The relevance of cognitive, clinical and premorbid variables in predicting functional outcome for individuals with first-episode psychosis: a 3 year longitudinal study

Familiality of the Intelligence Quotient in First Episode Psychosis: Is the Degree of Family Resemblance Associated With Different Profiles?

BACKGROUND AND HYPOTHESIS

There is uncertainty about the relationship between the family intelligence quotient (IQ) deviation and the risk for schizophrenia spectrum disorders (SSD). This study tested the hypothesis that IQ is familial in first episode psychosis (FEP) patients and that their degree of familial resemblance is associated with different profiles.

STUDY DESIGN

The participants of the PAFIP-FAMILIAS project (129 FEP patients, 143 parents, and 97 siblings) completed the same neuropsychological battery. IQ-familiality was estimated through the Intraclass Correlation Coefficient (ICC). For each family, the intra-family resemblance score (IRS) was calculated as an index of familial similarity. The FEP patients were subgrouped and compared according to their IRS and IQ.

STUDY RESULTS

IQ-familiality was low-moderate (ICC = 0.259). A total of 44.9% of the FEP patients had a low IRS, indicating discordancy with their family-IQ. Of these patients, those with low IQ had more schizophrenia diagnosis and a trend towards poorer premorbid adjustment in childhood and early adolescence. Whereas FEP patients with low IQ closely resembling their family-IQ were characterized by having the lowest performance in executive functions.

CONCLUSIONS

The deviation from the familial cognitive performance may be related to a particular pathological process in SSD. Individuals with low IQ who do not reach their cognitive familial potential show difficulties in adjustment since childhood, probably influenced by environmental factors. Instead, FEP patients with high phenotypic family resemblance might have a more significant genetic burden for the disorder.

Premorbid adjustment as predictor of long-term functionality: Findings from a 10-year follow-up study in the PAFIP-cohort

The literature indicates that patients with schizophrenia spectrum disorders often show deficits in premorbid adjustment. Additionally, these impairments have been correlated with critical disease parameters, evident in both early and advanced stages. The principal objective of this study was to investigate the association between premorbid adjustment and functional outcomes a decade following the initial episode of psychosis. A cluster analysis was performed to group patients according to their premorbid adjustment scores as assessed with the Premorbid Adjustment Scale (PAS). The measurements of The Disability Assessment Scale (DAS), The Global Assessment of Function (GAF) scale, ​​and The Quality of Life Scale (QLS) were used to compare the functionality of the groups at a 10-year follow-up. A total of 231 patients were classified into three groups based on their premorbid adjustment: "good PAS", "deteriorating PAS", and "chronically poor PAS". The three groups differed significantly in their sociodemographic and cognitive baseline characteristics. At the 10-year follow-up, "good PAS" group had better scores than the other groups in the variables of functionality and quality of life. The relationship found between premorbid adjustment and long-term functional results in patients with psychosis can help us predict the evolution of patients and act accordingly.

The relevance of processing speed in the functioning of people with first-episode psychosis

Deficits in functioning affect people with first-episode psychosis. Deficits in cognitive performance are common in such individuals and appear to be related to functioning. The present study examined the relationship between the domains of cognitive performance and personal and social functioning, as well as evaluating which cognitive domains are the most closely related to personal and social functioning and whether they explain variations once other clinical and sociodemographic aspects are accounted for. Ninety-four people with first-episode psychosis participated in the study; they were assessed with the MATRICS battery. Symptoms were evaluated with the Emsley factors of the positive and negative syndrome scale. Cannabis use, duration of untreated psychosis, suicide risk, perceived stress, antipsychotic doses, and premorbid intelligence quotient was accounted for. Processing speed, attention/vigilance, working memory, visual learning, reasoning and problem solving correlated to personal and social functioning. Processing speed emerged as the strongest predictor of social and personal functioning and underscores the importance of targeting this domain in treatment. Moreover, suicide risk and excited symptoms were also significant variables in functioning. Early intervention, focusing on improvement of processing speed, may be crucial to the improvement of functioning in first-episode psychosis. The relationship of this cognitive domain with functioning in first-episode psychosis should be studied further.

Cognition and social functioning in first episode psychosis: A systematic review of longitudinal studies

Introduction

This systematic review aimed to answer whether we can predict subsequent social functioning in first episode psychosis (FEP) by means of an initial cognitive examination. In order to do this, we gathered longitudinal studies which evaluated neurocognition and/or social cognition regarding their impact on long-term social functioning of FEP patients.

Methods

The MOOSE method was employed and 28 studies covering data from a total of 2572 patients with longitudinal trajectories from 2 months to 5 years were reviewed.

Results

In general, cognitive deficits impacted on the social functioning of the FEP patients across the time. The neurocognitive domains which most closely predicted social functioning were processing speed, sustained attention and working memory. An overall cognitive dysfunction, low IQ and the academic trajectory were also found predictive. Regarding social cognition, the findings were not unanimous.

Discussion

In addition of the impact of each variable, several of the articles found a complex relationship between social cognition, neurocognition, social functioning and negative symptoms, pointing social cognition as a modulator of neurocognition but being modulated as well by negative symptoms. The principal clinical implication of this review is that the initial assessment of FEP patients and their rehabilitation must take cognition into account.

Disability and premorbid adjustment in schizophrenia: A retrospective analysis

Background

Schizophrenia is highly disabling. Though efforts at genetic mapping to identify those at risk of the illness have been promising but same cannot be said about predicting its associated disability before illness-onset (i.e., during premorbid phase). It is envisaged that Schizophrenia-related disability may be ameliorated if premorbid clinical markers are adequately predictive enough to identify those at risk and worked upon them.

Aim

This study aimed to determine whether there is a relationship between schizophrenia-related disability and premorbid adjustment.

Setting

This cross-sectional study was conducted at the out-patient clinic of the Neuropsychiatric Hospital, Aro, Abeokuta, Ogun State, Nigeria.

Methods

Three hundred patients with the diagnosis of schizophrenia and within the age range of 18-64 years were eligible for the study.

Results

Mean age of the participants was 41.9 ± 10.05 years with a slight female dominance (50.7%). Spearman's correlation revealed a direct correlation between disability and premorbid adjustment, albeit rather weak (r _s = 0.130, p = 0.025).

Conclusion

Pre-diagnostic factors such as premorbid functioning may play a role in the subsequent functioning of an individual post-diagnosis. Other research efforts may focus on yet-to-be identified premorbid factors that may be targets of prevention to reduce disability in schizophrenia.

Contribution

This research serves as a pioneer work on disability and premorbid adjustment and has provided a template for the early identification of those at risk of schizophrenia by providing an intervention opportunity at the premorbid stage.

Relapse of first-episode schizophrenia patients and neurocognitive impairment: The role of dopaminergic and anticholinergic burden

BACKGROUND

The prevention of relapse may be a key factor to diminish the cognitive impairment of first-episode schizophrenia (FES) patients. We aimed to ascertain the effects of relapse, and dopaminergic and anticholinergic treatment burdens on cognitive functioning in the follow-up.

METHODS

Ninety-nine FES patients participated in this study. Cognitive assessments were performed at baseline and after 3 years of follow-up or, in those patients who relapsed, after >2 months of stabilization of the new acute psychotic episode. The primary outcomes were final cognitive dimensions.

RESULTS

Repeated measures MANOVA analyses showed improvements in the whole sample on the end-point assessments in processing speed and social cognition. However, only impairment in social cognition showed a significant interaction with relapse by time in this sample. Relapse in FES patients was significantly associated with poor performance on end-point assessments of working memory, social cognition and global cognitive score. Anticholinergic burden, but not dopaminergic burden, was associated with verbal memory impairment. These significant associations resulted after controlling for baseline cognitive functioning, relapse and dopaminergic burden.

CONCLUSIONS

The relationship between relapse and cognitive impairment in recovered FES patients seems to be particularly complex at the short-term follow-up of these patients. While relapse was associated with working memory, social cognition impairments and global cognitive score, anticholinergic burden might play an additional worsening effect on verbal memory. Thus, tailoring or changing antipsychotics and other drugs to reduce their anticholinergic burden may be a potential modifiable factor to diminish cognitive impairment at this stage of the illness.

