainly into either schizophrenia or affective disorders. No evidence supports the view that the traditional conditions subsumed under ATPD all refer to this diagnostic category. The lack of defining features and poor prognostic validity argue against the separation of ATPD from borderland categories.

Employment status amongst those with psychosis at first presentation

INTRODUCTION

Employment is generally beneficial to health and quality of life. Despite many advances in the treatment of psychosis there are continuing reports of high levels of unemployment. In most studies of first episode psychosis (FEP) only rudimentary rates of employment are provided. We sought to establish the prevalence of employment amongst those with FEP from a geographically defined area, to compare employment categories for differences in demographical and clinical characteristics and finally, to examine factors associated with employment.

METHODS

All cases of FEP were assessed from a defined suburban area with a structured clinical interview for DSM-III-R diagnosis and a standardised assessment protocol. Employment status was divided into employed, non-labour force work and unemployed.

RESULTS

Of 162 cases of psychosis, those employed (46%) were indistinguishable from those in non-labour force work (21%). Those unemployed (33%) had significantly longer DUP, more negative symptoms and lower quality of life than those engaged in non-labour force work or those employed. Having a non-affective psychosis (chi(2) = 0.05, OR = 1.2; 95% CI 1.0, 1.4) was associated with being unemployed at presentation. Better (beta = -0.2, P = 0.00) academic premorbid adjustment was associated with being employed at presentation.

CONCLUSIONS

Although 67% of those with FEP from a geographically defined area are engaged in purposeful work, the rate of unemployment is nine times the local rate. Longer DUP and negative symptoms are associated with unemployment at presentation. Standardised reporting of employment status would greatly assist research in this area.

McLean-Harvard International First-Episode Project: two-year stability of DSM-IV diagnoses in 500 first-episode psychotic disorder patients

OBJECTIVE

Since stability of DSM-IV diagnoses of disorders with psychotic features requires validation, we evaluated psychotic patients followed systematically in the McLean-Harvard International First Episode Project.

METHOD

We diagnosed 517 patients hospitalized in a first psychotic illness by SCID-based criteria at baseline and at 24 months to assess stability of specific DSM-IV diagnoses.

RESULTS

Among 500 patients (96.7%) completing the study, diagnoses remained stable in 77.6%, ranking as follows: bipolar I disorder (96.5%) > schizophrenia (75.0%) > delusional disorder (72.7%) > major depressive disorder (MDD), severe, with psychotic features (70.1%) > brief psychotic disorder (61.1%) > psychotic disorder not otherwise specified (NOS) (51.5%) >> schizophreniform disorder (10.5%). Most changed diagnoses (22.4% of patients) were to schizoaffective disorder (53.6% of changes in 12.0% of subjects, from psychotic disorder NOS > schizophrenia > schizophreniform disorder = bipolar I disorder most recent episode mixed, severe, with psychotic features > MDD, severe, with psychotic features > delusional disorder > brief psychotic disorder > bipolar I disorder most recent episode manic, severe, with psychotic features). Second most changed diagnoses were to bipolar I disorder (25.9% of changes, 5.8% of subjects, from MDD, severe, with psychotic features > psychotic disorder NOS > brief psychotic disorder > schizophreniform disorder). Third most changed diagnoses were to schizophrenia (12.5% of changes, 2.8% of subjects, from schizophreniform disorder > psychotic disorder NOS > brief psychotic disorder = delusional disorder = MDD, severe, with psychotic features). These 3 categories accounted for 92.0% of changes. By logistic regression, diagnostic change was associated with nonaffective psychosis > auditory hallucinations > youth > male sex > gradual onset.

CONCLUSIONS

Bipolar I disorder and schizophrenia were more stable diagnoses than delusional disorder or MDD, severe, with psychotic features, and much more than brief psychotic disorder, psychotic disorder NOS, or schizophreniform disorder. Diagnostic changes mainly involved emergence of affective symptoms and were predicted by several premorbid factors. The findings have implications for revisions of DSM and ICD.

Mammalian nicotinic acetylcholine receptors: from structure to function

The classical studies of nicotine by Langley at the turn of the 20th century introduced the concept of a "receptive substance," from which the idea of a "receptor" came to light. Subsequent studies aided by the Torpedo electric organ, a rich source of muscle-type nicotinic receptors (nAChRs), and the discovery of alpha-bungarotoxin, a snake toxin that binds pseudo-irreversibly to the muscle nAChR, resulted in the muscle nAChR being the best characterized ligand-gated ion channel hitherto. With the advancement of functional and genetic studies in the late 1980s, the existence of nAChRs in the mammalian brain was confirmed and the realization that the numerous nAChR subtypes contribute to the psychoactive properties of nicotine and other drugs of abuse and to the neuropathology of various diseases, including Alzheimer's, Parkinson's, and schizophrenia, has since emerged. This review provides a comprehensive overview of these findings and the more recent revelations of the impact that the rich diversity in function and expression of this receptor family has on neuronal and nonneuronal cells throughout the body. Despite these numerous developments, our understanding of the contributions of specific neuronal nAChR subtypes to the many facets of physiology throughout the body remains in its infancy.

