Long-term follow-up of schizophrenia in 16 countries. A description of the International Study of Schizophrenia conducted by the World Health Organization

Parental bonding style and illness severity in a longitudinal study of individuals with first episode psychosis

A parenting style with high amounts of control combined with low caring or nurturing behaviour has been reported in association with mental disorders including schizophrenia. However, the association of parenting style with illness severity in individuals with schizophrenia has never been evaluated retrospectively or over a longitudinal time course. In a subset (n = 84) of the participants included in the AESOP (Aetiology and Ethnicity in Schizophrenia and Other Psychoses)-10 study, we evaluated participants' perceptions of their own parents' bonding style at the time of their first episode of psychosis using the parental bonding instrument (PBI). We then examined the association between different bonding styles, illness course and severity, and global functioning over a 10-year follow-up. Participants who perceived that their fathers had a more caring and less controlling parenting style showed better functioning at follow-up. However, in contrast to previous research, participants who reported having been subject to uncaring and controlling parenting styles were not found to have a notably worse course of illness or symptom severity over the follow-up period. These results indicate that more optimal parental bonding styles may be associated with better overall functioning in individuals with psychosis but not with other measures of illness outcome.

20-year trajectories of positive and negative symptoms after the first psychotic episode in patients with schizophrenia spectrum disorder: results from the OPUS study

This study aimed to identify the 20-year trajectories of positive and negative symptoms after the first psychotic episode in a sample of patients with an ICD-10 diagnosis of schizophrenia spectrum disorder, and to investigate the baseline characteristics and long-term outcomes associated with these trajectories. A total of 373 participants in the OPUS trial were included in the study. Symptoms were assessed at baseline and after 1, 2, 5, 10 and 20 years using the Scales for the Assessment of Positive and Negative Symptoms. We used latent class growth mixture modelling to identify trajectories, and multinominal regression analyses to investigate predictors of membership to identified trajectories. Five trajectories of positive symptoms were identified: early continuous remission (50.9% of the sample), stable improvement (18.0%), intermittent symptoms (10.2%), relapse with moderate symptoms (11.9%), and continuous severe symptoms (9.1%). Substance use disorder (odds ratio, OR: 2.83, 95% CI: 1.09-7.38, p=0.033), longer duration of untreated psychosis (OR: 1.02, 95% CI: 1.00-1.03, p=0.007) and higher level of negative symptoms (OR: 1.60, 95% CI: 1.07-2.39, p=0.021) were predictors of the relapse with moderate symptoms trajectory, while only longer duration of untreated psychosis (OR: 1.01, 95% CI: 1.00-1.02, p=0.030) predicted membership to the continuous severe symptoms trajectory. Two trajectories of negative symptoms were identified: symptom remission (51.0%) and continuous symptoms (49.0%). Predictors of the continuous symptoms trajectory were male sex (OR: 3.03, 95% CI: 1.48-6.02, p=0.002) and longer duration of untreated psychosis (OR: 1.01, 95% CI: 1.00-1.02, p=0.034). Trajectories displaying continuous positive and negative symptoms were linked to lower neurocognition, as measured by the Brief Assessment of Cognition in Schizophrenia (BACS) (z-score: -0.78, CI: -1.39 to -0.17, for continuous positive symptoms; z-score: -0.33, CI: -0.53 to -0.13, for continuous negative symptoms). The same trajectories were also linked to higher use of antipsychotic medication at 20-year follow-up (continuous positive symptoms: 78%; continuous negative symptoms: 67%). These findings suggest that the majority of patients with first-episode schizophrenia spectrum disorder have a trajectory with early stable remission of positive symptoms. Long duration of untreated psychosis and comorbid substance abuse are modifiable predictors of poor trajectories for positive symptoms in these patients. In about half of patients, negative symptoms do not improve over time. These symptoms, in addition to being associated with poor social and neurocognitive functioning, may prevent patients from seeking help.

They have taken out my spinal cord: an interpretative phenomenological analysis of self-boundary in psychotic experience within a sociocentric culture

INTRODUCTION

In the tradition of phenomenological psychiatry, schizophrenia is described as a disturbance of the minimal self, i.e. the most basic form of self-awareness. This disturbance of the minimal self at the individual level is assumed to precede the intersubjective disturbances such as boundary weakening. However, the role of intersubjective disturbances in the emergence and recovery of schizophrenic experience still remains an open question. This phenomenological study focuses on how encounters with others shape self-experience during from psychosis by analyzing this process from the perspective of cultural differences, which in current research is especially under-researched. While most phenomenological accounts are based on first person-accounts from Western, individualist cultures where the self is conceived and experienced as separate to others, the present study qualitatively investigates psychotic experiences of patients from Jaffna, Sri Lanka.

METHOD

Semi-structured interviews were conducted with three participants with a diagnosis of schizophrenia or first episode psychosis. The interviews were transcribed and analyzed using interpretative phenomenological analysis (IPA). Eight group experiential themes were identified across interviews.

RESULTS

The data suggest that intersubjective processes of boundary weakening such as invasiveness and hyperattunement may shape minimal self-experience and more specifically contribute to a mistrust of the own senses and to hyper-reflexivity. Interestingly, boundary weakening yields pervasive emotions and can be experienced as a threat to the whole social unit. On the one hand, the strengthening of self-other-boundary was achieved through opposition, closedness and withdrawal from others. On the other hand, this study suggests that the re-opening of self-other-boundaries in response to the crisis may help establish connectedness and may lead to recovery.

Neurological soft signs in first episode psychosis among psychiatric hospital patients and its relationship with dimensions of psychopathology: A comparative study

Background

Neurological soft signs (NSS), as subtle, nonlocalising neurological abnormalities, are considered as the potential markers of psychosis. However, comparative studies of antipsychotic-naïve patients with first-episode psychosis (FEP) and first degree relatives (FDRs) are uncommon. We compared the prevalence and pattern of NSS in FEPs, their healthy FDRs and a healthy non-relatives' control group (HC), highlighted the relationship between NSS and psychopathology and proposed cut-off scores for prevalence studies.

Materials and Methods

Two hundred and two participants per group were recruited. The FEPs were consecutive attendees; FDRs were accompanying caregivers; while the HC were from hospital staff. The Brief Psychiatric Rating Scale and the Neurological Evaluation Scale were used to assess psychopathology dimensions and NSS, respectively.

Results

Using an item score of two ('substantial impairment'), the prevalence of at least one NSS was: 91.5% (95% confidence interval [CI]: 86.7%-94.9%), 16.8% (95% CI: 11.8%-22.7%) and 6.5% (95% CI: 3.5%-10.9%), respectively, for FEP, FDRs and HC. FEPs were impaired in a broad range of signs. The noteworthy relationships were as follows: (i) a significant correlation between the negative symptoms' dimension versus number of NSS (r = 0.4), and NSS total score (r = 0.3), (ii) the anxiety/depression dimension correlated negatively with number of NSS (r = -0.3) and (iii) NSS cut across psychosis categories. We propose a cut-off score of ≥ 4 for the number of signs signifying probable impairment.

