Methodological aspects of onset assessment in schizophrenia

Factors influencing the validity of relatives' reports about symptoms of first-episode schizophrenia

Valid information on the early course of schizophrenia is necessary for clinical and research purposes, for example, to determine the onset of the disorder. Since reports given by psychotic patients are questionable, relatives are often asked about their observations. In order to test the quality of these reports, the recollections of emerging symptomatology were assessed systematically from 30 recent onset, postpsychotic schizophrenic patients and from 69 informants (mostly their close relatives) by means of the Interview for the Retrospective Assessment of the Onset of Schizophrenia (IRAOS). Patient-informant agreement rates like kappa were compared between the relatives of every single case. Multiple regression analyses demonstrated that personality and attributional factors, particularly causal attributions and the image the informant has about him/herself and about the patient, determine the quality of the informants' reports. Highest kappas over all symptoms, for instance, were reached by relatives who described the patient as “dominant” and themselves as “reserved”, and who attributed the disease to current psychosocial stress. Long and close contact to the patient tends to impair the quality of reports.

Prediction of duration of psychosis before first admission

Objective:

To assess the factors predicting the delay between onset of psychotic symptoms and first admission in a populationbased sample.

Method:

The duration of psychosis before admission was ascertained in a standardised way for 59 consecutively first-admitted patients presenting with psychotic symptoms.

Results:

The median of the duration of psychosis before admission was 3 months (interquartile range 0.5-14). A delay ≥ 3 months was independently predicted by family history of psychiatric hospitalisation (odds ratio [OR] = 12.1, 95% confidence interval [CI] 1.15-97.0, P = 0.02). low educational level (OR = 7.7, 95% CI 1.0-50.0, P = 0.05), poor global adjustment in the preceding year (OR = 0.93, 95% CI 0.860.99, P = 0.04). and by greater global severity of illness at admission (OR = 4.0, 95% CI 0.87-18.3, P = 0.07).

Conclusion:

As these factors are also known to predict poor outcome, our results suggest that the association between duration of untreated psychosis and poor prognosis may be mediated, at least in part, by such demographic and clinical variables.

Age of onset group characteristics in forensic patients with schizophrenia

This study aims to empirically identify age of onset groups and their clinical and background characteristics in forensic patients with schizophrenia. Hospital charts were reviewed of all 138 forensic patients with schizophrenia admitted to Geha Psychiatric Hospital that serves a catchment area of approximately 500,000 people, from 2000 to 2009 inclusive. Admixture analysis empirically identified early- (M = 19.99, SD = 3.31) and late-onset groups (M = 36.13, SD = 9.25). Early-onset was associated with more suicide attempts, violence before the age of 15, and early conduct problems, whereas late-onset was associated with a greater likelihood of violence after the age of 18 and marriage (P < 0.01). The current findings provide clinicians with a unique direction for risk assessment and indicate differences in violence between early- and late-onset schizophrenia, particularly co-occurrence of harmful behavioral phenotypes.

Antisaccade and prosaccade eye movements in individuals clinically at risk for psychosis: comparison with first-episode schizophrenia and prediction of conversion

Saccadic eye movements are well-described markers of cerebral function and have been widely studied in schizophrenia spectrum populations. However, less is known about saccades in individuals clinically at risk for schizophrenia. Therefore, we studied individuals in an at-risk mental state (ARMS) (N = 160), patients in their first episode of schizophrenia (N = 32) and healthy controls (N = 75). N = 88 ARMS participants showed an early at-risk mental state (E-ARMS), defined by cognitive-perceptive basic symptoms (COPER) or a combination of risk and loss of function, whereas N = 72 were in a late at-risk mental state (L-ARMS), defined by attenuated psychotic symptoms or brief limited intermittent psychotic symptoms. We examined prosaccades, reflecting overt attentional shifts, and antisaccades, measuring inhibitory control, as well as their relationship as an indicator of the interplay of bottom-up and top-down influences. L-ARMS but not E-ARMS participants had increased antisaccade latencies compared to controls. First-episode patients had higher antisaccade error rates compared to E-ARMS participants and controls, and increased latencies compared to all other groups. Prosaccade latencies did not differ between groups. We observed the expected negative correlation between prosaccade latency and antisaccade error rate, indicating that individuals with shorter prosaccade latencies made more antisaccade errors. The magnitude of the association did not differ between groups. No saccadic measure predicted conversion to psychosis within 2 years. These findings confirm the existence of antisaccade impairments in patients with schizophrenia and provide evidence that volitional response generation in the antisaccade task may be affected even before onset of clinically overt psychosis.

Duration of unspecific prodromal and clinical high risk states, and early help-seeking in first-admission psychosis patients

PURPOSE

Prevention of psychosis requires both presence of clinical high risk (CHR) criteria and early help-seeking. Previous retrospective studies of the duration of untreated illness (i.e. prodrome plus psychosis) did not distinguish between prodromal states with and without CHR symptoms. Therefore, we examined the occurrence of CHR symptoms and first help-seeking, thereby considering effects of age at illness-onset.

METHODS

Adult patients first admitted for psychosis (n = 126) were retrospectively assessed for early course of illness and characteristics of first help-seeking.

RESULTS

One-hundred and nine patients reported a prodrome, 58 with CHR symptoms. In patients with an early illness-onset before age 18 (n = 45), duration of both illness and psychosis were elongated, and CHR symptoms more frequent (68.9 vs. 33.3 %) compared to those with adult illness-onset. Only 29 patients reported help-seeking in the prodrome; this was mainly self-initiated, especially in patients with an early illness-onset. After the onset of first psychotic symptoms, help-seeking was mainly initiated by others. State- and age-independently, mental health professionals were the main first point-of-call (54.0 %).

CONCLUSIONS

Adult first-admission psychosis patients with an early, insidious onset of symptoms before age 18 were more likely to recall CHR symptoms as part of their prodrome. According to current psychosis-risk criteria, these CHR symptoms, in principle, would have allowed the early detection of psychosis. Furthermore, compared to patients with an adult illness-onset, patients with an early illness-onset were also more likely to seek help on their own account. Thus, future awareness strategies to improve CHR detection might be primarily related to young persons and self-perceived subtle symptoms.