Long-Term Outcomes of First-Admission Psychosis: A Naturalistic 21-Year Follow-Up Study of Symptomatic, Functional and Personal Recovery and Their Baseline Predictors

This study was aimed at characterizing long-term outcomes of first-admission psychosis and examining their baseline predictors. Participants were assessed at baseline for 38 candidate predictors and re-assessed after a median follow-up of 21 years for symptomatic, functional, and personal recovery. Associations between the predictors and the outcomes were examined using univariate and multivariate Cox regression models. At baseline, 623 subjects were assessed for eligibility, 510 met the inclusion/exclusion criteria and 243 were successfully followed-up (57.3% of the survivors). At follow-up, the percentages of subjects achieving symptomatic, functional, and personal recovery were 51.9%, 52.7%, and 51.9%, respectively; 74.2% met at least one recovery criterion and 32.5% met all three recovery criteria. Univariate analysis showed that outcomes were predicted by a broad range of variables, including sociodemographics, familial risk, early risk factors, premorbid functioning, triggering factors, illness-onset features, neurological abnormalities, deficit symptoms and early response to treatment. Many of the univariate predictors became nonsignificant when entered into a hierarchical multivariate model, indicating a substantial degree of interdependence. Each single outcome component was independently predicted by parental socioeconomic status, family history of schizophrenia spectrum disorders, early developmental delay, childhood adversity, and mild drug use. Spontaneous dyskinesia/parkinsonism, neurological soft signs and completion of high school remained specific predictors of symptomatic, functional, and personal outcomes, respectively. Predictors explained between 27.5% and 34.3% of the variance in the outcomes. In conclusion, our results indicate a strong potential for background and first-episode characteristics in predicting long-term outcomes of psychotic disorders, which may inform future intervention research.

A family study on first episode of psychosis patients: Exploring neuropsychological performance as an endophenotype

INTRODUCTION

Family studies provide a suitable approach to analyzing candidate endophenotypes of schizophrenia, including cognitive features.

OBJECTIVE

To characterize different neurocognitive functions in a group of patients with first episode of psychosis (FEP), their first-degree relatives (parents and siblings), and healthy controls (HC), in order to identify potential endophenotypes for schizophrenia spectrum disorders (SSD).

METHODS

Participants were assessed in the context of a national project in Spain called PAFIP-FAMILIAS. They completed the same neuropsychological battery, which included tests of verbal memory, visual memory, processing speed, working memory, executive functions, motor dexterity, attention, and theory of mind. Group comparisons were performed using one-way ANOVA, followed by tests of multiple comparisons when appropriate.

RESULTS

One hundred thirty-three FEP patients were included, as well as 244 of their first-degree relatives (146 parents and 98 siblings) and 202 HC. In general, relatives showed an intermediate performance between the HC and the FEP patients in all neurocognitive domains. However, the domains of executive functions and attention stood out, as relatives (especially parents) showed similar performance to FEP patients. This was replicated when selecting patients subsequently diagnosed with schizophrenia and their relatives.

CONCLUSION

These findings suggest that executive and attention dysfunctions might have a family aggregation and could be relevant cognitive endophenotypes for psychotic disorders. The study shows the potential of exploring intra-family neuropsychological performance supporting neurobiological and genetic research in SSD.

Influence of clinical and neurocognitive factors in psychosocial functioning after a first episode non-affective psychosis: Differences between males and females

BACKGROUND

Deficits in psychosocial functioning are present in the early stages of psychosis. Several factors, such as premorbid adjustment, neurocognitive performance, and cognitive reserve (CR), potentially influence functionality. Sex differences are observed in individuals with psychosis in multiple domains. Nonetheless, few studies have explored the predictive factors of poor functioning according to sex in first-episode psychosis (FEP). This study aimed to explore sex differences, examine changes, and identify predictors of functioning according to sex after onset.

MATERIALS AND METHODS

The initial sample comprised 588 individuals. However, only adults with non-affective FEP (n = 247, 161 males and 86 females) and healthy controls (n = 224, 142 males and 82 females) were included. A comprehensive assessment including functional, neuropsychological, and clinical scales was performed at baseline and at 2-year follow-up. A linear regression model was used to determine the predictors of functioning at 2-year follow-up.

RESULTS

FEP improved their functionality at follow-up (67.4% of both males and females). In males, longer duration of untreated psychosis (β = 0.328, p = 0.003) and worse premorbid adjustment (β = 0.256, p = 0.023) were associated with impaired functioning at 2-year follow-up, while in females processing speed (β = 0.403, p = 0.003), executive function (β = 0.299, p = 0.020) and CR (β = -0.307, p = 0.012) were significantly associated with functioning.

CONCLUSION

Our data indicate that predictors of functioning at 2-year follow-up in the FEP group differ according to sex. Therefore, treatment and preventative efforts may be adjusted taking sex into account. Males may benefit from functional remediation at early stages. Conversely, in females, early interventions centered on CR enhancement and cognitive rehabilitation may be recommended.

Social brain network predicts real-world social network in individuals with social anhedonia

Social anhedonia (SA) impairs social functioning in schizophrenia. Previous evidence suggested that certain brain regions predict longitudinal change of real-world social outcomes, yet previous study designs have failed to capture the corresponding functional connectivity among the brain regions involved. This study measured the real-world social network in 22 pairs of individuals with high and low levels of SA, and followed up them for 21 months. We further explored whether resting-state social brain network characteristics could predict the longitudinal variations of real-world social network. Our results showed that social brain network characteristics could predict the change of real-world social networks in both the high SA and low SA groups. However, the results differed between the two groups, i.e., the topological characteristics of the social brain network predicted real-world social network change in the high SA group; whereas the functional connectivity within the social brain network predicted real-world social network change in the low SA group. Principal component analysis and linear regression analysis on the entire sample showed that the functional connectivity component centered at the right orbital inferior frontal gyrus could best predict social network change. Our findings support the notion that social brain network characteristics could predict social network development.

Stability of schizophrenia diagnosis in a 10-year longitudinal study on first episode of non-affective psychosis: Conclusions from the PAFIP cohort

OBJECTIVE

To evaluate the 10-year stability of schizophrenia diagnosis in a cohort of first-episode psychosis (FEP) patients and the factors associated with it.

METHODS

Changes in diagnosis of 209 FEP patients were described during 10 years of follow-up. Related factors with maintenance or change of schizophrenia diagnosis were evaluated in prospective and retrospective approaches through binary logistic regressions, ROC and survival curves.

RESULTS

Out of the 209 patients, 126 were diagnosed of schizophrenia 6 months after their inclusion in the clinical program. Prospective analyses showed that eight of those 126 schizophrenia patients had changed to a different diagnosis after 10 years, and predictors of change were better childhood premorbid adjustment, less severity of clinical global impression at baseline, and diagnosis of comorbid personality disorder during follow-up. Retrospectively, out of the 154 patients with schizophrenia in the 10-year assessment, 36 had a different diagnosis at baseline, and those factors related to a different prior diagnosis than schizophrenia were better socioeconomic status and shorter duration of untreated psychosis (DUP). A survival analysis on the timing of schizophrenia diagnosis showed that male gender and longer DUP were predictors of earlier definite diagnosis.

CONCLUSIONS

Diagnostic stability of schizophrenia in our FEP sample is high, especially prospective stability, and the group of patients with diagnostic change corresponded to a milder psychopathological profile before and at the onset of disease. Moreover, we observed a cautious attitude in the diagnosis of schizophrenia in patients with shorter DUP who had schizophrenia diagnosis after 10 years.

Cognitive Predictors of Social and Occupational Functioning in Early Psychosis: A Systematic Review and Meta-analysis of Cross-Sectional and Longitudinal Data

Many individuals with early psychosis experience impairments in social and occupational function. Identification of modifiable predictors of function such as cognitive performance has the potential to inform effective treatments. Our aim was to estimate the strength of the relationship between psychosocial function in early psychosis and different domains of cognitive and social cognitive performance. We conducted a systematic review and meta-analysis of peer-reviewed, cross-sectional, and longitudinal studies examining cognitive predictors of psychosocial function. Literature searches were conducted in PsycINFO, PubMed, and reference lists of relevant articles to identify studies for inclusion. Of the 2565 identified, 46 studies comprising 3767 participants met inclusion criteria. Separate meta-analyses were conducted for 9 cognitive domains. Pearson correlation values between cognitive variables and function were extracted. All cognitive domains were related to psychosocial function both cross-sectionally and longitudinally. Importantly, these associations remained significant even after the effects of symptom severity, duration of untreated psychosis, and length of illness were accounted for. Overall, general cognitive ability and social cognition were most strongly associated with both concurrent and long-term function. Associations demonstrated medium effect sizes. These findings suggest that treatments targeting cognitive deficits, in particular those focusing on social cognition, are likely to be important for improving functional outcomes in early psychosis.