Conclusion

The findings indicate that, subject to further studies, NSS could be regarded as a broader phenotype of neurologic dysfunction associated with psychosis proness.

Clinical Recovery Among Individuals With a First-Episode Schizophrenia an Updated Systematic Review and Meta-Analysis

BACKGROUND AND HYPOTHESIS

Through decades the clinical recovery outcomes among individuals diagnosed with schizophrenia have been highly inconsistent ranging from 13.5% to 57%. The primary objective of this updated examination was to report the pooled estimate and explore various moderators to improve the understanding of the course of schizophrenia.

STUDY DESIGN

A systematic literature search was set up on PubMed, PsycInfo, and EMBASE until January 13th, 2022. Both observational and interventional studies among cohorts of individuals with the first episode of schizophrenia reporting on clinical recovery were included. The PRISMA 2020 statement was used and data was extracted for a random-effects meta-analysis, meta-regression, and sensitivity analyses. Risk of bias was assessed using The Newcastle-Ottawa Scale.

STUDY RESULTS

A 20.8% (95% CI = 17.3 to 24.8) recovery rate was found among 26 unique study samples (mean trial duration, 9.5 years) including 3877 individuals (mean age, 26.4 years). In meta-regression none of the following study characteristics could uncover the diverse reported recovery rates; age at inclusion (P = .84), year of inclusion (P = .93), follow-up time (P = .99), drop-out rate (P = .07), or strictness of the recovery criteria (P = .35). Furthermore, no differences in recovery were found between early intervention services (EIS; 19.5%; 95% CI = 15.0 to 24.8) compared to other interventions (21%; 95% CI = 16.9 to 25.8), P = .65.

CONCLUSIONS

A clinical recovery rate of approximately 21% was found with minimum impact from various moderators. The rate was not different comparing EIS with other interventions implying that new initiatives are needed to improve the rate of recovery.

A Scoping and Systematic Review of Employment Processes and Outcomes for Young Adults Experiencing Psychosis

Young adults who experience psychosis want to work but are less likely to be employed than their peers. Sixty two studies relating to young adults with psychosis and employment were reviewed following a systematic search of five databases: CINAHL, PsycINFO, MEDLINE, SCOPUS and EMBASE. Publication date ranged from 1973 to 2019 with > 70% between 2010 and 2019. Intervention was considered in 29 papers; critical appraisal revealed 90% of these had moderate to good methodological quality with only three RCTs. Of 11 intervention types "Early Intervention" and "Individual Placement and Support" were most common; both demonstrating positive impact on obtaining employment. The review identified minimal participant perspectives and great variability in: terminology used; the reporting of participant attributes; intervention characteristics and ways employment outcomes were measured. Employment processes identified were preparing for, seeking, obtaining, keeping and re-obtaining employment, with current research efforts focused on obtaining work. More focus is required on keeping and re-obtaining employment.

The prognosis of schizophrenia: A systematic review and meta-analysis with meta-regression of 20-year follow-up studies

OBJECTIVE

The aim was to examine the general outcome of schizophrenia after 20 years or more.

METHODS

Using the PRISMA guidelines, we conducted a systematic review and meta-analysis with meta-regression on long-term follow-up studies of schizophrenia up until April 21, 2021. We included prospective studies with at least 20 years of follow-up on patients with a diagnosis of schizophrenia, and the studies had to include face-to-face clinical evaluation. We examined outcome in three nested groups: 'recovery', 'good or better' (including also 'recovery'), and 'moderate or better' (including also 'recovery' and 'good or better'). We used random-effects meta-analysis and meta-regression to examine mean estimates and possible moderators.

RESULTS

We identified 1089 records, which were screened by two independent researchers. 14 prospective studies (1991 patients) published between 1978 and 2020 were found eligible. The studies used a range of different scales and definitions for outcome, and some used the same definitions for different outcomes. To compare outcome across studies, we designed and applied a unified template for outcome definitions and cutoffs, based on earlier studies' recommendations. Our meta-analysis found that 24.2 % had 'recovered' (n = 246, CI: 20.3-28.0 %), 35.5 % had a 'good or better' outcome (n = 766, CI: 26.0-45.0%), and 59.7% had 'moderate or better' outcome (n = 1139, CI: 49.3-70.1 %).

CONCLUSIONS

The results contribute to debunk the myth that schizophrenia inevitably has a deteriorating course. Recovery is certainly possible. Schizophrenia remains, however, a severe and complex mental disorder, exhibiting a limited change in prognosis despite >100 years of research and efforts to improve treatment.

Mental health, normativity, and local knowledge in global perspective

Approaching mental health on a global scale with particular reference to low- and mid-income countries raises issues concerning the disregard of the local context and values and the imposition of values characteristic of the Global North. Seeking a philosophical viewpoint to surmount these problems, the present paper argues for a value-laden framework for psychiatry with the specific incorporation of value pluralism, particularly in relation to the Global South context, while also emphasizing personal values such as the choice of treatment. In sketching out this framework, the paper aims to overcome the clash between universalism and relativism about psychiatric categories by focusing on how overlaps between cultures can contribute to ontology-building. A case study analyzing ethnopsychiatric research in the context of South India will illustrate the proposed view, while also pointing out avenues for further research on the causal efficacy of local shared beliefs about mental disorder. If approaches across different traditions and theoretical frames are shown to work in treating similar ailments, causal connections appear to cut across the different ontologies. Ethnopsychiatry would play a central role in such research, namely in disclosing the variables and mechanisms at work within the local approaches.

Neurological Signs at the First Psychotic Episode as Correlates of Long-Term Outcome: Results From the AESOP-10 Study

Minor neurological signs are subtle deficits in sensory integration, motor coordination, and sequencing of complex motor acts present in excess in the early stages of psychosis. Still, it remains unclear whether at least some of these signs represent trait or state markers for psychosis and whether they are markers of long-term disease outcome of clinical utility. We examined the relationship between neurological function at illness onset assessed with the Neurological Evaluation Scale and subsequent illness course in 233 patients from AESOP-10 (Aetiology and Ethnicity in Schizophrenia and Other Psychoses), a 10-year follow-up study of a population-based cohort of individuals recruited at the time of their first episode of psychosis in the United Kingdom. In 56 of these patients, we also explored changes in neurological function over time. We included a group of 172 individuals without psychosis as controls. After 10 years, 147 (63%) patients had developed a non-remitting course of illness, and 86 (37%) a remitting course. Already at first presentation, patients who developed a non-remitting course had significantly more primary, motor coordination, and total signs than both remitting patients and healthy controls. While Motor Coordination signs did not change over time, rates of Primary, Sensory Integration, and Total signs increased, independently of illness course type. These findings suggest that motor coordination problems could be a useful early, quick, and easily detectable marker of subsequent clinical outcome. With other motor abnormalities, a measure of motor incoordination could contribute to the identification of the most vulnerable individuals, who could benefit from targeted and more assertive treatment approaches.

Symptom remission at 12-weeks strongly predicts long-term recovery from the first episode of psychosis

BACKGROUND

To determine the baseline individual characteristics that predicted symptom recovery and functional recovery at 10-years following the first episode of psychosis.