How common are psychotic and bipolar disorders? A 50-year follow-up of the Lundby population

BACKGROUND

The purpose was to present the prevalence of all psychotic and bipolar (BP) disorders in a total general population (n=3563), which has been followed from 1947 to 1997.

MATERIALS AND METHODS

Best-estimate consensus DSM-IV diagnoses, supported by data from interviews, case notes, registers and key-informants, were assessed. The period prevalence from 1947 to 1997 and the lifetime prevalence (LTP) in 1997, respectively, was calculated.

RESULTS

The period prevalence per 100 was: 4.24 for any psychotic or BP disorder, 2.25 for non-affective psychotic (NAP) disorder, 0.76 for psychotic disorder related to a general medical condition (GMC), 0.62 for affective psychotic (AP) disorder and 0.59 for substance-induced psychotic (SIP) disorder. The LTP per 100 was: 2.82 for any psychotic or BP disorder, 1.38 for NAP disorder, 0.54 for psychotic disorder related to a GMC, 0.48 for SIP disorder and 0.42 for AP disorder. The specific diagnosis with the highest period prevalence 1.43 per 100 and LTP 0.84 per 100, respectively, was schizophrenia. The LTP of psychotic disorder related to a GMC, SIP disorder, schizophrenia and delusional disorder, respectively, was higher than in most recent community studies while the LTP of brief psychotic disorder, schizophreniform disorder and AP disorder, respectively, was lower. However, the findings were in approximate accord with the estimates in the Psychoses in Finland (PIF) Study 1.

CONCLUSIONS

The findings suggest that psychotic disorders are common in the community, and should be considered a major public health concern.

Clinical and serotonergic predictors of non-affective acute remitting psychosis in patients with a first-episode psychosis

OBJECTIVE

The study aimed to establish clinical predictors of non-affective acute remitting psychosis (NARP) and assess whether these patients showed a distinct serotonergic profile.

METHOD

First-episode never treated psychotic patients diagnosed of paranoid schizophrenia (n=35; 21 men and 14 women) or NARP (n=28; 15 men and 13 women) were included.

RESULTS

NARP patients showed significantly lower negative symptomatology, better premorbid adjustment, shorter duration of untreated psychosis, more depressive symptomatology and a lower number of 5-HT2A receptors than the paranoid schizophrenia patients. In the logistic regression, the four variables associated with the presence of NARP were: low number of 5-HT2A receptors; good premorbid adjustment; low score in the item 'hallucinatory behaviour' and reduced duration of untreated psychosis.

CONCLUSION

Our findings support the view that NARP is a highly distinctive condition different from either affective psychosis or other non-affective psychosis such as schizophrenia, and highlight the need for its validation.

Early intervention in psychosis: concepts, evidence and future directions

The rise of the early intervention paradigm in psychotic disorders represents a maturing of the therapeutic approach in psychiatry, as it embraces practical preventive strategies which are firmly established in mainstream health care. Early intervention means better access and systematic early delivery of existing and incremental improvements in knowledge rather than necessarily requiring dramatic and elusive breakthroughs. A clinical staging model has proven useful and may have wider utility in psychiatry. The earliest clinical stages of psychotic disorder are non-specific and multidimensional and overlap phenotypically with the initial stages of other disorders. This implies that treatment should proceed in a stepwise fashion depending upon safety, response and progression. Withholding treatment until severe and less reversible symptomatic and functional impairment have become entrenched represents a failure of care. While early intervention in psychosis has developed strongly in recent years, many countries have made no progress at all, and others have achieved only sparse coverage. The reform process has been substantially evidence-based, arguably more so than other system reforms in mental health. However, while evidence is necessary, it is insufficient. It is also a by-product as well as a catalyst of reform. In early psychosis, we have also seen the evidence-based paradigm misused to frustrate overdue reform. Mental disorders are the chronic diseases of the young, with their onset and maximum impact in late adolescence and early adult life. A broader focus for early intervention would solve many of the second order issues raised by the early psychosis reform process, such as diagnostic uncertainty despite a clear-cut need for care, stigma and engagement, and should be more effective in mobilizing community support. Early intervention represents a vital and challenging project for early adopters in global psychiatry to consider.