Long term cortical thickness changes after a first episode of non- affective psychosis: The 10 year follow-up of the PAFIP cohort

Cortical thickness has been widely studied in individuals with schizophrenia and, in particular, first-episode psychosis. Abnormalities have been described, although there is, to date, a lack of consensus regarding changes across time and correlations with clinical and functional outcomes of the illness. One hundred and twenty-three first-episode psychosis patients and 74 healthy volunteers were subjected to magnetic resonance imaging scans and clinical and functional assessments by different scales at four consecutive visits during a 10 year follow-up period. Linear mixed effects models were applied to our data to compute cortical thickness changes over time in (1) schizophrenia patients versus healthy controls and (2) in patients with good versus poor functional outcome. The associations between cortical thickness percentage changes and clinical and functional status at 10 years were also assessed. The patients presented a thinner cortex than the controls at baseline (b's = -0.06; q ≤ 0.00023) with non-significant coefficients for the interaction term (follow-up time x group) (b's = -0.001; q ≥ 0.681). Poor functioning patients presented statistically significant coefficients for the interaction term (follow-up time x functionality) (left: b = -0.005, q = 0.019; right: b = -0.005, q = 0.022). In contrast, no correlations were found between cortical thickness measurements and clinical variables at 10 years. Overall, there were widespread thickness anomalies in first-episode psychosis patients across cortical regions that remained stable across time. Progressive thickness changes were related to patient functional outcomes, with progressive and steeper cortical thinning in patients with worse functional outcomes and a stabilization in those with better outcomes.

Autism spectrum in patients with schizophrenia: correlations with real-life functioning, resilience, and coping styles

BACKGROUND

Previous researches highlighted among patients with schizophrenia spectrum disorders (SSD) a significant presence of autistic traits, which seem to influence clinical and functional outcomes. The aim of this study was to further deepen the investigation, evaluating how patients with SSD with or without autistic traits may differ with respect to levels of functioning, self-esteem, resilience, and coping profiles.

METHODS

As part of the add-on autism spectrum study of the Italian Network for Research on Psychoses, 164 outpatients with schizophrenia (SCZ) were recruited at eight Italian University psychiatric clinics. Subjects were grouped depending on the presence of significant autistic traits according to the Adult Autism Subthreshold Spectrum (AdAS Spectrum) instrument ("AT group" vs "No AT group"). Other instruments employed were: Autism Spectrum Quotient (AQ), Specific Levels of Functioning (SLOF), Self-Esteem Rating scale (SERS), Resilience Scale for Adults (RSA), and brief-COPE.

RESULTS

The "AT group" reported significantly higher scores than the "No AT group" on SLOF activities of community living but significantly lower scores on work skills subscale. The same group scored significantly lower also on SERS total score and RSA perception of the self subscale. Higher scores were reported on COPE self-blame, use of emotional support and humor domains in the AT group. Several correlations were found between specific dimensions of the instruments.

CONCLUSION

Our findings suggest the presence of specific patterns of functioning, resilience, and coping abilities among SSD patients with autistic traits.

A network analysis approach to functioning problems in first psychotic episodes and their relationship with duration of untreated illness: Findings from the PAFIP cohort

BACKGROUND

The domains of functioning affected by first episode of psychosis (FEP) could be analysed as forming a network of interacting or even reinforcing elements. The reasons why longer duration of untreated psychosis (DUP) might be related to higher disability are not still clear. The aim of the present study is to evaluate how different areas of functioning are inter-related according to the length of DUP in patients with FEP, with a particular focus on studying the relative influence of each other according to lengthy delays in initial treatment.

METHOD

441 participants in an epidemiological and intervention program of first episode psychosis (PAFIP) were included in our study. Functioning problems at baseline were assessed with the WHO Disability Assessment Schedule (DAS). Three networks of functioning domains have been estimated according to the length of DUP.

RESULTS

All the DAS items took part in the different networks. We have not found differences across the edge weights in the short, medium and long DUP groups. The domains "social withdrawal", "participation in the household activities", "general interest and information", and "low level of activity" seem to act as bridge items with other areas of functioning in people with longer DUP.

CONCLUSIONS

Our results could have clinical implications for patients with longer DUP, in which case, social withdrawal, household activities, level of activity and general interest in the world around them, could be high-priority target areas of treatment, since they seem to be mediating the relation between others areas of functioning.

The interplay between functioning problems and symptoms in first episode of psychosis: An approach from network analysis

The relationship between psychotic symptoms and global measures of functioning has been widely studied. No previous study has assessed so far the interplay between specific clinical symptoms and particular areas of functioning in first-episode psychosis (FEP) using network analysis methods. A total of 191 patients with FEP (age 24.45 ± 6.28 years, 64.9% male) participating in an observational and longitudinal study (AGES-CM) comprised the study sample. Functioning problems were assessed with the WHO Disability Assessment Schedule (WHODAS), whereas the Positive and Negative Syndrome Scale (PANSS) was used to assess symptom severity. Network analysis were conducted with the aim of analysing the patterns of relationships between the different dimensions of functioning and PANSS symptoms and factors at baseline. According to our results, the most important nodes were "conceptual disorganization", "emotional withdrawal", "lack of spontaneity and flow of conversation", "delusions", "unusual thought content", "dealing with strangers" and "poor rapport". Our findings suggest that these symptoms and functioning dimensions should be prioritized in the clinical assessment and management of patients with FEP. These areas may also become targets of future early intervention strategies, so as to improve quality of life in this population.

Understanding sex differences in long-term outcomes after a first episode of psychosis

While sex differences in schizophrenia have long been reported and discussed, long-term sex differences in outcomes among first episode of psychosis (FEP) patients in terms of the efficacy of Early Intervention Services (EIS) has been an under-explored area. A total of 209 FEP patients (95 females and 114 males) were reassessed after a time window ranging from 8 to 16 years after their first contact with an EIS program (PAFIP) that we will call the 10-year PAFIP cohort. Multiple clinical, cognitive, functioning, premorbid, and sociodemographic variables were explored at 1-year, 3-year and 10-year follow-ups. At first contact, females were older at illness onset, had higher premorbid adjustment and IQ, and were more frequently employed, living independently, and accompanied by a partner and/or children. Existence of a schizophrenia diagnosis, and cannabis and alcohol consumption were more probable among men. During the first 3 years, women showed a significantly better response to minimal antipsychotic dosages and higher rates of recovery than men (50% vs. 30.8%). Ten years later, more females continued living independently and had partners, while schizophrenia diagnoses and cannabis consumption continued to be more frequent among men. Females also presented a lower severity of negative symptoms; however, functionality and recovery differences did not show significant differences (46.7% vs. 34.4%). Between the 3- and 10-year follow-up sessions, an increase in dosage of antipsychotics was observed. These results suggest that the better outcomes seen among women during the first 3 years (while they were treated in an EIS) were in the presence of more favourable premorbid and baseline characteristics. After an average period of 10 years, with the only difference being in negative symptoms course, outcomes for women approximated those of men, drawing particular attention to the increase in dosage of antipsychotic medication once FEP patients were discharged from the EIS program towards community-based services. These findings help to pose the question of whether it is advisable to target sexes and lengthen EIS interventions.

Neurocognitive functioning in patients with first-episode schizophrenia: results of a prospective 15-year follow-up study

To evaluate the course of neuropsychological impairment, patients with first-episode schizophrenia and healthy controls were assessed with a comprehensive test battery at the time of index treatment and after a 5- and 15-year follow-up period. Summary scores for verbal intelligence (VBI), spatial organization, verbal fluency, verbal learning, semantic memory, visual memory, delay/retention rate, short-term memory, visual-motor processing and attention (VSM) and abstraction/flexibility were constructed. Our results show that neurocognitive functioning is impaired already at the onset of schizophrenia and remains stable over the 15-year follow-up period with an improvement in VBI. With regard to the presence of a deficit syndrome, it became apparent that the group with a deficit syndrome showed a deterioration of neurocognitive functions during the follow-up period, most pronounced in VSM. On the other hand, the group without a deficit syndrome showed an improvement in neurocognitive functions at the 15-year follow-up, which exceeded the learning effects of healthy control subjects. Neurocognitive performance at index assessment strongly predicted the performance at the 15-year follow-up. Most likely due to the small sample size, there were only weak associations between treatment with different types of neuroleptics and neurocognitive performance.