METHODS

AESOP-10 is a 10-year follow up of an epidemiological, naturalistic population-based cohort of individuals recruited at the time of their first episode of psychosis in two areas in the UK (South East London and Nottingham). Detailed information on demographic, clinical, and social factors was examined to identify which factors predicted symptom and functional remission and recovery over 10-year follow-up. The study included 557 individuals with a first episode psychosis. The main study outcomes were symptom recovery and functional recovery at 10-year follow-up.

RESULTS

At 10 years, 46.2% (n = 140 of 303) of patients achieved symptom recovery and 40.9% (n = 117) achieved functional recovery. The strongest predictor of symptom recovery at 10 years was symptom remission at 12 weeks (adj OR 4.47; CI 2.60-7.67); followed by a diagnosis of depression with psychotic symptoms (adj OR 2.68; CI 1.02-7.05). Symptom remission at 12 weeks was also a strong predictor of functional recovery at 10 years (adj OR 2.75; CI 1.23-6.11), together with being from Nottingham study centre (adj OR 3.23; CI 1.25-8.30) and having a diagnosis of mania (adj OR 8.17; CI 1.61-41.42).

CONCLUSIONS

Symptom remission at 12 weeks is an important predictor of both symptom and functional recovery at 10 years, with implications for illness management. The concepts of clinical and functional recovery overlap but should be considered separately.

Jumping to conclusions at first onset of psychosis predicts longer admissions, more compulsory admissions and police involvement over the next 4 years: the GAP study

BACKGROUND

Jumping to conclusions (JTC), which is the proneness to require less information before forming beliefs or making a decision, has been related to formation and maintenance of delusions. Using data from the National Institute of Health Research Biomedical Research Centre Genetics and Psychosis (GAP) case-control study of first-episode psychosis (FEP), we set out to test whether the presence of JTC would predict poor clinical outcome at 4 years.

METHODS

One-hundred and twenty-three FEP patients were assessed with the Positive and Negative Syndrome Scale (PANSS), Global Assessment of Functioning (GAF) and the probabilistic reasoning 'Beads' Task at the time of recruitment. The sample was split into two groups based on the presence of JTC bias. Follow-up data over an average of 4 years were obtained concerning clinical course and outcomes (remission, intervention of police, use of involuntary treatment - the Mental Health Act (MHA) - and inpatient days).

RESULTS

FEP who presented JTC at baseline were more likely during the follow-up period to be detained under the MHA [adjusted OR 15.62, 95% confidence interval (CI) 2.92-83.54, p = 0.001], require intervention by the police (adjusted OR 14.95, 95% CI 2.68-83.34, p = 0.002) and have longer admissions (adjusted IRR = 5.03, 95% CI 1.91-13.24, p = 0.001). These associations were not accounted for by socio-demographic variables, IQ and symptom dimensions.

CONCLUSIONS

JTC in FEP is associated with poorer outcome as indicated and defined by more compulsion police intervention and longer periods of admission. Our findings raise the question of whether the implementation of specific interventions to reduce JTC, such as Metacognition Training, may be a useful addition in early psychosis intervention programmes.

Hospitalization risk factors in antipsychotic-treated schizophrenia, bipolar I disorder or major depressive disorder

Aim: To examine hospitalization risk factors in antipsychotic-treated patients with schizophrenia, bipolar I disorder (BD-I) or major depressive disorder (MDD). Patients & methods: Using Truven Health MarketScan® Commercial, Medicaid and Medicare Supplemental data (01/01/2012–06/30/2016), logistic regression models were performed to identify risk factors for both psychiatric and all-cause hospitalization in three separate analyses. Results: Significant risk factors included prior hospitalization (schizophrenia: odds ratio [95% CI]: 2.83 [2.50–3.21; psychiatric]; 2.58 [2.31–2.87; all-cause]; BD-I: 2.42 [2.23–2.63]; 2.09 [1.96–2.23]; MDD: 2.81 [2.49–3.16]; 2.21 [2.03–2.40]), previous antipsychotic treatment (schizophrenia: 1.71 [1.52–1.93]; 1.31 [1.18–1.46]; BD-I: 1.33 [1.23–1.44]; 1.22 [1.14–1.30]; MDD: 1.31 (1.11–1.54); 1.17 (1.04–1.32) and substance abuse (schizophrenia: 1.42 [1.27–1.60]; 1.37 [1.23–1.53]; BD-I: 1.72 [1.58–1.86]; 1.61 [1.50–1.72]; MDD: 1.90 [1.68–2.15] and 1.55 [1.41–1.71]). Conclusion: Prior hospitalization, previous antipsychotic treatment and substance abuse were associated with increased hospitalization risk in schizophrenia, BD-I or MDD.

Stability of outcomes after 5 years of treatment in an early intervention programme

AIM

It has been hypothesized that the first 5 years are critical in determining long-term recovery from psychotic disorders. We examine stability in recovery indices after 5 years for 56 patients treated in an early intervention programme for psychosis.

METHODS

Assessments of symptom remission and functional recovery were carried out 5 and 10 years after initiation of treatment.

RESULTS

Although overall rates of recovery were comparable at both times, there were significant changes for individuals reflecting both improvement and deterioration.

CONCLUSIONS

Evidence concerning the critical period hypothesis should examine stability in individuals rather than relying on cumulative indices.

An examination of components of recovery after five years of treatment in an early intervention program for psychosis

Recovery from psychotic disorders includes both symptomatic and functional components. Progress in understanding recovery requires careful replication and extension of findings using comparable measures. In the current paper, we present a study of five year recovery rates in an early intervention program in London, Canada with the same operational criteria as those used in a previous report from the OPUS cohort in Denmark. Our analysis extends the OPUS reports by including additional potential predictors of overall recovery, such as cognitive functioning, adherence to medication and early social support, and examining rates and predictors of individual components of recovery at five year follow-up. Consistent with reports from OPUS, we found younger age of onset and lower initial severity of negative symptoms to predict greater likelihood of overall recovery. Different patterns of predictors emerge when we examine individual components of recovery. Adherence to medication during the first year was the sole independent predictor of remission of positive symptoms, while early social adjustment and social support were more likely to predict negative symptom and functional aspects of recovery at five years. Cognitive functioning, as represented by IQ, did not predict any aspects of recovery. Our findings suggest the importance of examining the predictors of individual components in the quest to improve overall recovery.

Ethnicity and long-term course and outcome of psychotic disorders in a UK sample: the ÆSOP-10 study

BackgroundThe incidence of psychotic disorders is elevated in some minority ethnic populations. However, we know little about the outcome of psychoses in these populations.AimsTo investigate patterns and determinants of long-term course and outcome of psychoses by ethnic group following a first episode.MethodÆSOP-10 is a 10-year follow-up of an ethnically diverse cohort of 532 individuals with first-episode psychosis identified in the UK. Information was collected, at baseline, on clinical presentation and neurodevelopmental and social factors and, at follow-up, on course and outcome.ResultsThere was evidence that, compared with White British, Black Caribbean patients experienced worse clinical, social and service use outcomes and Black African patients experienced worse social and service use outcomes. There was evidence that baseline social disadvantage contributed to these disparities.ConclusionsThese findings suggest ethnic disparities in the incidence of psychoses extend, for some groups, to worse outcomes in multiple domains.