Reliability and validity of methods for measuring the duration of untreated psychosis: a quantitative review and meta-analysis

BACKGROUND

The duration of untreated psychosis (DUP) has been associated with a wide range of clinical outcomes, and is considered to be one of the key parameters in managing clinical high risk and first episode psychosis patients. However, considerable discrepancies exist in the way that DUP is estimated in different studies. There is no standard or consensus on which method is most reliable and valid for assessing DUP.

METHODS

This review aimed to quantitatively assess different DUP measurement instruments and definitions by comparing their inter-rater reliability, and their strength of validity in predicting biological and clinical outcomes.

RESULTS

Nine instruments designed for measuring DUP were found. Their inter-rater reliability were found to be adequate to excellent, although quite varied. This analysis did not show that any instrument was clearly outstanding compared to the others, although the limited available data do not exclude this possibility. DUP was also significantly associated with a range of outcomes, although mostly with small effect sizes. However, non-instrument based, ad hoc clinical interviews remained the most common way of measuring DUP. Definitions of onset of psychosis and onset of treatment were inconsistent among studies.

CONCLUSIONS

This review did not find quantitative evidence to support the use of one instrument over another. DUP remains a promising modifiable risk factor for a range of long-term clinical outcomes. Future research should quantify and improve the reliability and validity of the structured instruments for DUP measurement.

Improving the clinical prediction of psychosis by combining ultra-high risk criteria and cognitive basic symptoms

OBJECTIVE

Cognitive impairments are regarded as a core component of schizophrenia. However, the cognitive dimension of psychosis is hardly considered by ultra-high risk (UHR) criteria. Therefore, we studied whether the combination of symptomatic UHR criteria and the basic symptom criterion "cognitive disturbances" (COGDIS) is superior in predicting first-episode psychosis.

METHOD

In a naturalistic 48-month follow-up study, the conversion rate to first-episode psychosis was studied in 246 outpatients of an early detection of psychosis service (FETZ); thereby, the association between conversion, and the combined and singular use of UHR criteria and COGDIS was compared.

RESULTS

Patients that met UHR criteria and COGDIS (n=127) at baseline had a significantly higher risk of conversion (hr=0.66 at month 48) and a shorter time to conversion than patients that met only UHR criteria (n=37; hr=0.28) or only COGDIS (n=30; hr=0.23). Furthermore, the risk of conversion was higher for the combined criteria than for UHR criteria (n=164; hr=0.56 at month 48) and COGDIS (n=158; hr=0.56 at month 48) when considered irrespective of each other.

CONCLUSIONS

Our findings support the merits of considering both COGDIS and UHR criteria in the early detection of persons who are at high risk of developing a first psychotic episode within 48months. Applying both sets of criteria improves sensitivity and individual risk estimation, and may thereby support the development of stage-targeted interventions. Moreover, since the combined approach enables the identification of considerably more homogeneous at-risk samples, it should support both preventive and basic research.

Shades of vulnerability: latent structures of clinical caseness in prodromal and early phases of schizophrenia

The underlying structures of clinical caseness and need of care in prodromal (i.e., at-risk) and early phases of schizophrenia remain poorly characterized in their essential psycho-behavioral coherence. To identify the schizophrenia proneness-related subtypes within a population of young help-seekers referred to a dedicated, community-based early detection program (Programma 2000). A sample of consecutive referrals (n = 168) for suspected psychosis or first-episode schizophrenia spectrum psychosis received a detailed clinical assessment, including the early recognition inventory for the retrospective assessment of the onset of schizophrenia checklist. We used exploratory factor analysis (EFA) to determine the underlying dimensional structure and latent class analysis (LCA) to identify putative vulnerability subtypes. EFA identified four factors: dysphoria (irritability tension), paranoid autocentrism, introversive withdrawal, and disturbed subjective experience. LCA distinguished three classes, interpretable as carrying different degrees of "proneness to schizophrenia psychosis," which best captured the underlying continuum of clinical severity. The validity of the three classes was supported by distinct patterns of association with major clinical variables (i.e., diagnostic staging at referral). Vulnerability to schizophrenia psychosis in young help-seekers may manifest in three major clinical prototypes, presenting common levels of dysphoria and social withdrawal but different degrees of paranoid autocentrism and disturbed subjective experience. Overall, the results provide the empirical background to dissect shared features of clinical caseness from more schizophrenia-specific vulnerability components. This is of value for the refinement of the clinical staging model as well as for the pragmatic implementation of multiple-gate screening programs.

The characteristics and outcomes of hospitalised and outpatient-treated first-onset schizophrenia patients: a 5-year register linkage study

AIM

We compared the course and outcome of schizophrenia in two groups: (i) hospitalised patients (HP) (n = 5980) who were identified based on their first hospital admission for schizophrenia and (ii) outpatient-treated patients (OTP) who received disability pension because of schizophrenia but who had no hospital admissions for schizophrenia or other psychotic disorder before having been granted a disability pension for schizophrenia (n = 1220). Outcomes were compared using data on mortality, psychiatric hospital utilisation, relapse rate and occupational functioning.

METHODS

A nationwide register-based 5-year follow-up study of all first-onset schizophrenia cases between 1998 and 2003 in Finland. The data were linked with the register information of hospital admissions, disability pensions and National Causes of Death Registers.

RESULTS

When outcome of treatment was evaluated using mortality rate, relapses, hospital treatment and involuntary admissions as outcome measures, results indicated that OTP group had got along better with their illnesses than HP group. The mortality rates, number of psychiatric treatment days and relapse rate during the 5-year follow up were significantly lower in OTP group. Within the OTP group, there was a notable subgroup of never HP (n = 737, 60.4%), who did not require any psychiatric hospitalisation during the 5-year follow up.

CONCLUSIONS

Patients first identified as outpatients had better outcomes than patients first identified following a hospitalisation. Future studies are required to establish whether outpatient treatment is associated with more favourable prognosis, even after fully adjusting for severity of initial symptoms. The higher suicide mortality of hospital-treated patients suggests that hospital treatment of first-onset patients does not protect from suicide.

