Diagnostic précoce dans la schizophrénie : une mission pour les médecins généralistes ?

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

INTRODUCTION

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

METHODS

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

RESULTS

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

DISCUSSION

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

CONCLUSION

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

A decision model for the watch-and-wait strategy in systemic sclerosis-associated interstitial lung disease

OBJECTIVE

To develop a decision model to identify SSc-associated interstitial lung disease (ILD) patients who are eligible for watchful waiting at ILD diagnosis.

METHODS

One hundred and fifty-one SSc-ILD patients who received medical care at Seoul National University Hospital from 1986 to 2013 were enrolled in this retrospective cohort study. ILD was diagnosed by chest CT. Patients with and without immunosuppressive treatment were compared in terms of characteristics at ILD diagnosis to identify distinguishing variables. After multivariate analysis, a decision model for watchful waiting was formulated. Its validity was assessed by comparing the survival of patients whose management in real practice did and did not accord with the management recommended by the model.

RESULTS

The untreated group had better survival than the immunosuppressive treatment group (P = 0.0316, by log-rank test). The untreated group was less likely to have gastrointestinal involvement (P = 0.008) and pulmonary arterial hypertension (PAH), as determined by echocardiography) (P = 0.015) and more likely to have favourable initial forced vital capacity (P = 0.0004), favourable initial lung diffusion capacity for carbon monoxide (P = 0.0002) and a low CT grade (P < 0.001). The final watchful waiting decision model included lack of PAH and limited ILD extent on CT. Application of the model to the cohort revealed that patients who were eligible for watchful waiting (as determined by the model) and underwent this management strategy had better survival than eligible patients who underwent immunosuppressive treatment (P = 0.048, by log-rank test).

CONCLUSION

Watchful waiting may be effective for SSc-ILD patients who have minimal pulmonary involvement on CT and lack PAH on echocardiography at baseline.

Scleroderma-related lung disease: are adipokines involved pathogenically?

Scleroderma is a systemic autoimmune disease of unknown etiology whose characteristic features include endothelial cell dysfunction, fibroblast proliferation, and immune dysregulation. Although almost any organ can be pathologically involved in scleroderma, lung complications including interstitial lung disease (ILD) and pulmonary arterial hypertension (PAH) are the leading cause of death in patients with this condition. Currently, the molecular mechanisms leading to development of scleroderma-related lung disease are poorly understood; however, the systemic nature of this condition has led many to implicate circulating factors in the pathogenesis of some of its organ impairment. In this article we focus on a new class of circulating factors derived from adipose-tissue called adipokines, which are known to be altered in scleroderma. Recently, the adipokines adiponectin and leptin have been found to regulate biological activity in endothelial, fibroblast, and immune cell types in lung and in many other tissues. The pleiotropic nature of these circulating factors and their functional activity on many cell types implicated in the pathogenesis of ILD and PAH suggest these hormones may be mechanistically involved in the onset and/or progression of scleroderma-related lung diseases.

Systemic sclerosis increases the risks of deep vein thrombosis and pulmonary thromboembolism: a nationwide cohort study

OBJECTIVES

Few Asian studies have evaluated the risks of deep vein thrombosis (DVT) and pulmonary thromboembolism (PTE) in patients with SSc. We conducted a nationwide population-based cohort study to evaluate how SSc affected the incidence of DVT and PTE in Taiwan.

METHODS

We identified patients with an SSc diagnosis in Taiwan between 1998 and 2010 using the Catastrophic Illness Patient Database and the National Health Insurance Research Database. Each SSc patient was frequency matched to four control patients based on age, sex and index year and all patients were observed from the index date until the appearance of a DVT or PTE event or 31 December 2010. We calculated the hazard ratios and 95% CIs of DVT and PTE in the SSc and comparison cohorts using the Cox proportional hazards regression model.

RESULTS

We observed 1895 SSc patients and 7580 control patients for ∼10,128 and 46,488 person-years, respectively. The mean ages of the SSc and comparison cohorts were 50.3 and 49.9 years, respectively. After adjusting for age, sex and co-morbidities, the risks of DVT and PTE among the SSc patients were 10.5- and 7.00-fold higher than those of the control patients. The probability of developing DVT and PTE increased in the years following the SSc diagnosis.

CONCLUSION

SSc patients exhibited a significantly higher risk of developing DVT and PTE compared with the general population. Thus multidisciplinary teams should guide the assessment, treatment and holistic care of SSc patients.

Evaluation of GPs diagnostic knowledge and treatment practice in detection and treatment of early schizophrenia: a French postal survey in Brittany

AIMS

Evaluating French general practitioners (GPs) diagnostic knowledge and practice in the detection and treatment of early schizophrenia as well as needs and preferences with specialist services.

METHODS

A postal survey comprising 27 questions was conducted among 2,039 GPs from three counties of Western France. Composite scores were calculated to determine a level of diagnostic knowledge.

RESULTS

A total of 515 GPs (25.3%) responded to the survey. The mean score to determine a level of knowledge on the most important aspects in detecting early stages of schizophrenia was 5.3 ± 2.50 [median = 6 (range 0-10)]. The mean score to determine the overall knowledge of schizophrenia was 8.1 ± 2.98 [median = 8 (range 1-16)]. The majority of surveyed GPs (76.1%) would treat early schizophrenia pharmacologically. A majority of GPs (53.9%) advise an insufficient duration of anti-psychotic treatment for first episode psychosis. The vast majority (90.8%) were in favour of a specialized outpatient service.

CONCLUSIONS

French GPs tend to have a deficit in diagnostic knowledge and practice in detection and treatment of early schizophrenia. It seems important to provide GPs with continuing medical education (CME) on detection and management of early schizophrenia and to set up relevant specialized outpatient services.

Association of gastroesophageal factors and worsening of forced vital capacity in systemic sclerosis

OBJECTIVE

Interstitial lung disease (ILD) is a common complication of systemic sclerosis (SSc) and causes death. Once lung fibrosis occurs, disease course may become stable or decline. Little is known about risks for progression. We studied SSc-gastroesophageal (GE) involvement in relation to worsening forced vital capacity (FVC) on pulmonary function tests (PFT) to investigate whether it was related to progression. Our objective was to determine whether GE reflux and dysphagia are associated with progressive moderate/severe ILD as measured by PFT over 3 years.

METHODS

The Canadian Scleroderma Research Group is a multicenter SSc database that collects data annually. Using indicators of GE involvement and annual PFT, comparisons were made between no/mild ILD, stable moderate/severe ILD, and progressive moderate/severe ILD groups based on changes of FVC. Multivariate analyses determined associations between GE factors and ILD development and progression.

RESULTS

There were 1043 patients with SSc (mean age 55.7 yrs, mean disease duration 10.8 yrs); one-quarter had pulmonary fibrosis on chest radiograph that was related to FVC percentage predicted (Spearman's rho -0.39; p < 0.01). Physician indicators such as esophageal dysmotility (p = 0.009) and postesophageal dilatation (p = 0.041), and patient indicators such as difficulty swallowing (p = 0.016) and waking up choking (p = 0.026) were associated with low FVC. In comparing progressive and stable moderate/severe FVC (< 70% predicted), early satiety (p = 0.018) and a combination term of postdilatation and choking (p = 0.042) increased risk of progression of ILD. Topoisomerase I was not associated with progression over followup.

CONCLUSION

Symptoms of esophageal dysmotility were associated with worsening FVC in SSc, especially if both need for esophageal dilatation and choking were present.