Incidence and diagnostic stability of ICD-10 acute and transient psychotic disorders

OBJECTIVE

The 10th Revision of the International Classification of Diseases (ICD-10) introduced a new diagnostic category, F23 acute and transient psychotic disorders (ATPD) to embrace clinical concepts such as the French bouffée délirante, Kleist and Leonhard's cycloid psychoses, and the Scandinavian reactive and schizophreniform psychoses. The relative rarity of these disorders and insufficient follow-up studies with adequate numbers of patients makes ATPD classification as uncertain as their validity. The aim of this study was to evaluate incidence and validity of ATPD in terms of diagnostic stability.

METHOD

A 6-year analysis of readmission patterns of all subjects listed in the Danish psychiatric central register as having been first-ever admitted to hospital or treated in outpatient services with a diagnosis of ATPD from January 1 to December 31, 1996, was conducted.

RESULTS

The incidence of ATPD was 9.6 per 100 000 population, with a higher rate of females than males (9.8 vs 9.4). Incidence rates by age group were higher for males than for females, with a marked reversal of this pattern above 50 years. This contrasted with incidence of schizophrenia that was almost twice as high in males as in females, particularly in the 20-29 year age group. Of 416 cases with a first-admission diagnosis of ATPD, an increasing number tended to change on subsequent admissions, nearly half to another F2 category schizophrenia and related disorders. The overall stability rate reached only 39%.

CONCLUSIONS

Although demographic differences from schizophrenia are topics that deserve further research, poor diagnostic stability argues against attempts to separate ATPD from borderland disorders.

[Acute and transient psychotic disorders (ICD-10: F23). Empirical data and implications for therapy]

The defining clinical features of acute and transient psychotic disorders (ICD-10: F23) are an acute onset and a duration of psychotic symptoms not exceeding 1-3 months. Previous empirical investigations show that patients with this diagnosis have a favourable prognosis, but also a high risk of relapses (58-77%). The diagnostic stability in the further course of illness seems to be low (34-73%) with a frequent diagnostic change to schizophrenia and affective disorders being observed. As yet, data from controlled clinical trials regarding therapy do not exist. The implications for the treatment of acute and transient psychotic disorders are discussed with this background.

The relationship of reactive psychosis and ICD-10 acute and transient psychotic disorders: evidence from a case register-based comparison

BACKGROUND

ICD-10 introduced a new diagnostic category, F23 'acute and transient psychotic disorders' (ATPD), to embrace clinical concepts such as bouffée délirante, cycloid psychosis, psychogenic (reactive) psychosis and schizophreniform psychosis. The purpose of this study was to examine the relationship between the concept of reactive psychosis (RP), equivalent to the ICD-8 298 category of 'other psychoses', and ATPD.

SAMPLING AND METHOD

Since January 1, 1994, ICD-10 has replaced ICD-8 as official classification in Denmark. Patients given an ICD-8 298 diagnosis on their last admission in 1992-1993 were identified from the Danish Psychiatric Central Register, and the ICD-8 diagnoses assigned were compared with their ICD-10 diagnoses when readmitted in 1994-1995.

RESULTS

Diagnosis of RP was recorded in 19.2% of patients with functional psychoses in 1992-1993, whereas ATPD overall prevalence accounted for 8.7% of those with non-organic psychotic and affective disorders in 1994-1995. Thirty-eight per cent of patients with an ICD-8 298 diagnosis were readmitted during the years 1994-1995. Schizophrenia and related disorders (F2) and affective disorders (F3) accounted for three quarters of ICD-10 diagnoses. The most frequently used ATPD subcategories were F23.3 'other acute delusional psychotic disorders', F23.0 'acute polymorphic psychotic disorder without symptoms of schizophrenia' and F23.9 'acute and transient psychotic disorder unspecified'. A significant majority were female and associated acute stress was recorded only in 5.3% of cases.

CONCLUSIONS

ICD-8 298 register diagnosis of RP showed little empirical continuity to ATPD and conformed more to F23.3 acute delusional disorder among ATPD subtypes.

One-year stability of diagnosis in first-episode nonaffective psychosis: influence of sex

OBJECTIVE

To determine whether sex influences the frequency and direction of diagnostic change 1 year after a first episode of nonaffective psychosis.

METHOD

The subjects (n = 228) were individuals diagnosed with schizophrenia and other psychoses according to DSM-IV criteria at baseline and at 1 year.

RESULTS

When diagnostic shifts occurred, men mainly shifted toward schizophrenia (84.6%), which was associated with more severe symptoms. In contrast, 72% of women in whom a diagnostic shift occurred shifted away from a schizophrenia spectrum disorder toward mood disorder. A shift to mood disorder in women was associated with an early age of illness onset.

CONCLUSIONS

At initial presentation, nonaffective first-episode psychosis studies may underestimate the number of men and overestimate the number of women who will eventually receive a schizophrenia diagnosis.