Schizophrenia spectrum disorders in later life: prevalence and distribution of age at onset and sex in a dutch catchment area

OBJECTIVES

The prevalence of schizophrenia in later life is affected by both outflow of early onset patients, due to recovery and excess mortality, and inflow of patients with a later age at onset, making it likely that characteristics of older patients differ markedly from younger patients. We assessed the prevalence of schizophrenia and spectrum disorders and their distribution according to age at onset and sex in an elderly population.

DESIGN

Case register study.

SETTING AND PARTICIPANTS

All patients age 60 years and older, in contact with the Mental Health Organization in a psychiatric catchment area in Amsterdam (the Netherlands), diagnosed with schizophrenia, schizoaffective disorder, or delusional disorder.

MEASUREMENTS

One-year prevalence estimates, including rates according to age group, age at onset, and sex. In addition, we determined the effect of using different criteria for age at onset.

RESULTS

The one-year prevalence of all disorders was 0.71%, subdivided in 0.55% for schizophrenia, 0.14% for schizoaffective disorder, and 0.03% for delusional disorder. The one-year prevalence of early-onset schizophrenia was 0.35%, of late-onset schizophrenia 0.14%, and of very-late-onset schizophrenia-like psychosis 0.05%. Variation of onset criterion affected the proportion of early-onset versus late-onset schizophrenia patients stronger in women than in men. Women outnumbered men markedly in the prevalence estimates for most diagnostic subgroups, including early-onset schizophrenia.

CONCLUSIONS

We found the prevalence of schizophrenia among older persons to be well within the range reported for younger populations. The considerable proportion with a later age at onset and the strong female preponderance are distinguishing characteristics of older patients with clinical implications.

Five-year follow-up study of disability pension rates in first-onset schizophrenia with special focus on regional differences and mortality

OBJECTIVE

To evaluate the rate and regional determinants of disability pension in first-admission schizophrenia. In addition, we investigated whether patients with disability pension had increased mortality rates during follow-up.

METHOD

A nationwide register-based 5-year follow-up study of all patients with onset of schizophrenia between 1998 and 2001 (n=3,875).

RESULTS

A total of 1944 (50.2%) first-onset schizophrenia patients retired on disability pension during the 5-year follow-up. Males retired on pension at an earlier age and more often than females. Regional disability pension rates and retirement times for schizophrenia varied between hospital districts. Patients on disability pension had lower overall and suicide mortality, and they had less physical illness, depression and more psychotropic medication use than patients without disability pension. In regions with a short median time from onset time to retirement, there was significantly higher regional overall mortality and suicide mortality. Disability pension rates were also higher in regions with high involuntary treatment rate.

CONCLUSION

Half of the schizophrenia patients were pensioned off in 5 years. Lower mortality, especially suicide mortality among disability pensioners, suggests that the decision on a permanent disability pension, indicating for its part the activation of the service system, might be a relief to schizophrenic patients, helping them cope with illness. The retirement process has regional differences, which may be caused by the regional nature of treatment and resources.

Prediction of psychosis by mismatch negativity

BACKGROUND

To develop risk-adapted prevention of psychosis, an accurate estimation of the individual risk of psychosis at a given time is needed. Inclusion of biological parameters into multilevel prediction models is thought to improve predictive accuracy of models on the basis of clinical variables. To this aim, mismatch negativity (MMN) was investigated in a sample clinically at high risk, comparing individuals with and without subsequent conversion to psychosis.

METHODS

At baseline, an auditory oddball paradigm was used in 62 subjects meeting criteria of a late risk at-state who remained antipsychotic-naive throughout the study. Median follow-up period was 32 months (minimum of 24 months in nonconverters, n = 37). Repeated-measures analysis of covariance was employed to analyze the MMN recorded at frontocentral electrodes; additional comparisons with healthy controls (HC, n = 67) and first-episode schizophrenia patients (FES, n = 33) were performed. Predictive value was evaluated by a Cox regression model.

RESULTS

Compared with nonconverters, duration MMN in converters (n = 25) showed significantly reduced amplitudes across the six frontocentral electrodes; the same applied in comparison with HC, but not FES, whereas the duration MMN in in nonconverters was comparable to HC and larger than in FES. A prognostic score was calculated based on a Cox regression model and stratified into two risk classes, which showed significantly different survival curves.

CONCLUSIONS

Our findings demonstrate the duration MMN is significantly reduced in at-risk subjects converting to first-episode psychosis compared with nonconverters and may contribute not only to the prediction of conversion but also to a more individualized risk estimation and thus risk-adapted prevention.

Early and broadly defined psychosis risk mental states

Current definitions of the prodromal (or at-risk mental state) phase of schizophrenia include attenuated and/or transient psychotic symptoms as well as a combination of different risk indicators and a recent significant deterioration in global functioning. Data accumulated to date suggest rates of conversion to frank psychosis within two years in 25 to 40% of cases supporting the validity of these criteria. However, at this late phase of illness, functional deterioration is often already pronounced, highlighting the need for earlier identification. Moreover, negative symptoms and social impairments, cognitive deficits, other non-psychotic psychopathology and/or functional decline and non-specific biological indicators, often can be detected well before the at-risk mental state as currently defined; indicating that a broad characterization of an earlier stage may be possible. Identifying specific criteria to define this group of individuals, starting from the framework of familial high-risk, can help define a broader group of people, including earlier at-risk mental states, for future research. The hope is that this research will help facilitate intervention at earlier stages that may in turn minimize functional deterioration, and delay, attenuate or even prevent transition to psychosis. The disadvantages as well as the potential benefits of this approach are discussed.

Estrogens and men with schizophrenia: is there a case for adjunctive therapy?

Adjunctive use of estrogen therapy has been shown to be effective in enhancing the treatment of schizophrenia in women. In men, consideration of estrogen therapy has been impacted by concerns of feminising side effects, however, clinical trials of the use of estrogen in treating prostate cancer, bone density loss and even aggression and psychosis in dementia or traumatic brain injury, show this to be a safe and effective therapy. The current 14-day randomised placebo-controlled trial in 53 men with schizophrenia was conducted to evaluate the efficacy of 2 mg oral estradiol valerate as an adjunct to atypical antipsychotic treatment. Results demonstrated for estradiol participants a more rapid reduction in general psychopathology that occurred in the context of greater increases in serum estrogen levels and reductions in FSH and testosterone levels. Approximately 28% of estradiol participants did not achieve an increase (at least a 50% from baseline) in serum estrogen suggesting that further research is needed to refine the type, dose and administration route for estrogen therapy in men. Findings do, however, suggest further exploration of a therapeutic role for adjunctive estradiol treatment in men with schizophrenia is warranted.