The Influence of Premorbid Adjustment and Autistic Traits on Social Cognitive Dysfunction in Schizophrenia

OBJECTIVES

Premorbid dysfunction during childhood and adolescence is well documented in patients with schizophrenia. Literature pointed out multiple premorbid trajectories leading to different patients' cognitive status, symptomatology, and global functioning after disease onset. This study aimed at identifying groups of premorbid trajectories and disentangling between group differences in clinical and cognitive measures, focusing on theory of mind (ToM) and autistic traits (ATs).

METHODS

Ninety-seven patients with schizophrenia were recruited and assessed for cognitive and ToM abilities, psychopathology, and ATs. A two-step cluster analysis identified three different groups of patients based on premorbid adjustment during childhood, adolescence, and late adolescence (i.e., stable-good, stable-poor, and "deteriorating").

RESULTS

Compared to 66 healthy controls, results showed a widespread impairment in cognitive and ToM abilities among all groups of patients, except for affective ToM and executive functions in the stable-good group. Moreover, the stable-poor group exhibited more pronounced ATs and a more severe ToM impairment, compared to the other two groups of patients.

CONCLUSIONS

Our findings highlight the existence of a group of patients with poor premorbid adjustment since childhood, more pronounced ATs and a severe ToM impairment affecting those basic mentalizing skills that are usually preserved in schizophrenia. Results might have intriguing implications in identifying underpinning endophenotypes and implementing cutting-edge rehabilitation programs.

Premorbid Social Functioning and Affective Symptoms Predict Subjective Outcome Among Outpatients With Schizophrenia

Improving the subjective outcome of patients is an important target in the treatment of schizophrenia. Accordingly, the aim of the present study was to examine the association of factors deemed relevant in this context, i.e., premorbid functioning, residual symptoms, and side effects of antipsychotic medication, with subjective outcome. To this end, 70 clinically stable outpatients with schizophrenia were included into a cross-sectional study. Premorbid functioning, psychopathology, and side effects were assessed by using the Premorbid Adjustment Scale, the Positive and Negative Syndrome Scale, and the Udvalg for Kliniske Undersogelser Side Effect Rating Scale, respectively. Subjective outcome was measured in terms of life satisfaction (Life Satisfaction Questionnaire), self-esteem (Index of Self-Esteem), and needs for care (Berliner Bedürfnisinventar). Both premorbid social functioning and affective symptoms predicted life satisfaction, self-esteem, and patients' basic needs, whereas positive and negative symptoms predicted needs in the health, social, and functional domains. Concerning side effects, parkinsonism and akathisia showed a significant negative correlation with self-esteem. These findings highlight the complex nature of subjective outcome in patients suffering from schizophrenia. Evidently, premorbid social functioning plays a prominent role in the experienced subjective outcome during the course of the illness. Furthermore, these preliminary findings underscore that constant efforts are essential to treat residual symptoms of the disorder and to avoid extrapyramidal motor side effects of antipsychotic medication. Longitudinal studies are needed to investigate this latter point in more detail.

Perceived stress mediates the relationship between social adaptation and quality of life in individuals at ultra high risk of psychosis

AIM

Quality of life (QoL) and social functioning have emerged as good predictors of the outcome of psychotic disorders. Poor QoL and social functioning are usually present before the onset of the first episode of psychosis. Our study aimed to explore the relationship between social adaptation and QoL in young people at risk of psychosis (ultra-high-risk, UHR) and healthy controls (HCs), and to investigate potential mediating effects of stress measures (perceived stress, stressful life events).

METHODS

The study included 55 UHR subjects and 40 HC. Social functioning was assessed with the Social Adaptation Self-evaluation Scale (SASS). Stress measures included the assessment of stressful life events and perceived stress. We compared stress and QoL measures between UHR and HC, and also compared UHR with low or normal social adaptation. A mediation analysis was performed to explore whether stress measures mediated the relationship between social adaptation and QoL.

RESULTS

UHR were less frequently employed and reported more stress, poorer QoL and lower social adaptation than HC. QoL and social adaptation were associated with stress measures. UHR with low social adaptation reported more perceived stress and less QoL than UHR with normal social adaptation and HC. Perceived stress mediated the relationship between social adaptation and QoL.

CONCLUSIONS

Social adaptation is less developed in UHR subjects than in healthy subjects and has a negative impact on quality of life. This association is mediated by perceived stress.

Predicting Symptomatic and Functional Improvements over 1 Year in Patients with First-Episode Psychosis Using Resting-State Electroencephalography

OBJECTIVE

Although early intervention from the beginning of a psychotic episode is essential for a better prognosis, biomarkers predictive of symptomatic and functional improvement in early psychotic disorders are lacking. This study aimed to investigate whether the spectral power of resting-state electroencephalography (EEG) can be used as a predictive marker of the 1-year prognosis in patients with first-episode psychosis (FEP).

METHODS

Twenty-four patients with FEP and matched healthy control (HC) subjects were examined with resting-state EEG at baseline. The symptomatic severity and functional status of FEP patients were assessed at baseline and reassessed after 1 year of usual treatment. Repeated measures analysis of variance was conducted to compare EEG spectral powers across the groups. Multiple regression analysis revealed EEG spectral powers predictive of symptomatic and functional improvement in FEP patients at the 1-year follow-up.

RESULTS

Delta band power in the frontal and posterior regions was significantly higher in patients with FEP than in HCs. Higher delta band power in the posterior region predicted later improvement of positive symptoms and general functional status. Lower delta band power in the frontal region predicted improvement of negative symptoms and general functioning after 1 year.

CONCLUSION

These results suggest that increased delta absolute power is observed from the beginning of psychotic disorders. Furthermore, decreased delta power in the frontal region and increased delta power in the posterior region might be used as a predictive marker of a better prognosis of FEP, which would aid early intervention in clinical practice.

Common Data Elements for National Institute of Mental Health-Funded Translational Early Psychosis Research

The National Institutes of Health has established the PhenX Toolkit as a web-based resource containing consensus measures freely available to the research community. The National Institute of Mental Health (NIMH) has introduced the Mental Health Research Core Collection as part of the PhenX Toolkit and recently convened the PhenX Early Psychosis Working Group to generate the PhenX Early Psychosis Specialty Collection. The Working Group consisted of two complementary panels for clinical and translational research. We review the process, deliberations, and products of the translational research panel. The Early Psychosis Specialty Collection rationale for measure selection as well as additional information and protocols for obtaining each measure are available on the PhenX website (https://www.phenxtoolkit.org). The NIMH strongly encourages investigators to use instruments from the PhenX Mental Health Research Collections in NIMH-funded studies and discourages use of alternative measures to collect similar data without justification. We also discuss some of the potential advances that can be achieved by collecting common data elements across large-scale longitudinal studies of early psychosis.

Job- and schoolprescription: A local adaptation to individual placement and support for first episode psychosis

AIM

Individual placement and support (IPS) for first episode psychosis (FEP) has proven effective for employment and education, but yields differing results across geographical regions. Local adaptations may be necessary for various reasons, such as regional differences in employment- and welfare services; in educational opportunities and job markets. The aim of this study was to investigate the efficacy of an adapted Norwegian intervention offering early IPS for education and employment to persons with FEP.

METHOD

Matched control (N = 66) study with a 1-year early IPS intervention and a 2-year follow up. A rating of fidelity to the IPS model was conducted.

RESULTS

Fidelity was "good." Adaptations to the model included the use of internships and flexible combinations of education and employment. Thirty out of 33 participants completed the intervention. Fourteen were in competitive employment >20 h/wk post intervention, compared to 2 in the control group. Fifteen participants were enrolled in education >20 h/wk, 10 of whom also had employment >20 h/wk and 3 < 20 h/wk, compared to 5 in the control group, with 2 having employment <20 h/wk on the side. Symptom levels did not predict outcome.

CONCLUSION

The School- and JobPrescription adaptation of IPS, allowing for temporary internships as a step towards obtaining the goal of paid competitive employment and facilitating flexible combinations of employment and education, showed encouraging results. These were however not sustained after closure of the intervention. At the 2-year follow up, Job- and SchoolPrescription advantages had waned, underscoring the point in IPS that support should be time-unlimited.

Negative symptoms in first-episode psychosis: Clinical correlates and 1-year follow-up outcomes in London Early Intervention Services

AIM

Negative symptoms (NS) have been associated with poor outcome and remain difficult to treat in patients with psychosis. This study examined the association of NS with clinical features at first presentation to mental health services for psychosis and with outcomes at 1-year follow-up.

METHODS

Clinical data were utilized from five London Early Intervention Services (EIS) included in the MiData audit database. The sample comprised 484 first-episode psychosis patients with complete Positive and Negative Syndrome Scale data at baseline and 1-year follow-up. Multiple imputation (N = 50) was conducted to account for missing follow-up data.