Two distinct patterns of treatment resistance: clinical predictors of treatment resistance in first-episode schizophrenia spectrum psychoses

BACKGROUND

Clozapine remains the only evidence-based antipsychotic for treatment-resistant schizophrenia (TRS). The ability to predict which patients with their first onset of schizophrenia would subsequently meet criteria for treatment resistance (TR) could help to diminish the severe functional disability which may ensue if TR is not recognized and correctly treated.

METHOD

This is a 5-year longitudinal assessment of clinical outcomes in a cohort of 246 first-episode schizophrenia spectrum patients recruited as part of the NIHR Genetics and Psychosis (GAP) study conducted in South London from 2005 to 2010. We examined the relationship between baseline demographic and clinical measures and the emergence of TR. TR status was determined from a review of electronic case records. We assessed for associations with early-, and late-onset TR, and non-TR, and differences between those TR patients treated with clozapine and those who were not.

RESULTS

Seventy per cent (n = 56) of TR patients, and 23% of the total study population (n = 246) were treatment resistant from illness onset. Those who met criteria for TR during the first 5 years of illness were more likely to have an early age of first contact for psychosis (<20 years) [odds ratio (OR) 2.49, 95% confidence interval (CI) 1.25-4.94] compared to those with non-TR. The relationship between an early age of first contact (<20 years) and TR was significant in patients of Black ethnicity (OR 3.71, 95% CI 1.44-9.56); and patients of male gender (OR 3.13 95% CI 1.35-7.23).

CONCLUSIONS

For the majority of the TR group, antipsychotic TR is present from illness onset, necessitating increased consideration for the earlier use of clozapine.

Outcomes following first-episode psychosis – Why we should intervene early in all ages, not only in youth

OBJECTIVE

To compare baseline demographics and 10-year outcomes of a first-episode psychosis patient incidence cohort in order to establish whether current youth-focussed age-based criteria for early intervention services are justified by patient needs. The patients in this cohort were treated prior to the establishment of early intervention services. The study aimed to test the hypothesis that those who develop psychosis at a younger age have worse outcomes than those who develop psychosis at an older age.

METHODS

Data on first-episode psychosis patients from the ÆSOP-10 longitudinal follow-up study were used to compare baseline characteristics, and 10-year clinical, functional and service use outcomes between those patients who would and would not have met age-based criteria for early intervention services, in Australia or in the United Kingdom.

RESULTS

In total, 58% men and 71% women with first-episode psychosis were too old to meet current Australian-early intervention age-entry criteria (χ² = 9.1, p = 0.003), while 21% men and 34% women were too old for UK-early intervention age-entry criteria (χ² = 11.1, p = 0.001). The 10-year clinical and functional outcomes did not differ significantly between groups by either Australian- or UK-early intervention age-entry criteria. Service use was significantly greater among the patients young enough to meet early intervention age-criteria (Australia: incidence rate ratio = 1.35 [1.19, 1.52], p < 0.001; United Kingdom: incidence rate ratio = 1.65 [1.41, 1.93], p < 0.001).

CONCLUSION

Current early intervention services are gender- and age-inequitable. Large numbers of patients with first-episode psychosis will not receive early intervention care under current service provision. Illness outcomes at 10-years were no worse in first-episode psychosis patients who presented within the age range for whom early intervention has been prioritised, though these patients had greater service use. These data provide a rationale to consider extension of early intervention to all, rather than just to youth.

Ten-year outcomes in first episode psychotic major depression patients compared with schizophrenia and bipolar patients

We aimed to investigate long-term outcomes in psychotic major depression patients compared to schizophrenia and bipolar/manic psychosis patients, in an incidence sample, while accounting for diagnostic change. Based on Aetiology and Ethnicity in Schizophrenia and Other Psychoses (ÆSOP and ÆSOP-10), a first episode psychosis cohort was followed-up 10years after first presentation. The Schedules for Clinical Assessment in Neuropsychiatry, WHO Life Chart and Global Assessment of Functioning were used to assess clinical, social and service use outcomes. Seventy-two PMD patients, 218 schizophrenia patients and 70 psychotic bipolar disorder/mania patients were identified at baseline. Differences in outcome between PMD and bipolar patients based on baseline and lifetime diagnosis were minimal. Differences in clinical, social and service use outcomes between PMD and schizophrenia were more substantial with PMD patients showing better outcomes on most variables. However, there was some weak evidence (albeit not quite statistically significant at p<0.05) based on lifetime diagnoses that PMD patients were more likely to attempt suicide (OR 2.31, CI 0.98-5.42, p0.055) and self-harm (OR 2.34, CI 0.97-5.68, p0.060). PMD patients have better social and service use outcomes compared to people with schizophrenia, but may be more likely to attempt suicide or self-harm. This unique profile is important for clinicians to consider in any risk assessment.

High educational performance is a distinctive feature of bipolar disorder: a study on cognition in bipolar disorder, schizophrenia patients, relatives and controls

BACKGROUND

Schizophrenia is associated with lower intelligence and poor educational performance relative to the general population. This is, to a lesser degree, also found in first-degree relatives of schizophrenia patients. It is unclear whether bipolar disorder I (BD-I) patients and their relatives have similar lower intellectual and educational performance as that observed in schizophrenia.

METHOD

This cross-sectional study investigated intelligence and educational performance in two outpatient samples [494 BD-I patients, 952 schizophrenia spectrum (SCZ) patients], 2231 relatives of BD-I and SCZ patients, 1104 healthy controls and 100 control siblings. Mixed-effects and regression models were used to compare groups on intelligence and educational performance.

RESULTS

BD-I patients were more likely to have completed the highest level of education (odds ratio 1.88, 95% confidence interval 1.66-2.70) despite having a lower IQ compared to controls (β = -9.09, S.E. = 1.27, p < 0.001). In contrast, SCZ patients showed both a lower IQ (β = -15.31, S.E. = 0.86, p < 0.001) and lower educational levels compared to controls. Siblings of both patient groups had significantly lower IQ than control siblings, but did not differ on educational performance. IQ scores did not differ between BD-I parents and SCZ parents, but BD-I parents had completed higher educational levels.

CONCLUSIONS

Although BD-I patients had a lower IQ than controls, they were more likely to have completed the highest level of education. This contrasts with SCZ patients, who showed both intellectual and educational deficits compared to healthy controls. Since relatives of BD-I patients did not demonstrate superior educational performance, our data suggest that high educational performance may be a distinctive feature of bipolar disorder patients.

Clinical factors related to schizophrenia relapse

OBJECTIVE

Relapses represent one of the main problems of schizophrenia management. This article reviews the clinical factors associated with schizophrenia relapse.

METHODS

A research of the last 22 years of literature data was performed. Two-hundred nineteen studies have been included.