Deficient maturation of aspects of attention and executive functions in early onset schizophrenia

The few existing long-term, neuropsychological follow-up studies of early onset schizophrenia (EOS) patients have reported relative stability in some cognitive functions but abnormal developmental trajectories in verbal memory, set shifting, aspects of attention, and speed of information processing throughout late adolescence into early adulthood. The current 5-year follow-up study compared the development of specific cognitive functions in EOS patients (N = 17) from the time of first-episode to chronic phase with that of healthy controls (N = 38) and secondarily to patients with other early onset, non-organic, non-affective psychoses (EOP) (N = 11). Speed of processing of executive functions, set shifting, and attention improved significantly in the healthy controls and reflected continuous functional maturation during late adolescence and early adulthood. The developmental progression of attention and set shifting but not speed of processing of executive functions was significantly subnormal in EOS patients. Other specific cognitive functions that had attained functional maturity in the healthy controls before or around the time of the baseline assessment showed normal development in EOS patients during the follow-up period, indicating stable cognitive deficits. These results suggest post-onset developmental deficits in two out of the three aspects of attention and executive functions that have protracted maturational trajectories and that overlap the age of onset of EOS. No significant difference in the development of any specific cognitive function was found between the EOS and EOP group.

Course of intelligence deficits in early onset, first episode schizophrenia: a controlled, 5-year longitudinal study

Only few prospective longitudinal studies have assessed the course of intelligence deficits in early onset schizophrenia (EOS), and these have used different age appropriate versions of Wechsler Intelligence Scales and age appropriate norms. The post-psychotic development of intelligence in EOS has predominantly been characterized as relatively stable in these studies. However, comparisons of IQs from different test versions based on the different norms may not permit unequivocal interpretations. The objective of the current study was to compare the development of intelligence in EOS patients (N = 10) from their first psychotic episode to 5 years of post onset with that of healthy controls (N = 35) and patients who at baseline had been diagnosed with other non-affective psychoses (N = 8). The same version of a Wechsler Intelligence Scale was administered at both baseline and follow-up assessments, and the same norms were used to derive IQs at baseline and follow-up. Significantly smaller change in mean full scale intelligence quotient (FSIQ) was found in diagnostically stable EOS patients compared with healthy controls during the follow-up period. However, no statistically significant difference in mean FSIQ change was observed between patients with EOS and patients with other non-affective psychoses, although this result must be interpreted with caution due to the small sample sizes. The results suggest abnormally slow acquisition of new intellectual information and skills in EOS patients during the first 5 years after full clinical presentation.

Basic symptoms and ultrahigh risk criteria: symptom development in the initial prodromal state

Symptom development during the prodromal phase of psychosis was explored retrospectively in first-episode psychosis patients with special emphasis on the assumed time-related syndromic sequence of "unspecific symptoms (UN)-predictive basic symptoms (BS)-attenuated psychotic symptoms (APS)-(transient) psychotic symptoms (PS)." Onset of syndromes was defined by first occurrence of any of their respective symptoms. Group means were inspected for time differences between syndromes and influence of sociodemographic and clinical characteristics on the recalled sequence. The sequence of "UN-BS/APS-PS" was clearly supported, and both BS and, though slightly less, APS were highly sensitive. However, onset of BS and APS did not show significant time difference in the whole sample (N = 126; 90% schizophrenia), although when each symptom is considered independently, APS tended to occur later than first predictive BS. On descriptive level, about one-third each recalled an earlier, equal and later onset of BS compared with APS. Level of education showed the greatest impact on the recall of the hypothesized sequence. Thereby, those with a higher school-leaving certificate supported the assumed sequence, whereas those of low educational background retrospectively dated APS before BS. These findings rather point out recognition and recall bias inherent to the retrospective design than true group characteristics. Future long-term prospective studies will have to explore this conclusively. However, as regards the criteria, the results support the notion of BS as at least a complementary approach to the ultrahigh risk criteria, which may also allow for an earlier detection of psychosis.

Review of the operational definition for first-episode psychosis

AIM

Given the growing interest in the study of first-episode psychosis, clinical and research programmes would benefit from a conceptual clarification of how to operationalize 'first-episode psychosis'. We review the variety of definitions in use and discuss their relative merits with respect to both clinical (e.g. early treatment) and research (e.g. obtaining meaningfully homogeneous populations) agendas.

METHODS

We completed a selective review of the literature to investigate how first-episode psychosis was operationally defined.

RESULTS

Operational definitions for 'first-episode psychosis' fall largely into three categories: (i) first treatment contact; (ii) duration of antipsychotic medication use; and (iii) duration of psychosis. Each definitional category contains a number of underlying assumptions that contribute to the strengths and weaknesses of the definition.

CONCLUSIONS

The term 'first-episode psychosis' as used within clinical and research settings is misleading regardless of which operational definition is used. This term is typically used to refer to individuals early in the course of a psychotic illness or treatment rather than individuals who are truly in the midst of a first 'episode' of illness. The alternative of 'recent-onset psychosis' with related definitions based on 'duration of psychosis' is proposed. Based on this review, we provide suggestions with regard to the overarching pragmatic consideration of setting up a clinical service that can attract and assemble a population of early psychosis patients for the related purposes of treatment and research.

The association between pre-morbid adjustment, duration of untreated psychosis and outcome in first-episode psychosis

BACKGROUND

The association between the duration of untreated psychosis (DUP) and outcome of schizophrenia may be confounded by other factors such as poor pre-morbid adjustment. The aim of the present study was to examine the independent contributions of DUP and of pre-morbid adjustment to the clinical and social outcomes of schizophrenia.