Treatment costs and clinical outcome for first episode schizophrenia patients: a 3-year follow-up of the Swedish "Parachute Project" and two comparison groups

OBJECTIVE

To evaluate "need-specific treatment" of first episode schizophrenia syndrome patients.

METHOD

Sixty-one consecutive first episode schizophrenia syndrome patients were followed over 3 years. They were compared with a Historical "treatment as usual" group (n = 41) and a Prospective group from a high quality social and biological psychiatry centre (n = 25).

RESULTS

Symptomatic and functional outcome was significantly better compared with the Historical group and equal with the Prospective group. During the first year, the direct costs for in- and out-patient care per patient in the Parachute project were less than half of those in the Prospective group.

CONCLUSION

The study confirms the feasibility, clinically and economically, with a large scale application of "need-specific treatments" for first episode psychotic patients.

Revisiting cycloid psychosis: a case of an acute, transient and recurring psychotic disorder

We report a case of recurrent psychosis, spanning decades, with full inter-episode recovery and minimal functional impairment. While it is difficult to classify this disorder using DSM IV-TR criteria, Leonhard and others have described a 'cycloid psychosis' that correlates well with the phenomenology and course of this case. We believe this may represent a subset within the ICD-10 category of 'acute and transient psychotic disorders'. While this disorder, of unknown incidence, is not well reported in the U.S., it is worthy of further investigation and clinical attention given its generally favorable prognosis and potentially distinct pathophysiology and treatment.

Non-affective Acute Remitting Psychosis: a preliminary report from Iran

OBJECTIVE

To investigate the concept of 'Non-affective Acute Remitting Psychosis' (NARP) in a group of patients with first episode psychosis in Iran.

METHOD

This is a 24-month follow-up study of 54 patients with first-episode psychosis admitted consecutively to a psychiatric hospital in Tehran, Iran. At the end of follow-up, consensus judgments were made on fulfillment of the NARP criteria as well as illness course and treatment. NARP was defined as a psychotic illness with acute onset (developed within 1 week), short duration (remission within 6 months), and the absence of prominent mood symptoms.

RESULTS

Of 49 patients who completed the follow-up, 15 (30.6%) had NARP, accounting for 60% of non-affective psychoses. Ten patients with NARP remained relapse free, four had a very short-lived relapse, and only one developed a chronic illness. Throughout the follow-up, patients with NARP received fewer months of treatment than did patients with other non-affective psychoses.

CONCLUSION

The high proportion of NARP among patients with first episode psychosis, and the favorable course is in keeping with previous studies in developing countries.

Determining the chronology and components of psychosis onset: The Nottingham Onset Schedule (NOS)

The Nottingham Onset Schedule (NOS) is a short, guided interview and rating schedule to measure onset in psychosis. Onset is defined as the time between the first reported/observed change in mental state/behaviour to the development of psychotic symptoms. Onset is conceptualised as comprising of (i) a prodrome of two parts: a period of 'unease' followed by 'non-diagnostic' symptoms; (ii) appearance of psychotic symptoms; and (iii) a build-up of diagnostic symptoms leading to a definite diagnosis. Twenty consecutive cases of first-episode psychosis were administered the NOS schedule to determine its psychometric properties including inter-rater and test-retest reliability. Its clinical and research potential as a reliable measure of duration of untreated psychosis (DUP) was assessed in a cohort of 99 cases of first-episode psychosis (56 schizophrenia, 43 affective psychoses). NOS identified all prodromal symptoms previously reported in other studies. There was high degree of inter-rater and test-retest reliability for all components of NOS. Duration of untreated psychosis was significantly longer (p<0.05) in schizophrenia (mean 179 days, S.D. 344; median 52 days) than in affective psychosis (mean 15 days, S.D. 116; median 12 days) but there were no gender differences between lengths of prodrome or treatment delays. The NOS provides a standardised and reliable way of recording early changes in psychosis and identifying relatively precise time points for measuring several durations in emerging psychosis. The scale is easy to use and is not time-consuming or labour intensive. Onset, as measured by NOS, is significantly longer in schizophrenic disorders than in affective psychosis. A small proportion of schizophrenia cases have very long DUP. Some cases with schizophrenia receive anti-psychotics in the prodromal phase, prior to the emergence of frank psychotic symptoms.

Longitudinal follow-up in acute and transient psychotic disorders and schizophrenia

We prospectively studied the long-term course of individuals with acute and transient psychotic disorders and a control group with positive schizophrenia matched for age and gender. Follow-up investigations using standardised instruments were performed at three time-points covering 7 years after the index episode or 12 years after the first episode. During follow-up, those with positive schizophrenia experienced a deterioration in their general functioning whereas those with acute and transient psychotic disorders retained their high level of functioning. At the end of the observation period, 12 out of 39 (31%) of those with acute and transient psychotic disorders were functioning well without medication compared with 0 out of 38 with positive schizophrenia.