RESULTS

Three main groups of factors are related to relapse: factors associated with pharmacological treatment, add-on psychotherapeutic treatments and general risk factors. Overall, the absence of a maintenance therapy and treatment with first generation antipsychotics has been associated with higher risk of relapse. Further, psychotherapy add-on, particularly with cognitive behaviour therapy and psycho-education for both patients and relatives, has shown a good efficacy for reducing the relapse rate. Among general risk factors, some could be modified, such as the duration of untreated psychosis or the substance misuse, while others could not be modified as male gender or low pre-morbid level of functioning.

CONCLUSION

Several classes of risk factors have been proved to be relevant in the risk of relapse. Thus, a careful assessment of the risk factors here identified should be performed in daily clinical practice in order to individualise the relapse risk for each patient and to provide a targeted treatment in high-risk subjects.

The course of negative symptoms over the first five years of treatment: Data from an early intervention program for psychosis

BACKGROUND

Cross-sectional studies suggest that negative symptoms are constituted by separable domains of reduced expressiveness and reduced motivation, but there is little data on the longitudinal course of these symptoms. We examined evidence for differences in the course and correlates of these two domains in a prospective study of patients presenting with a first episode of psychosis.

METHODS

Of 132 patients who were followed up for five years, it was possible to monitor reduced expressiveness and motivation on a weekly basis for 127. Information on treatment delay, premorbid adjustment, intellectual functioning, anxiety, depression and psychosocial functioning were also collected.

RESULTS

Over the five year follow-up, symptoms of reduced motivation occurred in 95.3% of patients and reduced expressiveness in 68.5%; and deficits in motivation were more likely to be unremitting (15.7%) than expressive deficits (5.5%). There were differences in the correlates of the proportion of time each patient experienced symptoms of each domain. Depression, weeks of full time occupation and weeks on a disability pension were associated with both domains. Anxiety was associated only with diminished motivation. Lower performance IQ; extrapyramidal symptoms (EPS) and dysrhythmic EEG were associated only with proportion of time showing reduced expressiveness.

CONCLUSIONS

The prospective data support previous cross-sectional findings that, while these domains of negative symptoms are correlated, they do show differences in prevalence over time and in their correlates.

Different outcomes of never-treated and treated patients with schizophrenia: 14-year follow-up study in rural China

BACKGROUND

The long-term outcome of never-treated patients with schizophrenia is unclear.

AIMS

To compare the 14-year outcomes of never-treated and treated patients with schizophrenia and to establish predictors for never being treated.

METHOD

All participants with schizophrenia (n = 510) in Xinjin, Chengdu, China were identified in an epidemiological investigation of 123 572 people and followed up from 1994 to 2008.

RESULTS

The results showed that there were 30.6%, 25.0% and 20.4% of patients who received no antipsychotic medication in 1994, 2004 and 2008 respectively. Compared with treated patients, those who were never treated in 2008 were significantly older, had significantly fewer family members, had higher rates of homelessness, death from other causes, being unmarried, living alone, being without a caregiver and poor family attitudes. Partial and complete remission in treated patients (57.3%) was significantly higher than that in the never-treated group (29.8%). Predictors of being in the never-treated group in 2008 encompassed baseline never-treated status, being without a caregiver and poor mental health status in 1994.

CONCLUSIONS

Many patients with schizophrenia still do not receive antipsychotic medication in rural areas of China. The 14-year follow-up showed that outcomes for the untreated group were worse. Community-based mental healthcare, health insurance and family intervention are crucial for earlier diagnosis, treatment and rehabilitation in the community.

The Theory of Industrial Society and Cultural Schemata: Does the "Cultural Myth of Stigma" Underlie the WHO Schizophrenia Paradox?

The WHO's International Studies of Schizophrenia conclude that schizophrenia may have a more benign course in "developing" societies than in the West. The authors focus on this finding's most common corollary: cultural schemata are shaped by the transition from agrarian to industrial society. Developing societies are viewed as traditional, gemeinschaft cultures lacking the stigmatizing beliefs about persons with mental illness held in modern, gesellschaft cultures of developed societies. The Stigma in Global Context-Mental Health Study formalized the cultural myth of public stigma (CMPS) with propositions linking level of development to intolerant, exclusionary, and individualistic attitudes. In 17 countries, the authors find no support for the corollary; where support is found, the findings are opposite expectations, with developed societies reporting lower stigma levels. Reconceptualizing of the cultural landscape on more specific dimensions also produces null or contrary findings. This correction to nostalgic myths of cultural context in developing societies thwarts misguided treatment, policy, and stigma-reduction efforts.

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.

Mortality in schizophrenia and other psychoses: a 10-year follow-up of the ӔSOP first-episode cohort

The excess mortality in people with psychotic disorders is a major public health concern, but little is known about the clinical and social risk factors which may predict this health inequality and help inform preventative strategies. We aimed to investigate mortality in a large epidemiologically characterized cohort of individuals with first-episode psychosis compared with the general population and to determine clinical and social risk factors for premature death. All 557 individuals with first-episode psychosis initially identified in 2 areas (Southeast London and Nottinghamshire, United Kingdom) were traced over a 10-year period in the ӔSOP-10 study. Compared with the general population, all-cause (standardized mortality ratio [SMR] 3.6, 95% confidence interval [CI] 2.6-4.9), natural-cause (SMR 1.7, 95% CI 1.0-2.7) and unnatural-cause (SMR 13.3, 95% CI 8.7-20.4) mortality was very high. Illicit drug use was associated with an increased risk of all-cause mortality (adj. rate ratio [RR] 2.31, 95% CI 1.06-5.03). Risk of natural-cause mortality increased with a longer time to first remission (adj. RR 6.61, 95% CI 1.33-32.77). Family involvement at first contact strongly reduced risk of unnatural-cause mortality (adj. RR 0.09, 95% CI 0.01-0.69). Our findings suggest that the mortality gap in people with psychotic disorders remains huge and may be wider for unnatural-cause mortality than previously reported. Efforts should now focus on further understanding and targeting these tractable clinical and social risk factors of excess mortality. Early intervention and dual diagnosis services may play a key role in achieving more rapid remission and carer involvement and addressing substance use problems to reduce excess mortality in psychosis.

Cognition and the prediction of functioning in patients with a first treated episode of psychosis: a prospective study

Past research on the role of cognitive performance in predicting later psychosocial functioning for individuals with first treated episode of a psychotic disorder has yielded inconsistent results. Several factors have been suggested as determining the strength of any such relationship including the type of functioning measured, time of the cognitive assessment, covariates included and the use of global versus specific measures of cognitive functioning. In the current study, we examined the importance of these factors in a five year prospective study of individuals with first episode psychotic disorders. Just over 80% of the sample had a schizophrenia spectrum disorder. Cognitive assessments were carried out after initiation of treatment on 113 patients, and at one year for 79 patients. There was evidence that cognition predicted occupational functioning and use of a disability pension, but not a summary index of functioning or use of supervised housing, at follow-up. Overall I.Q. was a more consistent predictor than measures of specific cognitive functions, and there was evidence that cognition assessed after presentation for treatment, particularly after a year of treatment, was more predictive of later functioning than premorbid I.Q. Cognitive functioning, however, did not add to the prediction of outcomes beyond the level possible using past educational achievement or academic premorbid adjustment.