METHOD

A longitudinal, prospective, 2-year follow-up study of 423 patients with first-episode schizophrenia-spectrum psychosis was conducted. Patients were comprehensively assessed at entry, 1-year and 2-year follow-up. At entry, DUP was measured by IRAOS (an instrument for the assessment of onset and early course of schizophrenia) and pre-morbid adjustment was measured by the Pre-morbid Adjustment Scale (PAS) as 'pre-morbid social adaptation' and 'pre-morbid school adaptation'. Outcome measures included the Scale for the Assessment of Positive Symptoms (SAPS), the Scale for the Assessment of Negative Symptoms (SANS), the Social Network Schedule and social information. Multiple linear regression models were used for data analysis.

RESULTS

The median DUP was 48 weeks, which is long compared to other studies. Longer DUP was independently associated with more psychotic symptoms at entry, 1-year and 2-year follow-up. Poorer pre-morbid social adaptation was independently associated with more negative symptoms and smaller social network at entry and 1-year follow-up. Poorer pre-morbid school adaptation was independently associated with poor vocational outcome at 1-year and 2-year follow-up.

CONCLUSIONS

Longer DUP is associated with poorer 2-year outcome of psychosis in schizophrenia-spectrum disorders, when pre-morbid functioning and other prognostic factors are controlled for. Impaired pre-morbid development is independently associated with more negative symptoms and poorer social outcome.

Does a detection team shorten duration of untreated psychosis?

INTRODUCTION

Duration of untreated psychosis (DUP) is shown to be associated with poor outcome in many domains. It has been shown that it is possible to shorten DUP when combining a detection team and an information campaign. The aim of this study was to evaluate whether DUP was shortened during the first 3 years after establishing detection teams without a concomitant information campaign.

METHODS

All patients included in the OPUS trial were examined with the Instrument for Retrospective Assessment of Onset of Psychosis to determine DUP. A total of 552 patients with first episode psychotic disorder (n=470) or schizotypal disorder (n=82) were included in the study. The 3-year inclusion period was divided into six consecutive periods of 6 months each.

RESULTS

The median DUP was 52 weeks. DUP was not significantly reduced during the 3-year inclusion period, but a larger proportion of patients with symptoms below the threshold for frank psychosis were included compared with the beginning of the trial. The proportion referred from primary care remained small (8-10%) and unchanged during the inclusion period.

DISCUSSION

The availability of a detection team increased the referral of patients with schizotypal disorder, but the DUP among psychotic patients remained almost unaltered throughout the period. It seems that an information campaign and possibilities for direct access and self-referral are necessary in order to shorten DUP.

Characteristics of early psychosis

There is little research on characteristics related to course and prognosis of early-onset psychosis. The present article aims to advance our knowledge of this disorder for the purpose of proper diagnosis and treatment. It focuses on premorbid and prodromal characteristics, treatment history, symptoms and classifications, and differences between subgroups with affective and schizophrenic psychosis. A chart review was constructed to study a group of 129 subjects (12-18 years) with psychotic symptoms referred to the University Medical Center in Utrecht. The group was characterized by early-but nonspecific-treatment, developmental problems (mostly social), and clear prodromal symptoms. Drug abuse, depressive symptoms, and suicidal behavior were also frequent. Male sex, a relatively long prodromal phase, school problems, and drug abuse were more indicative of the schizophrenic subgroup. Introversion was characteristic for boys with schizophrenia. Classifications, however, were not stable. These findings suggest that early recognition of psychosis can be enhanced in health and youth care facilities. Careful examination of the prodromal phase seems helpful to differentiate between schizophrenic and affective psychosis.

Transition to psychosis: 6-month follow-up of a Chinese high-risk group in Hong Kong

OBJECTIVES

The identification of individuals at high risk of becoming psychotic within the near future creates opportunities for early intervention before the onset of psychosis. This study sets out to identify a group of symptomatic young people in a Chinese population with the high likelihood of transition to psychosis within a follow-up period of 6 months, and to determine the rate of transition to psychosis in this group.

METHOD

Symptomatic individuals with a family history of psychotic disorder, sub-threshold psychotic symptoms or brief transient psychotic symptoms were identified using the operationalized criteria of an 'At Risk Mental State'. The individuals were prospectively assessed monthly on a measure of psychopathology for 6 months.

RESULTS

Eighteen out of 62 individuals (29%) made the transition to frank psychosis within a 6 month follow-up period, with the majority occurring within 3 months. In addition, significant differences were found in the intake Positive and Negative Syndrome Scale, Comprehensive Assessment of 'At Risk Mental State' and Global Assessment of Functioning scores between the group that ultimately became psychotic and the group that did not.

CONCLUSION

The period of the highest risk of transition to psychosis was within the 3 months after the study began. Thus, distressed youths in our outpatient clinic, who meet the high-risk criteria should be monitored most closely in the initial 3 months, particularly those individuals with high levels of psychopathology and functional decline.

Positive symptoms and duration of illness predict functional laterality and attention modulation in schizophrenia

OBJECTIVE

Dichotic listening (DL) performance in schizophrenia, reflecting hemispheric asymmetry and the functional integrity of the left temporal lobe, can vary with clinical characteristics. Previous studies have not taken the co-linearity of clinical variables into account. The aim of the present study was to evaluate the roles of positive symptoms and duration of illness in DL through Structural Equation Modeling (SEM), thus allowing for complex relationships between the variables.

METHOD

We pooled patients from four previous DL studies to create a heterogeneous group of 129 schizophrenic patients, all tested with a consonant-vowel syllables DL procedure that included attentional instructions.

RESULTS

A model where positive symptoms predicted a laterality component and duration of illness predicted an attention component in DL was confirmed.

CONCLUSION

Positive symptoms predicted reduced functional laterality, suggesting involvement of left temporal lobe language processing. Duration of illness predicted impaired attention modulation, possibly reflecting the involvement of frontotemporal networks.

Women have later onset than men in schizophrenia--but only in its paranoid form. Results of the DSP project

According to the literature, schizophrenia begins in men earlier than in women. It has been argued that the gender-bound age difference is due to the protective antidopaminergic effect of estrogens in women. However, the effect of gender on the age of onset may vary between different types of schizophrenias, and can also be modulated by marital status and by age at onset of illness. Comprehensive data were collected on 3306 DSM IIR schizophrenia patients, aged 15-64 years, who had been discharged from psychiatric hospitals in Finland in 1982, 1986 and 1990. The age of onset of illness (AOI) was defined by the age at the first admission (AFA). Male patients were admitted earlier than female patients, and a small second peak in women appeared at the age of 40-44. However, there were no gender differences in AFA within diagnostic subgroups, except in paranoid schizophrenia in which AFA was lower in men than in women even when marital status was taken into account. Within paranoid schizophrenia, this effect of gender was significant only in those of the patients whose AFA was higher than 30 years. It is suggested that there is no gender difference in AOI in early onset schizophrenia. In later onset, paranoid schizophrenia, the illness seems to manifest in women later than in men.