RESULTS

Baseline NS were associated with male gender (B = -1.63, P < .05), younger age at onset (B = -.15, P <. 05), a higher level of impairment on the Global Assessment of Functioning (disability) Scale at baseline (B = -.19, P <. 010), an absence of reported substance misuse prior to baseline assessment (B = -3.05, P <. 001) and unemployment at baseline (B = -.93, P <. 01). At 1-year follow-up, NS at presentation were associated with worse Global Assessment of Functioning Scale for symptom (B = -.28, P < .01) and disability (B = -.27, P <. 05) and with hospital admission (OR = 1.06, P < .01).

CONCLUSIONS

Negative symptoms at presentation to EIS were associated with worse functioning at entry and poorer outcomes 1 year later. Future research is required to better understand the aetiology and trajectories of NS in early psychosis and propose novel targeted interventions.

Intersecting disadvantage: Unpacking poor outcomes within early intervention in psychosis services

AIM

In order to strengthen specialized early intervention in psychosis (EIP) services, a contextually nuanced understanding of psychosocial forces driving suboptimal treatment response is critical. This study sought to examine factors driving poor outcomes through a systematic emic coding of psychosocial assessments for discharged EIP clients categorized as leaving with all treatment goals met (AG) or no treatment goals met (NG).

METHODS

Psychosocial assessments at baseline, 1 year, 2 years and discharge were extracted from an EIP research registry and systematically coded. One hundred and thirty clients met the study's inclusion criteria (72 NG, 58 AG) from a larger pool of 278. Assessments were coded, quantized and analysed using a combination of basic inferential statistics and thematic analysis.

RESULTS

Structural adversity, individual trauma, history of aggression/violence, limited insight and long treatment histories prior to EIP, were strong and significant predictors of poor client outcomes (NG), while motivation for treatment, college goals or preparedness at baseline, baseline engagement in constructive activities, social strengths, individual strengths, talents and family support strongly predicted better outcomes (AG). Race/ethnicity also significantly predicted outcome group. Analyses underscore the powerful impact of multiple converging forms of structural disadvantage, on the one hand, and individual, family and social strengths and supports on the other, in shaping clients' response to EIP treatment.

CONCLUSIONS

Findings emphasize the importance of greater empirical attention to background structural and socio-economic conditions among early psychosis clients and their multifaceted impacts and underscore the potential value of programmatic components explicitly designed to support clients from multiply disadvantaged backgrounds.

Vulnerability to psychosocial disability in psychosis

Psychosocial disability affects a number of individuals with psychosis and often begins years before the formal onset of disorder. This suggests that for many, their psychosocial disability is enduring, and targeted interventions are therefore needed earlier in their developmental trajectories to ensure that psychosocial disability does not become entrenched. Poor psychosocial functioning also affects individuals with a range of different emerging mental health problems, putting these young people at risk of long-term social marginalisation and economic disadvantage; all of which are known risk factors for the development of psychosis. Identification of the markers of poor psychosocial functioning will help to inform effective treatments. This editorial will discern the early trajectories and markers of poor psychosocial outcome in psychosis, and highlight which individuals are most at risk of having a poor outcome. This editorial will also discuss whether early interventions are currently being targeted appropriately and will propose how intervention and preventative strategies can be implemented, to restore psychosocial trajectories in a way that enables young people to maximise their life chances.

Social vs. non-social measures of learning potential for predicting community functioning across phase of illness in schizophrenia

Studies demonstrate that dynamic assessment (i.e., learning potential) improves the prediction of response to rehabilitation over static measures in individuals with schizophrenia. Learning potential is most commonly assessed using neuropsychological tests under a test-train-test paradigm to examine change in performance. Novel learning potential approaches using social cognitive tasks may have added value, particularly for the prediction of social functioning, but this area is unexplored. The present study is the first to investigate whether patients with schizophrenia demonstrate social cognitive learning potential across phase of illness. This study included 43 participants at clinical high risk (CHR), 63 first-episode, and 36 chronic schizophrenia patients. Assessment of learning potential involved test-train-test versions of the Wisconsin Card Sorting Test (non-social cognitive learning potential) and the Facial Emotion Identification Test (social cognitive learning potential). Non-social and social cognition pre-training scores (static scores) uniquely predicted concurrent community functioning in patients with schizophrenia, but not in CHR participants. Learning potential showed no incremental explanation of variance beyond static scores. First-episode patients showed larger non-social cognitive learning potential than CHR participants and were similar to chronic patients; chronic patients and CHR participants were similar. Group differences across phase of illness were not observed for social cognitive learning potential. Subsequent research could explore whether non-social and social cognitive learning potential relate differentially to non-social versus social types of training and rehabilitation.

Self-stigma versus stigma resistance in schizophrenia: Associations with resilience, premorbid adjustment, and clinical symptoms

Self-stigma is regarded as a barrier to recovery from schizophrenia and the identification of factors protecting from its development may help identify vulnerable patients and subsequently, implement effective preventive and therapeutic interventions. Hence, this study aimed to assess whether resilience, premorbid adjustment, and psychopathology might differently impact self-stigma and stigma resistance among 54 regular attendees of a specialized outpatient clinic. There was no significant association between sociodemographic variables and self-stigma/stigma resistance, while resilience was negatively correlated with self-stigma and positively correlated with stigma resistance. In addition, we detected a negative correlation between self-stigma and both academic and social functioning during late adolescence. Most residual symptoms correlated with self-stigma, while no association was found between stigma resistance and psychopathology, except for depressed symptoms. These data provide evidence that future self-stigma reduction interventions may consider to focus on the improvement of resilience in order to promote schizophrenia patients' stigma resistance. In addition, the improvement of depressive symptoms as well as interventions focusing on the strengthening of social adjustment during the prodromal phase may be effective in preventing self-stigma.

The mediating effect of family function and medication adherence between symptoms and mental disability among Chinese patients with schizophrenia: a cross-sectional study

Schizophrenia is a debilitating, chronic, and high-refractory mental illness. Researchers should focus considerable attention to patients with mental disability. This study aims to explore the mediating effect of family function and medication adherence between symptoms and mental disability among Chinese patients with schizophrenia during the convalescent stage. Data from a cross-sectional sample of 499 Chinese patients with schizophrenia were used in this study. The participants were recruited and independently interviewed using the General Information Sheet, Positive and Negative Syndrome Scale (PANSS), World Health Organization Disability Assessment Schedule II (WHO-DAS II), Family APGAR Index (APGAR), and Morisky Medication Adherence Scale (MMAS-8) as outcome measures. A structural equation modeling strategy was used to analyze data. To analyze the correlation matrix, we applied the maximum-likelihood method to estimate the parameters. Bootstrapping was used to validate the mediation effects. Findings from the structural equation modeling demonstrated that family function and medication adherence played mediating roles between psychiatric symptoms and disability. This study presents a partial mediation model. Psychiatrists and nurses should assess the level of family function and medication adherence for schizophrenia, as well as provide interventions to improve family function and medication adherence, thereby eventually mediating disability.

Predictors of functioning in people suffering from first-episode psychosis 1 year into entering early intervention service in Hong Kong

AIM

To explore the changes of functioning in people suffering from first-episode psychosis throughout their first year into an early intervention service, and the baseline predictors of their functioning levels at baseline, 6 and 12 months METHOD: Consecutive subjects presenting to an early intervention service were recruited from 1 February 2013 to 31 May 2015. Information on their socio-demographic status was collected. Structured instruments were used to assess their premorbid functioning, duration of untreated psychosis, psychopathology and insight at baseline. Psychosocial functioning was assessed by Social Occupational Functioning Assessment Scale (SOFAS) and Role Functioning Scale at baseline, 6 and 12 months.

RESULTS

A total of 269 subjects were recruited. The mean baseline scores for SOFAS were 53.1 (standard deviation = 13.6) and 21.5 (standard deviation = 4.0), respectively. Positive and negative psychopathology, insight and mode of onset were significant factors associated with baseline functioning. Functioning by both instruments showed significant improvement after 6 months, and the gains were maintained at 12 months. For SOFAS, baseline insight (P = 0.008), education attainment (P = 0.016) and its own baseline score (P = 0.024) were predictive at 6 months, while for 12 months, only education attainment was predictive (P = 0.008). For Role Functioning Scale, its baseline score (P = 0.034) was predictive at 6 months, while at 12 months, only female gender predicted better role functioning.