Global mental health and its discontents: an inquiry into the making of global and local scale

Global Mental Health's (GMH) proposition to "scale up" evidence-based mental health care worldwide has sparked a heated debate among transcultural psychiatrists, anthropologists, and GMH proponents; a debate characterized by the polarization of "global" and "local" approaches to the treatment of mental health problems. This article highlights the institutional infrastructures and underlying conceptual assumptions that are invested in the production of the "global" and the "local" as distinct, and seemingly incommensurable, scales. It traces how the conception of mental health as a "global" problem became possible through the emergence of Global Health, the population health metric DALY, and the rise of evidence-based medicine. GMH also advanced a moral argument to act globally emphasizing the notion of humanity grounded in a shared biology and the universality of human rights. However, despite the frequent criticism of GMH promoting the "bio"-medical model, we argue that novel logics have emerged which may be more important for establishing global applicability than arguments made in the name of "nature": the procedural standardization of evidence and the simplification of psychiatric expertise. Critical scholars, on the other hand, argue against GMH in the name of the "local"; a trope that underlines specificity, alterity, and resistance against global claims. These critics draw on the notions of "culture," "colonialism," the "social," and "community" to argue that mental health knowledge is locally contingent. Yet, paying attention to the divergent ways in which both sides conceptualize the "social" and "community" may point to productive spaces for an analysis of GMH beyond the "global/local" divide.

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.

The Concept of Schizophrenia: From Unity to Diversity

After over 100 years of research without clarifying the aetiology of schizophrenia, a look at the current state of knowledge in epidemiology, genetics, precursors, psychopathology, and outcome seems worthwhile. The disease concept, created by Kraepelin and modified by Bleuler, has a varied history. Today, schizophrenia is considered a polygenic disorder with onset in early adulthood, characterized by irregular psychotic episodes and functional impairment, but incident cases occur at all ages with marked differences in symptoms and social outcome. Men’s and women’s lifetime risk is nearly the same. At young age, women fall ill a few years later and less severely than men, men more rarely and less severely later in life. The underlying protective effect of oestrogen is antagonized by genetic load. The illness course is heterogeneous and depressive mood the most frequent symptom. Depression and schizophrenia are functionally associated, and affective and nonaffective psychoses do not split neatly. Most social consequences occur at the prodromal stage. Neither schizophrenia as such nor its main symptom dimensions regularly show pronounced deterioration over time. Schizophrenia is neither a residual state of a neurodevelopmental disorder nor a progressing neurodegenerative process. It reflects multifactorial CNS instability, which leads to cognitive deficits and symptom exacerbations.

Factors contributing to the duration of untreated psychosis

BACKGROUND

Shortening the duration of untreated psychosis (DUP) - with the aim of improving the prognosis of psychotic disorders - requires an understanding of the causes of treatment delay. Current findings concerning several candidate risk factors of a longer DUP are inconsistent. Our aim was to identify factors contributing to DUP in a large sample that represents the treated prevalence of non-affective psychotic disorders.

METHOD

Patients with a non-affective psychotic disorder were recruited from mental health care institutes from 2004 to 2008. Of the 1120 patients enrolled, 852 could be included in the present analysis. Examined candidate factors were gender, educational level, migration status, premorbid adjustment and age at onset of the psychotic disorder. DUP was divided into five ordinal categories: less than one month, one month to three months, three months to six months, six months to twelve months and twelve months and over. An ordinal logistic regression analysis was used to identify the risk factors of a longer DUP.

RESULTS

Median DUP was less than one month (IQR 2). The factors migration status (p=0.028), age at onset of the psychotic disorder (p=0.003) and gender (p=0.034) were significantly associated with DUP in our analysis.

CONCLUSION

First generation immigrant patients, patients with an early onset of their psychotic disorder and male patients seem at risk of a longer DUP. These findings can assist in designing specific interventions to shorten treatment delay.

Cross-cultural invariance of the factor structure of the Schizotypal Personality Questionnaire across Spanish and American college students

The main goal of this study was to examine the cross-cultural invariance of the factor structure of the Schizotypal Personality Questionnaire (SPQ) (Raine, 1991) in two large samples of Spanish and American young adults. The final sample was made up of 2313 college students (508 men, 22%). Their mean age was 20.5 years (S.D.=3.2). The results indicated that the Stefanis et al. (2004) four-factor model yielded the best goodness-of-fit indices compared to alternative models. Moreover, the results support configural, metric, and partial measurement invariance of the covariances of the SPQ across the two samples. The finding of measurement equivalence across cultures provides essential evidence of construct validity for the schizotypy dimensions and of the cross-cultural validity of SPQ scores. The finding of comparable dimensional structures in cross-cultural samples lends further support to the continuum model of schizotypy and schizophrenia spectrum disorders. Future studies should continue to examine the validity of scores on the SPQ and other schizotypy measures and their variation or consistency across cultures.

Effectiveness of a community-based intervention for people with schizophrenia and their caregivers in India (COPSI): a randomised controlled trial

BACKGROUND

Observational evidence suggests that community-based services for people with schizophrenia can be successfully provided by community health workers, when supervised by specialists, in low-income and middle-income countries. We did the COmmunity care for People with Schizophrenia in India (COPSI) trial to compare the effectiveness of a collaborative community-based care intervention with standard facility-based care.

METHODS

We did a multicentre, parallel-group, randomised controlled trial at three sites in India between Jan 1, 2009 and Dec 31, 2010. Patients aged 16-60 years with a primary diagnosis of schizophrenia according to the tenth edition of the International Classification of Diseases, Diagnostic Criteria for Research (ICD-10-DCR) were randomly assigned (2:1), via a computer-generated randomisation list with block sizes of three, six, or nine, to receive either collaborative community-based care plus facility-based care or facility-based care alone. Randomisation was stratified by study site. Outcome assessors were masked to group allocation. The primary outcome was a change in symptoms and disabilities over 12 months, as measured by the positive and negative syndrome scale (PANSS) and the Indian disability evaluation and assessment scale (IDEAS). Analysis was by modified intention to treat. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN 56877013.

FINDINGS

187 participants were randomised to the collaborative community-based care plus facility-based care group and 95 were randomised to the facility-based care alone group; 253 (90%) participants completed follow-up to month 12. At 12 months, total PANSS and IDEAS scores were lower in patients in the intervention group than in those in the control group (PANSS adjusted mean difference -3.75, 95% CI -7.92 to 0.42; p=0.08; IDEAS -0.95, -1.68 to -0.23; p=0.01). However, no difference was shown in the proportion of participants who had a reduction of more than 20% in overall symptoms (PANSS 85 [51%] in the intervention group vs 44 [51%] in the control group; p=0.89; IDEAS 75 [48%] vs 28 [35%]). We noted a significant reduction in symptom and disability outcomes at the rural Tamil Nadu site (-9.29, -15.41 to -3.17; p=0.003). Two patients (one in each group) died by suicide during the study, and two patients died because of complications of a road traffic accident and pre-existing cardiac disease. 18 (73%) patients (17 in the intervention group) were admitted to hospital during the course of the trial, of whom seven were admitted because of physical health problems, such as acute gastritis and vomiting, road accident, high fever, or cardiovascular disease.