Duration of untreated psychosis may predict acute treatment response in first-episode schizophrenia

There is growing evidence for a relationship between the duration of untreated psychosis (DUP) and the prognosis in schizophrenia. The objective of this study is to evaluate whether DUP and premorbid level of social functioning are related to treatment response in acute treatment of first-episode schizophrenia. Seventy-nine first-episode schizophrenia patients were assessed with BPRS, SAPS, and SANS on admission and discharge during their first hospitalisation. Percentage of the difference between admission and discharge in total scores of all scales were taken as measures of absolute symptom reduction. The median DUP was 6 months (mean=8.6). DUP was correlated with reduction in BPRS and SAPS scores but not SANS scores. Patients with a short DUP (n=41) also showed a higher reduction in BPRS, and SAPS scores than those with a long DUP. Premorbid Adjustment Scale (PAS) scores were inversely correlated with age at onset and positively correlated with BPRS scores at admission. We did not find any relationship between PAS scores and response to treatment. Our findings suggest that DUP may be an important predictor of response in acute treatment of first-episode schizophrenia and thus, attempts for early diagnosis may also have a positive effect on acute treatment response.

The PRIME North America randomized double-blind clinical trial of olanzapine versus placebo in patients at risk of being prodromally symptomatic for psychosis. I. Study rationale and design

The first double-blind placebo-controlled clinical trial of an atypical neuroleptic medication is being conducted in symptomatic treatment-seeking patients meeting new diagnostic criteria for a putative prodromal syndrome. This identifies them as being at high risk for developing psychosis in the near future. The study aims include prevention of psychosis onset and disability, as well as palliation of ongoing symptomatology. This report presents the study rationale and design. Recent studies will be reviewed that have advanced our knowledge about the early course of schizophrenia and our ability to predict onset prospectively, advances that have rendered prodromal intervention research feasible and ethical. The study design has many novel features. It tests for prevention versus delay in psychosis onset, as well as for efficacy and safety in a newly defined clinical population. This has required the development of innovative clinical research assessment instruments and a new operational definition of psychosis onset. The integration of these novel elements into an otherwise typical clinical trial design is detailed. The companion report will address sample recruitment and the clinical phenomenology at baseline of this putative "prodromal" entity.

The PRIME North America randomized double-blind clinical trial of olanzapine versus placebo in patients at risk of being prodromally symptomatic for psychosis. II. Baseline characteristics of the "prodromal" sample

The first double-blind placebo-controlled clinical trial of an atypical neuroleptic medication is being conducted in symptomatic treatment-seeking patients meeting new diagnostic criteria for a putative prodromal syndrome. This identifies them as being at high risk for developing psychosis in the near future. The study aims include prevention of psychosis onset and disability, as well as palliation of ongoing symptomatology. The purpose of this report is to describe the study's "prodromally symptomatic" sample at baseline, i.e., at intake immediately prior to randomization and prior to receiving study medication. Sixty treatment-seeking patients meeting prodromal inclusion criteria were recruited across four sites: New Haven, CT (n=39), Toronto, Ontario (n=9), Calgary, Alberta (n=6), and Chapel Hill, NC (n=6). The sample was young (median age 16), largely male (65%), and came from families with high titers of serious mental illness (44%). Most patients (93%) met criteria for the Attenuated Positive Symptom (APS) prodromal syndrome and presented with significant but nonpsychotic suspiciousness, perceptual aberrations, unusual thought content, and conceptual disorganization. They presented with minimal to mild affective symptoms and substance use/abuse, but they were quite functionally compromised (mean Global Assessment of Functioning (GAF) score=42). The prodromal sample was compared with other clinical-trial samples of adolescent depression, adolescent mania, and first episode schizophrenia. Prodromal patients proved not to be depressed or manic. They were less severely ill than untreated first episode schizophrenia but more severely ill than treated first episode schizophrenia. While not psychotically disabled, these patients nevertheless present with a clinical syndrome. Subsequent reports will detail the effects of drug versus placebo on prodromal symptoms, neuropsychological profile, and the rate of conversion to psychosis.

Prodromal schizophrenia and atypical antipsychotic treatment

Early recognition and intervention in psychosis is the focus of more intensive research. In this paper, we critically review the ideas that have emerged in this field. We also propose a model or hypothesis for testing in the prodromal phase of schizophrenia. Attention to practical and ethical issues, particularly with the use of atypical antipsychotics in one arm of the protocol, is addressed. Studies by Yung and Falloon describe prodromal intervention with psychosocial strategies and time-limited low potency neuroleptics, respectively, that suggest benefits of such a model. Although we have respect for the DSM system, this paper is written more from a Bleulerian than Kraepelinian perspective in that we emphasize affective, cognitive, and negative symptoms in addition to positive symptoms. The paper recognizes the strong conceptual disagreements implicit in this area stemming not only from Kraepelin and Bleuler but work from the 1930s by Cameron. The clinical research advocated is timely in that the atypicals are more congruent to the Bleulerian conception with a neurodevelopmental hypothesis of schizophrenia. We also have exciting new imaging and genetic technologies to refine our concepts of schizophrenia and its prodromal and premorbid phases.

Duration of pretreatment phases in schizophrenia: women and men

OBJECTIVE

To determine the relative duration of the prepsychotic prodrome and the period of untreated psychosis in women and men with schizophrenia.

METHOD

From a larger study population, we selected 27 women and 34 men treated at 1 facility. To determine the time of first behavioural change and the time of first psychotic symptoms, we administered the Interview for the Retrospective Assessment of the Onset of Schizophrenia (IRAOS). Subjects' mothers were interviewed using the same instrument. Time of first treatment was determined by hospital record.