CONCLUSION

Factors predictive of functioning levels at the three time points were different. Phase-specific intervention should be offered to enhance functional recovery of people with first-episode psychosis.

Premorbid academic and social functioning in patients with schizophrenia and its associations with negative symptoms and cognition

OBJECTIVE

The study aimed to explore premorbid academic and social functioning in patients with schizophrenia, and its associations with the severity of negative symptoms and neurocognitive impairment.

METHOD

Premorbid adjustment (PA) in patients with schizophrenia was compared to early adjustment in unaffected first-degree relatives and healthy controls. Its associations with psychopathology, cognition, and real-life functioning were investigated. The associations of PA with primary negative symptoms and their two factors were explored.

RESULTS

We found an impairment of academic and social PA in patients (P ≤ 0.000001) and an impairment of academic aspects of early adjustment in relatives (P ≤ 0.01). Patients with poor PA showed greater severity of negative symptoms (limited to avolition after excluding the effect of depression/parkinsonism), working memory, social cognition, and real-life functioning (P ≤ 0.01 to ≤0.000001). Worse academic and social PA were associated with greater severity of psychopathology, cognitive impairment, and real-life functioning impairment (P ≤ 0.000001). Regression analyses showed that worse PA in the academic domain was mainly associated to the impairment of working memory, whereas worse PA in the social domain to avolition (P ≤ 0.000001).

CONCLUSION

Our findings suggest that poor early adjustment may represent a marker of vulnerability to schizophrenia and highlight the need for preventive/early interventions based on psychosocial and/or cognitive programs.

Pathways to functional outcomes following a first episode of psychosis: The roles of premorbid adjustment, verbal memory and symptom remission

OBJECTIVE

Most studies have investigated either the singular or relative contributions of premorbid adjustment, verbal memory and symptom remission to functional outcomes in first-episode psychosis. Fewer studies have examined the pathways of these factors in impacting functioning. Our study addresses this gap. The objective was to determine whether the relationship between premorbid adjustment and functional outcomes was mediated by verbal memory and symptom remission.

METHOD

A total of 334 first-episode psychosis participants (aged 14-35 years) were assessed on premorbid adjustment, verbal memory upon entry, and positive and negative symptom remission and functioning at multiple time points over a 2-year follow-up.

RESULTS

Mediation analyses showed that over the first year, the relationship between premorbid adjustment and functioning was mediated by verbal memory and positive symptom remission (β = -0.18; 95% confidence interval = [-0.51, -0.04]), as well as by verbal memory and negative symptom remission (β = -0.41; 95% confidence interval = [-1.11, -1.03]). Over 2 years, the relationship between premorbid adjustment and functioning was mediated by verbal memory and only negative symptom remission (β = -0.38; 95% confidence interval = [-1.46, -0.02]).

CONCLUSION

Comparatively less malleable factors (premorbid adjustment and verbal memory) may contribute to functional outcomes through more malleable factors (symptoms). Promoting remission may be an important parsimonious means to achieving better functional outcomes.

Patterns and predictors of trajectories for social and occupational functioning in patients presenting with first-episode non-affective psychosis: A three-year follow-up study

BACKGROUND

Functional impairment is prevalent in patients with first-episode psychosis (FEP). Longitudinal course of functioning in the early stage of psychotic illness is under-studied. In this report, we aimed to investigate the patterns and baseline predictors of social-occupational functional trajectories over 3 years, utilizing growth mixture modeling (GMM) analysis, in a large representative Chinese young FEP cohort in Hong Kong.

METHOD

Six hundred seventeen consecutive patients aged 15-25 years presenting with first-episode non-affective psychosis to a specialized early intervention service were studied. Data on demographic, pre-treatment and baseline clinical characteristics were collected. Individual class membership of functioning derived from GMM was based on ratings on Social and Occupational Functioning Scale (SOFAS) measured at five different time-points (baseline, 6, 12, 24 and 36 months) across 3-year follow-up.

RESULTS

Four distinct functional trajectories were identified including persistently poor (48.1%, n = 320), early improved (31.3%, n = 203), gradually improved (14.8%, n = 69) and improved-deteriorated (5.8%, n = 25) trajectories. Multinomial regression analysis revealed that male gender, lower educational attainment, a diagnosis of schizophrenia-spectrum disorder and a receipt of inpatient treatment upon initial presentation independently predicted persistently poor trajectory membership.

CONCLUSION

The current study reveals a heterogeneous course of social-occupational functioning in FEP. Our finding that approximately half of the patients displaying persistently poor trajectory over 3 years indicates functional impairment as an unmet therapeutic need in early illness phase. Further research applying individual-based trajectory analysis in FEP is warranted to facilitate better characterization of longitudinal patterns of functioning and development of targeted intervention to promote early recovery.

The role of premorbid adjustment in schizophrenia: Focus on cognitive remediation outcome

Premorbid adjustment has been associated with several outcomes in schizophrenia and has been proposed as an index of cognitive reserve. This study aims to comprehensively analyse the relation between premorbid adjustment and clinical, neurocognitive, socio-cognitive and functional assessments, as well as to investigate the effect of premorbid adjustment on cognitive improvements after a cognitive remediation therapy protocol. Seventy-nine clinically stabilised outpatients with schizophrenia underwent a combined intervention consisting of cognitive remediation therapy added to standard rehabilitation therapy. All patients were assessed at baseline for psychopathology, premorbid adjustment, intellectual level, cognition and functioning. Cognitive evaluations were also repeated after the intervention. At baseline, significant correlations were observed between premorbid adjustment and working memory. The global cognitive improvement after treatment was significantly predicted by age and premorbid adjustment. This study confirms the association between premorbid adjustment and cognitive impairment and is the first to highlight the possible role of premorbid adjustment on the capacity to recover from cognitive deficits through a cognitive remediation therapy protocol. The data suggest that cognitive remediation may be particularly effective for people in the early course and that the assessment of premorbid adjustment could be of value to design individualised interventions.

Family history of psychosis and outcome of people with schizophrenia in rural China: 14-year follow-up study

OBJECTIVE

This study examined the differences in 14-year outcomes of persons with schizophrenia with and without family history of psychosis in a rural community in China.

METHODS

All participants with schizophrenia (n=510) aged 15 years and older were identified in a 1994 epidemiological investigation of 123,572 people and followed up in 2004 and 2008 in Xinjin County, Chengdu, China.

RESULTS

Individuals with positive family history of schizophrenia had significantly younger age of first onset than those with negative family history of schizophrenia in 1994 and 2004. Compared with individuals with negative family history of schizophrenia, those with positive family history of schizophrenia had significantly higher rate of homelessness and lower rate of death due to other reasons in 10-year (2004) and 14-year follow-up (2008). There were no significantly differences of mean scores on PANSS, SDSS and GAF in 2008 between positive and negative family history groups.

CONCLUSIONS

The positive family history of schizophrenia is strongly related to younger age of onset, and may predict a poorer long-term outcome (e.g., higher rate of homelessness) in persons with schizophrenia in the rural community. The findings have implications for further studies on specific family-related mechanisms on clinical treatment and rehabilitation, as well as for planning and delivering of community-based mental health services.

Primary and persistent negative symptoms: Concepts, assessments and neurobiological bases

Primary and persistent negative symptoms (PPNS) represent an unmet need in the care of people with schizophrenia. They have an unfavourable impact on real-life functioning and do not respond to available treatments. Underlying etiopathogenetic mechanisms of PPNS are still unknown. The presence of primary and enduring negative symptoms characterizes deficit schizophrenia (DS), proposed as a separate disease entity with respect to non-deficit schizophrenia (NDS). More recently, to reduce the heterogeneity of negative symptoms by using criteria easily applicable in the context of clinical trials, the concept of persistent negative symptoms (PNS) was developed. Both PNS and DS constructs include enduring negative symptoms (at least 6months for PNS and 12months for DS) that do not respond to available treatments. PNS exclude secondary negative symptoms based on a cross-sectional evaluation of severity thresholds on commonly used rating scales for positive symptoms, depression and extrapyramidal side effects; the DS diagnosis, instead, excludes all potential sources of secondary negative symptoms based on a clinical longitudinal assessment. In this paper we review the evolution of concepts and assessment modalities relevant to PPNS, data on prevalence of DS and PNS, as well as studies on clinical, neuropsychological, brain imaging electrophysiological and psychosocial functioning aspects of DS and PNS.