INTERPRETATION

The collaborative community-based care plus facility-based care intervention is modestly more effective than facility-based care, especially for reducing disability and symptoms of psychosis. Our results show that the study intervention is best implemented as an initial service in settings where services are scarce, for example in rural areas.

FUNDING

Wellcome Trust.

Cross-cultural comparisons of attitudes toward schizophrenia amongst the general population and physicians: a series of web-based surveys in Japan and the United States

Cross-cultural differences in attitudes toward schizophrenia are suggested, while no studies have compared such attitudes between the United States and Japan. In our previous study in Japan (Hori et al., 2011), 197 subjects in the general population and 112 physicians (excluding psychiatrists) enrolled in a web-based survey using an Internet-based questionnaire format. Utilizing the identical web-based survey method in the United States, the present study enrolled 172 subjects in the general population and 45 physicians. Participants' attitudes toward schizophrenia were assessed with the English version of the 18-item questionnaire used in our previous Japanese survey. Using exploratory factor analysis, we identified four factors labeled "social distance," "belief of dangerousness," "underestimation of patients' abilities," and "skepticism regarding treatment." The two-way multivariate analysis of covariance on the four factors, with country and occupation as the between-subject factors and with potentially confounding demographic variables as the covariates, revealed that the general population in the US scored significantly lower than the Japanese counterparts on the factors "social distance" and "skepticism regarding treatment" and higher on "underestimation of patients' abilities." Our results suggest that culture may have an important role in shaping attitudes toward mental illness. Anti-stigma campaigns that target culture-specific biases are considered important.

A survey of psychosis risk symptoms in Kenya

Defining the prepsychotic state in an effort to prevent illness progression and the development of disorders such as schizophrenia is a rapidly growing area of psychiatry. The presentation of psychotic symptoms can be influenced by culture; however, there has not been any previous assessment of psychosis risk symptoms in the continent of Africa. Our study aimed to measure the prevalence of psychosis risk in a community sample in Nairobi, Kenya, and to evaluate the effects of key demographic variables. A culturally modified version of the 12-item PRIME-Screen (mPRIME) was self-administered by 2758 youth (aged 14-29 years) recruited through house-to-house visits in Nairobi, Kenya. The prevalence and severity of psychosis risk items from the mPRIME and the effects of sex and age on symptoms were evaluated. k-Means cluster analysis was used to identify symptom groups. Depending on the mPRIME item, 1.8% to 19.5% of participants reported certainty of having had a psychosis risk symptom. Overall, 45.5% reported having had any psychosis risk symptom. Females had a significantly higher mean severity score on items evaluating persecutory ideation and auditory hallucinations. Symptom severity on 5 items showed a modest (R = 0.09-0.13) but significant correlation with age. Cluster analysis identified 4 groups of participants: normative (55%), high symptom (11%), intermediate symptom (19%), and grandiose symptom (15%). Psychosis risk symptoms appear to be highly prevalent in Kenyan youth. Longitudinal studies are needed to determine the correlation of identified symptoms with transition to psychotic illness, as well as the associated functionality and distress, to develop appropriate intervention strategies.

Five-year mortality in a cohort of people with schizophrenia in Ethiopia

BACKGROUND

Schizophrenia is associated with a two to three fold excess mortality. Both natural and unnatural causes were reported. However, there is dearth of evidence from low and middle income (LAMIC) countries, particularly in Africa. To our knowledge this is the first community based report from Africa.

METHODS

We followed a cohort of 307 (82.1% males) patients with schizophrenia for five years in Butajira, rural Ethiopia. Mortality was recorded using broad rating schedule as well as verbal autopsy. Standardized Mortality Ratio (SMR) was calculated using the mortality in the demographic and surveillance site as a reference.

RESULT

Thirty eight (12.4%) patients, 34 men (11.1%) and 4 women (1.3%), died during the five-year follow up period. The mean age (SD) of the deceased for both sexes was 35 (7.35). The difference was not statistically significant (p = 0.69). It was 35.3 (7.4) for men and 32.3 (6.8) for women. The most common cause of death was infection, 18/38 (47.4%) followed by severe malnutrition, 5/38 (13.2%) and suicide 4/38 (10.5%). The overall SMR was 5.98 (95% CI = 4.09 to 7.87). Rural residents had lower mortality with adjusted hazard ratio (HR) of 0.30 (95% CI = 0.12-0.69) but insidious onset and antipsychotic treatment for less than 50% of the follow up period were associated with higher mortality, adjusted HR 2.37 (95% CI = 1.04-5. 41) and 2.66(1.054-6.72) respectively.

CONCLUSION

The alarmingly high mortality observed in this patient population is of major concern. Most patients died from potentially treatable conditions. Improving medical and psychiatric care as well as provision of basic needs is recommended.

Personality disorders in later life: questions about the measurement, course, and impact of disorders

Lifespan perspectives have played a crucial role in shaping our understanding of many forms of psychopathology. Unfortunately, little attention has been given to personality disorders in middle adulthood and later life. Several issues are responsible for this deficiency, including difficulty applying the diagnostic criteria for personality disorders to older people and challenges in identifying appropriate samples of older participants. The goal of this review is to explore the benefits of considering older adults in the study of personality disorders. Later life offers a unique opportunity for investigators to consider links between personality pathology and consequential outcomes in people's lives. Many domains are relevant, including health, longevity, social adjustment, marital relationships, and the experience of major life events. We review each domain and consider ways in which the study of middle-aged and older adults challenges researchers to evaluate how personality disorders in general are defined and measured.

Collaborative community based care for people and their families living with schizophrenia in India: protocol for a randomised controlled trial

BACKGROUND

There is a large treatment gap with few community services for people with schizophrenia in low income countries largely due to the shortage of specialist mental healthcare human resources. Community based rehabilitation (CBR), involving lay health workers, has been shown to be feasible, acceptable and more effective than routine care for people with schizophrenia in observational studies. The aim of this study is to evaluate whether a lay health worker led, Collaborative Community Based Care (CCBC) intervention, combined with usual Facility Based Care (FBC), is superior to FBC alone in improving outcomes for people with schizophrenia and their caregivers in India.

METHODS/DESIGN

This trial is a multi-site, parallel group randomised controlled trial design in India.The trial will be conducted concurrently at three sites in India where persons with schizophrenia will be screened for eligibility and recruited after providing informed consent. Trial participants will be randomly allocated in a 2:1 ratio to the CCBC+FBC and FBC arms respectively using an allocation sequence pre-prepared through the use of permuted blocks, stratified within site. The structured CCBC intervention will be delivered by trained lay community health workers (CHWs) working together with the treating Psychiatrist. We aim to recruit 282 persons with schizophrenia. The primary outcomes are reduction in severity of symptoms of schizophrenia and disability at 12 months. The study will be conducted according to good ethical practice, data analysis and reporting guidelines.

DISCUSSION

If the additional CCBC intervention delivered by front line CHWs is demonstrated to be effective and cost-effective in comparison to usually available care, this intervention can be scaled up to expand coverage and improve outcomes for persons with schizophrenia and their caregivers in low income countries.