RESULTS

The first sign of behavioural disturbance occurred at approximately the same age in women and men. The prepsychotic prodrome was almost twice as long for women as for men. The duration of untreated psychosis did not differ between the 2 sexes. Substance abuse did not influence the observed difference between men and women in the duration of the prepsychotic phase. The interval between first behavioural sign and first treatment was, on average, 6 years for men and 9 years for women.

CONCLUSION

As-yet-unknown factors speed up the progression from nonspecific symptoms to psychosis in men or delay it in women.

P300 reduction and prolongation with illness duration in schizophrenia

BACKGROUND

The P300 component of the auditory event-related potential (ERP) is both reduced in amplitude and delayed in schizophrenia. P300 is prolonged and, less consistently, reduced with normal aging. Additional latency delays are observed in neurodegenerative disorders. We asked whether P300 is reduced and delayed with longer illness duration in schizophrenia, consistent with a neurodegenerative process.

METHODS

P300 amplitude and latency were recorded to infrequent auditory target stimuli from 35 men with schizophrenia (DSM-III-R) and 26 control men. Effects of current age, age of onset, and duration of illness on P300 were assessed using regression analysis.

RESULTS

P300 amplitude showed no age-related decrease in either group; however, among schizophrenic participants, P300 amplitude correlated positively with onset age and negatively with illness duration. P300 latency correlated positively with age in schizophrenic participants and also tended to increase with age in controls. Slopes of the latency-age relationships were significantly greater in schizophrenic participants than in control participants. Latency also correlated positively with illness duration but showed no relationship to onset age.

CONCLUSIONS

P300 amplitude and latency are reduced and delayed with longer illness duration in schizophrenia, consistent with a progressive pathophysiological process. Reduced P300 amplitude may also be a marker of an early onset variant of schizophrenia.

Depression, negative symptoms, social stagnation and social decline in the early course of schizophrenia

OBJECTIVE

The aim of this study was to investigate when social consequences in schizophrenia emerge, and what conditions give rise to the social disadvantage evident in people suffering from schizophrenia.

METHOD

Early course in schizophrenia was studied in a population-based sample of 232 first illness-episode cases retrospectively from onset to first admission, and in a representative subsample of 115 patients prospectively at six cross-sections over a period of 5 years. Data on non-specific and negative symptomatology and social development was compared with data from an age- and sex-matched control group drawn from the normal population.

RESULTS

In total, 73% of the patients showed a prodromal phase of several years. First signs were depressive and negative symptoms. In 57% of cases social disability emerged 2 to 4 years before first admission. Social consequences depended on the level of social development at onset. An early onset involved social stagnation, and a late onset was associated with social decline. Men's poorer social outcome was determined by their lower level of social development at onset and socially adverse illness behaviour. The 5-year symptom-related course showed no gender difference. At 81% the lifetime prevalence of depressive mood until first admission was several times higher in schizophrenics than in healthy controls. Early depression predicted a lower subsequent score for affective flattening. Suicide indicators were predicted by lack of self-confidence and feelings of guilt early in the illness.

CONCLUSION

Taking into account a prodromal phase of several years on average before first hospital admission, early detection, case identification and intervention are urgently needed. The intervention must be targeted at syndromes such as early depression, negative symptoms and certain forms of cognitive and social impairment.

Earlier puberty as a predictor of later onset of schizophrenia in women

OBJECTIVE

The aim of this study was to determine whether puberty plays a mediating role in onset of schizophrenia. The hypothesis was that there is an inverse relation between age at puberty (menarche) and age at onset in women.

METHOD

Competent and consenting individuals with DSM-IV-defined schizophrenia or schizoaffective disorder and their mothers underwent a 45-minute interview to ascertain age at first odd behavior, age at first psychotic symptoms, age at first hospitalization, and ages at various indices of puberty. Information about substance use, head injury, perinatal trauma, and first-degree family history of schizophrenia was also obtained.

RESULTS

In the women (N = 35), the earlier the age at menarche, the later the ages at both the first psychotic symptoms and the first hospitalization. There was no significant association between puberty and onset in the men (N = 45). Other than gender, none of the examined variables played a role in the interaction of puberty and onset of illness.

CONCLUSIONS

In women, early puberty (whether through hormonal or social influence) was associated with later onset of schizophrenia. This effect was not found in men; in fact, the trend was in the opposite direction.

Age at onset and outcome in schizophrenia are related to the degree of familial loading

BACKGROUND

Recent research suggests that high familial loading is associated with early onset of schizophrenia. Results concerning outcome have been controversial.

METHOD

We assessed the relationship between familial loading, age at onset and outcome in all Finnish patients with schizophrenia born between 1950 and 1969. Patients and their first-degree relatives were identified using nationwide registers. Familial loading scores were calculated for schizophrenia and for combined psychotic disorders, and patients were accordingly classified into three groups: high (n = 761), intermediate (n = 14,247), and low familial loading (n = 725). Linear mixed models and the Cox proportional hazard model were used in the analyses.

RESULTS

Onset was earliest, hospitalisation longest and risk of retirement in receipt of a disability pension highest in the group with high familial loading, with opposite extremes found in the group with low familial loading.

CONCLUSIONS

High familial loading for schizophrenia is associated with early onset and poor outcome of schizophrenia.

Relationship of neuropsychological and MRI measures to age of onset of schizophrenia

Age of onset of schizophrenia (AOS) may be largely determined by neurobiological factors. We examined in a diverse sample of schizophrenia out-patients the relationships of AOS with neuropsychological abilities and structural brain abnormalities as measured on cerebral magnetic resonance imaging (MRI). A total of 82 out-patients meeting DSM-III-R criteria for schizophrenia were evaluated with a comprehensive neuropsychological battery and semi-automated quantitatively analysed cerebral MRI. Earlier AOS correlated with poorer performance in learning and abstraction/cognitive flexibility, and with larger volumes of caudate and lenticular nuclei, and smaller volume of thalamus on MRI. A model for predicting AOS consisting of abstraction and thalamic and caudate volumes remained significant after controlling for duration of illness, current age and daily neuroleptic dose. In conclusion, AOS may be related to specific rather than general measures of cognitive performance and structural brain abnormalities.