Disability multilevel modelling in first episodes of psychosis at 3-year follow-up

The description of longitudinal bio-psycho-social profiles in FEP samples may be useful for the prediction of disability trajectories. This study aimed to describe the differences between disability status of FEP patients at baseline and their change over time, analysing how variables associated to the psychological status, and the environment of the patient can affect his or her disability trajectory, once the influence of health condition and socio-demographic variables has been controlled for. Using data from a 3-year follow-up study on early psychosis (PAFIP), a multilevel structure in which the longitudinal measurements (within level) were nested within the individuals (between level), was modeled. The contribution of the different time-varying and time-invariant variables to the patients' disability outcomes was tested through eight nested models. Consecutive models, that successively added health related, socio-demographic, psychological and environmental variables to the unconditional model were estimated, by means of deviance and fit statistics. The present work revealed the importance of psychological and environmental factors in the explanation of disability changes in the context of FEP. We may conclude that longitudinal assessments of time-varying predictors - living situation (b=-0.10, p<0.05), economic support (b=0.11, p<0.01) and insight (b=-0.08, p<0.05) - explain a relevant amount of disability variation over time, independently from symptoms' severity, duration of untreated psychosis, age, gender and years of education. Additionally, the level of premorbid adjustment (b=0.05, p<0.001) was associated to differences in disability outcomes among FEP patients.

Predictors and moderators of treatment outcome in patients receiving multi-element psychosocial intervention for early psychosis: results from the GET UP pragmatic cluster randomised controlled trial

BackgroundThe GET UP multi-element psychosocial intervention proved to be superior to treatment as usual in improving outcomes in patients with first-episode psychosis (FEP). However, to guide treatment decisions, information on which patients may benefit more from the intervention is warranted.AimsTo identify patients' characteristics associated with (a) a better treatment response regardless of treatment type (non-specific predictors), and (b) a better response to the specific treatment provided (moderators).MethodSome demographic and clinical variables were selected a priori as potential predictors/moderators of outcomes at 9 months. Outcomes were analysed in mixed-effects random regression models. (Trial registration: ClinicalTrials.gov, NCT01436331)ResultsAnalyses were performed on 444 patients. Education, duration of untreated psychosis, premorbid adjustment and insight predicted outcomes regardless of treatment. Only age at first contact with the services proved to be a moderator of treatment outcome (patients aged ⩾35 years had greater improvement in psychopathology), thus suggesting that the intervention is beneficial to a broad array of patients with FEP.ConclusionsExcept for patients aged over 35 years, no specific subgroups benefit more from the multi-element psychosocial intervention, suggesting that this intervention should be recommended to all those with FEP seeking treatment in mental health services.

Association between family history of psychiatric disorders and long-term outcome in schizophrenia - The Northern Finland Birth Cohort 1966 study

Family history of psychiatric disorders has been associated with impaired outcome in schizophrenia, but very few studies have investigated its long-term social and occupational outcome. We investigated the association of family history of psychiatric disorders, especially psychosis, with long-term social, occupational, clinical and global outcome in schizophrenia. The study sample comprises of the Northern Finland Birth Cohort 1966. Cohort members with psychosis were detected by Finnish national registers. Altogether 69 individuals with schizophrenia spectrum diagnosis participated, mean age 43, after on average 17 years since onset of illness. The information regarding family history of psychiatric disorders were gathered from registers and interviews. A Strauss-Carpenter Outcome Scale, PANSS and SOFAS were conducted to assess the outcome. Results showed that the family history of any psychiatric disorder was associated with more severe positive and emotional symptoms in PANSS. The family history of psychosis was not associated with outcomes. These findings suggest that family history of psychiatric disorders has a small association with outcome in schizophrenia. Despite family history of psychosis being a strong risk factor for schizophrenia, after years of illness it does not seem to affect outcome.

Characterization of premorbid functioning during childhood in patients with deficit vs. non-deficit schizophrenia and in their healthy siblings

Impaired premorbid adjustment has been reported in patients with schizophrenia, generally in association with unfavorable aspects of the illness (e.g., poor outcome and severe negative symptoms). Several studies attempted to define the domains of premorbid dysfunction associated with negative symptoms and poor outcome; however, most of them assessed broadly defined negative symptoms. The present study was aimed to characterize premorbid functioning in a group of patients with deficit schizophrenia (DS), characterized by the presence of at least two primary and persistent negative symptoms (PPNS), and one of patients with a diagnosis of schizophrenia who did not meet criteria for DS (NDS). The presence of emotional/behavioral problems during childhood was investigated using the Childhood Behavior Checklist (CBCL) in both patient groups and in their respective healthy siblings. The Premorbid Adjustment Scale (PAS) was also used to assess premorbid functioning during childhood in the two patient groups. PPNS were also treated as a continuous variable and correlated with the indices of premorbid functioning regardless the DS/NDS categorization. DS patients, as compared to NDS, showed higher scores on the CBCL subscale "Withdrawn". Both DS and NDS patients showed, as compared to their healthy siblings, a greater impairment on almost all CBCL subscales. PAS findings revealed that DS patients had poorer premorbid adjustment than NDS. No significant correlation between premorbid functioning and PPNS was observed. These findings support the hypothesis that DS has a different developmental trajectory with respect to NDS, and that premorbid adjustment is one of the essential aspects of its characterization.

Effects of glutamate positive modulators on cognitive deficits in schizophrenia: a systematic review and meta-analysis of double-blind randomized controlled trials

Hypofunction of N-methyl-d-aspartate (NMDA) receptors has been proposed to have an important role in the cognitive impairments observed in schizophrenia. Although glutamate modulators may be effective in reversing such difficult-to-treat conditions, the results of individual studies thus far have been inconsistent. We conducted a systematic review and meta-analysis to examine whether glutamate positive modulators have beneficial effects on cognitive functions in patients with schizophrenia. A literature search was conducted to identify double-blind randomized placebo-controlled trials in schizophrenia or related disorders, using Embase, Medline, and PsycINFO (last search: February 2015). The effects of glutamate positive modulators on cognitive deficits were evaluated for overall cognitive function and eight cognitive domains by calculating standardized mean differences (SMDs) between active drugs and placebo added to antipsychotics. Seventeen studies (N=1391) were included. Glutamate positive modulators were not superior to placebo in terms of overall cognitive function (SMD=0.08, 95% confidence interval=-0.06 to 0.23) (11 studies, n=858) nor each of eight cognitive domains (SMDs=-0.03 to 0.11) (n=367-940) in this population. Subgroup analyses by diagnosis (schizophrenia only studies), concomitant antipsychotics, or pathway of drugs to enhance the glutamatergic neurotransmission (glycine allosteric site of NMDA receptors or α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptors) suggested no procognitive effect of glutamate positive modulators. Further, no effect was found in individual compounds on cognition. In conclusion, glutamate positive modulators may not be effective in reversing overall cognitive impairments in patients with schizophrenia as adjunctive therapies.

Continued cannabis use at one year follow up is associated with elevated mood and lower global functioning in bipolar I disorder

BACKGROUND

There is limited knowledge about how environmental factors affect the course of bipolar disorder (BD). Cannabis has been proposed as a potential risk factor for poorer course of illness, but the role of cannabis use has not been studied in a first treatment BD I sample.

METHODS

The present study examines the associations between course of illness in first treatment BD I and continued cannabis use, from baseline to one year follow up. Patients (N = 62) with first treatment DSM-IV BD I were included as part of the Thematically Organized Psychosis study (TOP), and completed interviews and self-report questionnaires at both baseline and follow up. Cannabis use within the last six months at baseline and use between baseline and follow up ("continued use") was recorded.

RESULTS

After controlling for confounders, continued cannabis use was significantly associated with elevated mood (YMRS) and inferior global functioning (GAF-F) at follow up. Elevated mood mediated the effect of cannabis use on global functioning.

CONCLUSIONS

These results suggest that cannabis use has clinical implications for the early course of BD by increasing mood level. More focus on reducing cannabis use in clinical settings seems to be useful for improving outcome in early phase of the disorder.

Severity of core symptoms in first episode schizophrenia and long-term remission

A definable concept of symptomatic remission in schizophrenia has been proposed by the Remission in Schizophrenia Working Group (RSWG). Nevertheless no studies to date assessed eventual differences in core symptoms at onset between remitters and non-remitters. The present study evaluated whether the severity of core symptoms differed among 48 patients with first episode schizophrenia (FES), and whether it predicted long-term (16-years) remission. Particularly, the present study aimed to verify if RSWG remission criteria might identify a sub-group of patients with mild core symptoms at their first episode. In the present study the severity of core symptoms was significantly lower in remitted than in non-remitted patients; interestingly, five out of the eight core symptoms already satisfied the severity criteria for remission in most remitted patients. Among the core symptoms only the severity of social withdrawal predicted the long-term outcome, while age at onset, duration of untreated psychosis and employment status did not exert any effect. Concluding, patients with FES presenting, mild core symptoms, particularly low negative symptoms, were more likely to reach long-term remission. Therefore, RSWG remission criteria seem to identify a subgroup of FES patients with mild severe core symptoms so with a higher probability to reach remission.