TRIAL REGISTRATION

The trial is registered with the International Society for the Registration of Clinical Trials and the allocated unique ID number is ISRCTN 56877013.

Clinical course and outcome of schizophrenia in a predominantly treatment-naive cohort in rural Ethiopia

The established view that schizophrenia may have a favorable outcome in developing countries has been recently challenged; however, systematic studies are scarce. In this report, we describe the clinical outcome of schizophrenia among a predominantly treatment-naive cohort in a rural community setting in Ethiopia. The cohort was identified in a 2-stage sampling design using key informants and measurement-based assessment. Follow-up assessments were conducted monthly for a mean duration of 3.4 years (range 1-6 years). After screening 68 378 adults, ages 15-49 years, 321 cases with schizophrenia (82.7% men and 89.6% treatment naive) were identified. During follow-up, about a third (30.8%) of cases were continuously ill while most of the remaining cohort experienced an episodic course. Only 5.7% of the cases enjoyed a near-continuous complete remission. In the final year of follow-up, over half of the cases (54%) were in psychotic episode, while 17.6% were in partial remission and 27.4% were in complete remission for at least the month preceding the follow-up assessment. Living in a household with 3 or more adults, later age of onset, and taking antipsychotic medication for at least 50% of the follow-up period predicted complete remission. Although outcome in this setting appears better than in developed countries, the very low proportion of participants in complete remission supports the recent observation that the outcome of schizophrenia in developing countries may be heterogeneous rather than uniformly favorable. Improving access to treatment may be the logical next step to improve outcome of schizophrenia in this setting.

Rethinking theoretical approaches to stigma: a Framework Integrating Normative Influences on Stigma (FINIS)

A resurgence of research and policy efforts on stigma both facilitates and forces a reconsideration of the levels and types of factors that shape reactions to persons with conditions that engender prejudice and discrimination. Focusing on the case of mental illness but drawing from theories and studies of stigma across the social sciences, we propose a framework that brings together theoretical insights from micro, meso and macro level research: Framework Integrating Normative Influences on Stigma (FINIS) starts with Goffman's notion that understanding stigma requires a language of social relationships, but acknowledges that individuals do not come to social interaction devoid of affect and motivation. Further, all social interactions take place in a context in which organizations, media and larger cultures structure normative expectations which create the possibility of marking "difference". Labelling theory, social network theory, the limited capacity model of media influence, the social psychology of prejudice and discrimination, and theories of the welfare state all contribute to an understanding of the complex web of expectations shaping stigma. FINIS offers the potential to build a broad-based scientific foundation based on understanding the effects of stigma on the lives of persons with mental illness, the resources devoted to the organizations and families who care for them, and policies and programs designed to combat stigma. We end by discussing the clear implications this framework holds for stigma reduction, even in the face of conflicting results.

Biological, life course, and cross-cultural studies all point toward the value of dimensional and developmental ratings in the classification of psychosis

The diagnostic criteria for schizophrenia in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) are based on the premise that it is a discrete illness entity, in particular, distinct from the affective psychoses. This assumption has persisted for more than a century, even though patients with a diagnosis of schizophrenia show a wide diversity of symptoms and outcomes, and no biological or psychological feature has been found to be pathognomonic of the disorder. However, there has been sustained, and indeed growing, criticism of the concept. For example, writing about the diagnosis of schizophrenia more than a decade ago,2 one of Britain's most sophisticated nosological experts, Ian Brockington, enjoined "It is important to loosen the grip which the concept of 'schizophrenia' has on the minds of psychiatrists. Schizophrenia is an idea whose very essence is equivocal, a nosological category without natural boundaries, a barren hypothesis. Such a blurred concept is 'not a valid object of scientific enquiry'."3 Should Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition(DSM-V), persist with the neo-Kraepelinian concept of schizophrenia with all its defects, or should it deconstruct psychosis into its component dimensions? In this article, we will address the question by considering 2 main themes, firstly, the role of culture and ethnicity in the diagnosis of psychosis, and secondly, a life course approach to understanding psychosis. We will then discuss whether more progress would be achieved in DSM-V by abandoning the familiar categorical system and instead moving to a dimensional system which rates both developmental impairment and symptom factor scores. However, we will begin by briefly reviewing the recent history of the classification of the psychoses.

Stigmatization of severe mental illness in India: Against the simple industrialization hypothesis

BACKGROUND

Major international studies on course and outcome of schizophrenia suggest a better prognosis in the rural world and in low-income nations. Industrialization is thought to result in increased stigma for mental illness, which in turn is thought to worsen prognosis. The lack of an ethnographically derived and cross-culturally valid measure of stigma has hampered investigation. The present study deploys such a scale and examines stigmatizing attitudes towards the severely mentally ill among rural and urban community dwellers in India.

AIM

To test the hypothesis that there are fewer stigmatizing attitudes towards the mentally ill amongst rural compared to urban community dwellers in India.

MATERIALS AND METHODS

An ethnographically derived and vignette-based stigmatization scale was administered to a general community sample comprising two rural and one urban site in India. Responses were analyzed using univariate and multivariate statistical methods.

RESULT

Rural Indians showed significantly higher stigma scores, especially those with a manual occupation. The overall pattern of differences between rural and urban samples suggests that the former deploy a punitive model towards the severely mentally ill, while the urban group expressed a liberal view of severe mental illness. Urban Indians showed a strong link between stigma and not wishing to work with a mentally ill individual, whereas no such link existed for rural Indians.

CONCLUSION

This is the first study, using an ethnographically derived stigmatization scale, to report increased stigma amongst a rural Indian population. Findings from this study do not fully support the industrialization hypothesis to explain better outcome of severe mental illness in low-income nations. The lack of a link between stigma and work attitudes may partly explain this phenomenon.

A 15-year follow-up of schizophrenia in Ireland

OBJECTIVES

Psychiatric hospitalisation rates in Ireland have been high. Recent studies indicate that this is not a consequence of raised incidence. This study explored the possibility that poor outcome may have been responsible for this high hospitalisation prevalence.

METHOD

Through participation in the WHO Study, Determinants of Outcome of Severe Mental Disorders (DOSMeD), we followed up a cohort of 67 first-onset schizophrenic patients over 15 years to determine symptomatic and functional outcomes and to compare these with outcomes of the cohorts recruited to the International Study of Schizophrenia (ISoS).

RESULTS

Thirty-seven (55%) of the original 67 were successfully followed up over 15 years and, of these, 43% were continuously psychotic for most of the period; a similar proportion had recurrent episodes of illness; two-thirds of subjects had moderate to severe symptoms for most of the time; and, in terms of functional outcome, over four-fifths were unemployed at follow-up.

CONCLUSIONS

Outcome for the majority of followed-up patients was poor in symptomatic and functional terms. While this outcome was one of the poorest among the DOSMeD groups the question whether functional psychotic illness outcome is inherently poorer in Ireland than elsewhere remains unanswered. The high rate of attrition (45%) from the group during the follow-up period vitiated interpretation of outcome overall. The high number of suicides among the group was noteworthy.