Psychoneuroendocrinology of schizophrenia

The study of psychoneuroendocrinology of schizophrenia has yielded an extensive but inconclusive body of data. Investigations to date have been limited by several factors, including the confounding effects of neuroleptic drugs, methodological limitations, and lack of appreciation for the heterogeneity of the illness. Previously, the focus of research has been on the measurement of anterior pituitary hormones, guided by the assumptions that these hormones are regulated by the central nervous system (CNS) to a significant degree and that the unique anatomic relationship of the pituitary gland to the hypothalamus and the CNS is potentially relevant. Patients with schizophrenia do appear to have distinct endocrinologic profiles. However, although the hormonal differences between patients with schizophrenia and the general population appear to be subtle in magnitude. Nonetheless, investigation, and the exploration of the possible effect of gonadal and posterior pituitary hormones merits particular attention.

The reliability of interview data for age at which infants' toothcleaning begins

A number of studies have reported on the age at which toothbrushing started and drawn important conclusions. Such studies often relied on parental recall of a particular event that occurred some years previously, assuming the quality of retrospectively reported data. The present study aimed to investigate consistency of reporting the age at which toothcleaning began. Mothers from two different cultural backgrounds, 100 Caucasian and 150 Asian living in a deprived inner city area, were interviewed in their homes on two separate occasions, when the sample child was 6-24 months old and again at 3-4 years. Of the 39 Caucasian and 31 Asian mothers who specified an age at which toothbrushing commenced at both interviews, complete agreement occurred among 4 (10%) Caucasian and 2 (6%) Asian mothers, with a variation of +/- 2 months among 12 (31%) and 5 (16%) respectively. Intraclass correlation coefficients were -0.01 for Caucasian and -0.46 for Asian mothers. Kappa values were 0 and -0.09 respectively. Of the 139 mothers who stated that their children's teeth were not cleaned at the time of the first interview, 17 claimed an earlier age than this at the second interview. It was concluded that there was little agreement between the two interviews, although the extent of the variation differed between the two cultural groups. Although these findings represent relatively deprived population groups, caution is recommended in unquestioningly accepting the accuracy of retrospective reporting of oral hygiene practices in dental surveys until evidence of better reliability is available.

Nondementia nonpraecox dementia praecox? Late-onset schizophrenia

Schizophrenia has traditionally been viewed as a psychotic disorder with onset in adolescence or early adulthood and a deteriorating course. Over the past decade, the authors have been studying patients meeting DSM-III-R as well as specified research criteria for late-onset schizophrenia (onset after age 45) and several comparison groups with psychiatric, neurologic, neuropsychologic, brain-imaging, psychophysiological, and psychosocial assessments. Results to date suggest a number of similarities and differences between late-onset schizophrenia and comparison groups of other older patients with psychoses (including earlier-onset schizophrenia). Later-onset schizophrenia is probably a neurobiologically distinct subtype of schizophrenia. Differential involvement of cortico-striato-pallido-thalamic circuitry may explain differences in age at onset. The authors propose a new conceptual model for level of functioning at different stages of life in late-onset schizophrenia.

Pubertal development and onset of psychosis in childhood onset schizophrenia

In this study, pubertal development was examined for a sample of children and adolescents with childhood onset schizophrenia (COS) defined as psychosis by age 12. Developmental and psychiatric histories were obtained for 28 adolescents (mean age 14.5 +/- 2.3 years) with severe, treatment refractory COS (14 males, 14 females). Age of onset of psychosis was also examined in relation to menarche and development of secondary sex characteristics. Girls had a trend towards developing secondary sex characteristics earlier than boys (P = 0.06), consistent with North American norms. Males (N = 14) and females (N = 14) had similar age of onset of psychosis. The age of development of secondary sex characteristics was associated with onset of psychosis for girls, but this finding was driven by one outlier. There was no significant correlation between development of psychosis and menarche. Neither male nor female probands differed significantly from their well siblings or from North American norms in their age of onset of pubertal development. There was no evidence of early onset of secondary sex characteristics for this sample. Finally, there was an absence of a clear relationship between onset of psychosis and indices of sexual development for these very early onset cases.

Epidemiology of schizophrenia

OBJECTIVE

To characterize the epidemiology of schizophrenia.

METHOD

Narrative literature review.

RESULTS

Each year 1 in 10,000 adults (12 to 60 years of age) develops schizophrenia. Based on a restrictive and precise definition of the diagnosis and using standardized assessment methods and large, representative populations, the incidence rates appear stable across countries and cultures and over time, at least for the last 50 years. Schizophrenic patients are not born into ecological and social disadvantage. The uneven distribution of prevalence rates is a result of social selection: an early onset leads to social stagnation, a late onset to descent from a higher social status. The main age range of risk for schizophrenia is 20 to 35 years. It is still unclear whether schizophrenia-like late-onset psychoses (for example, late paraphrenia) after age 60 should be classified as schizophrenia either psychopathologically or etiologically. In 75% of cases, first admission is preceded by a prodromal phase with a mean length of 5 years and a psychotic prephase of one year's duration. On average, women fall ill 3 to 4 years later than men and show a second peak of onset around menopause. Consequently, late-onset schizophrenias are more frequent and more severe in women than in men. The sex difference in age of onset is smaller in cases with a high genetic load and greater in cases with a low genetic load. Type of onset and core symptoms do not differ between the sexes. The most pronounced sex difference is the socially negative illness behaviour of young men.

CONCLUSIONS

Among the factors determining social course and outcome are level of social development at onset, the disorder itself (for example, genetic liability, severity of symptoms, and functional deficits), general biological factors (for example, estrogen), and sex- and age-specific illness behaviour.

Treatment of schizophrenia and delusional disorder in the elderly

With increasing longevity, greater numbers of patients with schizophrenia and delusional disorder will be surviving into advanced age. Antipsychotics form the core of the treatment for both of these psychotic disorders. Treatment of elderly patients with antipsychotics is, however, complicated by a much higher risk of adverse effects such as tardive dyskinesia. More is known about treating patients with schizophrenia than those with delusional disorder. The introduction of newer atypical antipsychotics may herald a new era in the pharmacotherapy of elderly psychotic patients. Nonetheless, judicious dosing is essential in the geriatric population. We discuss the benefits and limitations of the main forms of treatment.