Relationship between clinical improvement and functional gains with clozapine in schizophrenia

Impairment in psychosocial functioning is a key feature in schizophrenia, but few studies have examined the relationship between improvements in symptoms and functioning. We examined the relationship between change in symptoms and change in functioning in a group of patients with treatment-resistant schizophrenia after 6 and 12 weeks of clozapine treatment. Participants were assessed prior to clozapine and again at 6 and 12-week on the 18-item Brief Psychiatric Rating Scale (BPRS) and the Social and Occupational Functioning Scale (SOFAS). Change scores in BPRS and SOFAS at 6 and 12-week post-clozapine were calculated and the direct relationship was assessed via regression models. Forty-three participants were included in this study; age of sample was 42.1 ± 12.7 years, with 31 (72.1%) male participants. At baseline, the mean BPRS total and SOFAS scores were 46.98 ± 12.86 and 33.07 ± 10.79, respectively. There were significant improvements in BPRS total and SOFAS scores at 6 weeks, but no significant differences between 6 and 12-week assessments. There was no significant change in negative symptoms at both follow-up assessments. At 6-week, change in symptoms was not correlated with change in functioning and while the relationship between change in symptoms and functioning was stronger at 12 weeks, none of the BPRS factors emerged as a significant predictor. The present study found that lower baseline SOFAS score was the most robust predictor for improvements in SOFAS at 6 and 12-weeks. There appears to be a "ceiling" for functional improvements on clozapine, but follow-up studies are needed to examine functional gains beyond 12 weeks.

Family history of psychosis and social, occupational and global outcome in schizophrenia: a meta-analysis

OBJECTIVE

We aimed to investigate associations between family history of psychosis and long-term occupational, social and global (i.e. combined occupational, social and clinical) outcome in schizophrenia.

METHOD

A systematic search to identify potentially relevant studies was conducted using seven electronic databases and a manual search of literature. Only observational studies with a follow-up period of at least 2 years were included.

RESULTS

The search identified 4081 unique potentially relevant articles, of which 14 met our inclusion criteria. The presence of family history of psychosis was associated with poor occupational and global outcome (n=3; r=0.17; P=0.008, n=11; r=0.13; P=0.002, respectively).

CONCLUSION

This was the first systematic review on the effects of family history of psychosis on occupational and social outcome in schizophrenia. Based on the review, the presence of family history of psychosis has a relatively small but statistically significant association with long-term occupational and global outcome in patients with schizophrenia.

Persistent negative symptoms after first episode schizophrenia: A 2-year follow-up study

BACKGROUND

The aim of this study is to determine the rate of persistent negative symptoms according to different criteria during two years of follow-up after first-episode schizophrenia.

METHODS

The study sample consisted of 105 patients with first-episode schizophrenia who completed at least 12 months of follow-up period. We used 6 different definitions of persistent negative symptoms (PNS) based on the Scale for the Assessment of Negative Symptoms subscale scores at seven time points throughout the follow-up. In some definitions of PNS, patients with suprathreshold depressive symptoms were excluded. Premorbid adjustment and baseline cognitive performances of the patients were assessed.

RESULTS

The PNS rates were between 14.2 and 27.9% in the first year and 11.1 and 25.8% in the second year. Seventy-eight percent of the patients who met the strictest PNS criteria during the first 12 months met the same criteria also during the second 12-month-period. Those with PNS had earlier onset, lower premorbid functioning, worse executive functioning and attention at baseline, and lower rates of working/studying during the 2-year follow-up. Duration of education and untreated psychosis are the independent variables that contribute to the PNS status at the first year of follow-up in logistic regression analysis.

CONCLUSION

Our findings suggest that PNS has specific predictors and effect on the course of illness after first-episode schizophrenia.

Psychotic symptoms, cognition and affect as predictors of psychosocial problems and functional change in first-episode psychosis

OBJECTIVE

To enable further understanding of how cognitive deficits and psychopathology impact psychosocial functioning in first-episode psychosis patients, we investigated how psychopathology and cognitive deficits are associated with psychosocial problems at baseline, and how these predict psychosocial functioning at 12 months follow-up. Also, we tested whether the effect of baseline psychopathology on psychosocial functioning decreases between baseline and 12 months and the effect of baseline cognition increases.

METHODS

Eight neurocognitive and four social cognitive subdomains and psychopathology (positive and negative symptoms, depression and anxiety) were assessed at baseline in 153 non-affective first-episode psychosis (FEP) patients. Psychosocial functioning (work/study, relationships, self-care, disturbing behavior and general psychosocial functioning) was assessed at baseline and 12 months. Spearman correlations were examined and backward regression models were computed to test our hypotheses.

RESULTS

At baseline, psychosocial functioning was associated strongest with positive and negative symptoms of all assessed clinical domains, followed by neurocognition and social cognition. In contrast, psychosocial functioning at 12 months was not predicted by psychotic symptoms, but rather by neurocognition, social cognition and depression. Change in social functioning in the first 12 months after baseline was predicted by positive and negative symptoms, but to a similar degree by neurocognition and social cognition.

CONCLUSIONS

Whereas psychotic symptoms show marked impact on psychosocial functioning at illness onset, cognitive deficits appear to be more accurate longitudinal predictors of psychosocial problems and functional recovery in the early course of psychosis.

Interdisciplinary approaches to the phenomenology of auditory verbal hallucinations

Despite the recent proliferation of scientific, clinical, and narrative accounts of auditory verbal hallucinations (AVHs), the phenomenology of voice hearing remains opaque and undertheorized. In this article, we outline an interdisciplinary approach to understanding hallucinatory experiences which seeks to demonstrate the value of the humanities and social sciences to advancing knowledge in clinical research and practice. We argue that an interdisciplinary approach to the phenomenology of AVH utilizes rigorous and context-appropriate methodologies to analyze a wider range of first-person accounts of AVH at 3 contextual levels: (1) cultural, social, and historical; (2) experiential; and (3) biographical. We go on to show that there are significant potential benefits for voice hearers, clinicians, and researchers. These include (1) informing the development and refinement of subtypes of hallucinations within and across diagnostic categories; (2) "front-loading" research in cognitive neuroscience; and (3) suggesting new possibilities for therapeutic intervention. In conclusion, we argue that an interdisciplinary approach to the phenomenology of AVH can nourish the ethical core of scientific enquiry by challenging its interpretive paradigms, and offer voice hearers richer, potentially more empowering ways to make sense of their experiences.

Adolescent insanity revisited: course and outcome in early-onset schizophrenia spectrum psychoses in an 8-year follow-up study

OBJECTIVES

Despite inclusion of adolescent insanity-a concept proposed by Thomas Clouston in late XIX century-into the broader nosological entity of dementia praecox, the uniqueness of early psychosis is still discussed. The aim of the current study is the assessment of course and outcome in the large sample of early-onset psychosis subjects.

METHOD

Of 299 patients hospitalized in the period 1998-2008 in an adolescent psychiatry ward with schizophrenia spectrum diagnosis 158 completed a follow-up interview. Data concerning current diagnosis, further admissions, current treatment status and occupational and relationship outcome were analyzed after a mean of 8 years of follow-up.

RESULTS

Mean age at the index admission and the follow-up was 16.6 ± 1.2 and 24.5 ± 3.0 years respectively. After the subsequent discharge almost all subjects (97%) at least briefly continued psychiatric treatment and 75% of patients had been readmitted. Overall diagnostic stability was 42%. For schizophrenia spectrum disorders and schizophrenia diagnostic stability was 72% and 78%, respectively. At the follow-up assessment 119 (77.3%) of the traced subjects declared current psychiatric treatment and 110 (73.3%) were receiving pharmacotherapy. Almost half of the subjects (48%) were employed or studying and more than a third (35.8%) remained in a stable relationship. Different distributions of baseline diagnoses were observed in males and females, and the latter showed a better outcome.

CONCLUSION

Early-onset psychoses were characterized by limited diagnostic stability, a necessity for further treatment and hospitalizations and significant percentage of unfavorable functional outcomes. Baseline diagnosis of acute and transient psychotic disorders and female gender were associated with an overall better outcome.