Characteristics of early- and late-diagnosed schizophrenia: implications for first-episode studies

The role of religiosity types in the phenomenology of hallucinations: A large cross-sectional community-based study in a predominantly Muslim society

Religiosity is a multidimensional construct known to influence the occurrence of hallucinations. However, it remains unknown how different religiosity types affect clinically relevant phenomenological features of hallucinations. Therefore, we wished to explore associations between intrinsic and extrinsic (non-organizational and organizational) religiosity and hallucinations severity, distress or impact on daily function in a non-clinical Muslim population. We recruited a representative sample of full-time students at Qatar's only national university via systematic random sampling and administered the Questionnaire of Psychotic Experiences online. The study design was cross-sectional. Using structural equation modeling, we estimated effects of the religiosity types on hallucinations severity, distress or impact on daily function in the past week while accounting for sociodemographic variables, anxiety, depressive symptoms, and, delusions. Extrinsic non-organizational religiosity (ENORG) was associated with experiencing reduced distress or impact on daily function from hallucinations both directly and indirectly through intrinsic religiosity. In contrast, extrinsic non-organizational religiosity (EORG) was associated with increased hallucinations distress or impact albeit only through higher intrinsic religiosity. We found no association between any religiosity types and hallucinations severity. Younger and married participants from lower socio-economic class had comparatively more severe hallucinations and more distress from them. Qatari nationality was positively associated EORG and negatively associated with hallucinations distress or impact. Evidence of differential associations between the religiosity types, socioeconomic and cultural groups, and distress or impact from past week's hallucinations supports the importance of alignment between religious, mental health, and well-being education.

Is there a continuum of psychotic experiences in the general population?

Summary

Aims - Schizophrenia is a severe mental illness that affects 1% of the population. The diagnosis is made according to current diagnostic systems of DSM-1V (American Psychiatric Association, 1994) and ICD-10 (World Health Organisation, 1992), on the basis of characteristic ‘positive’ and ‘negative’ symptoms. The traditional model assumes a categorical view of the schizophrenia syndrome and its core symptoms, in which differences between psychotic symptoms and their normal counterparts are considered to be qualitative. An alternative, dimensional approach assumes that schizophrenia is not a discrete illness entity, but that psychotic symptoms differ in quantitative ways from normal experiences and behaviours. This paper reviews evidence for the continuity of psychotic symptoms with normal experiences, focusing on the symptoms of hallucinations and delusions. Methods - A qualitative review of the relevant literature. Results - The literature suggests that although current epidemiological approaches yield substantial evidence for a continuum view, it is rarely interpreted as such. Conclusions - The traditional concept ofschizophrenia as a homogeneous disease entity has become outdated and is in dire need of a more valid and clinically useful successor.

Declaration of Interests

Support has been received in the last two years from the Dutch Research Council, The Dutch Ministry of Health, Maastricht University, The Dutch Brain Society, ZON-MW, The Province of Limburg, The Council of Maastricht, Eli Lilly, Janssen-Cilag, Pfizer, Astra-Zeneca and Bristol Meyer Squibb. None of these funding sources represents a conflict of interest in relation to this article.

The cumulative needs for care monitor: a unique monitoring system in the south of the Netherlands

INTRODUCTION

Patients diagnosed with severe mental illness (SMI) have a complex combination of psychiatric, somatic and social needs for care, requiring an integrated, multidisciplinary health care approach. The present paper describes the methods of the cumulative needs for care monitor (CNCM), a monitoring system in operation in a geographically defined area.

METHODS

The CNCM provides information on need for care, functioning and other outcomes in SMI patients in the area. This information can be used not only to plan treatment at the individual level, but also to conduct health services research at the group level.

A systematic review and meta-analysis of the psychosis continuum: evidence for a psychosis proneness-persistence-impairment model of psychotic disorder

A systematic review of all reported incidence and prevalence studies of population rates of subclinical psychotic experiences reveals a median prevalence rate of around 5% and a median incidence rate of around 3%. A meta-analysis of risk factors reveals associations with developmental stage, child and adult social adversity, psychoactive drug use, and also male sex and migrant status. The small difference between prevalence and incidence rates, together with data from follow-up studies, indicates that approximately 75-90% of developmental psychotic experiences are transitory and disappear over time. There is evidence, however, that transitory developmental expression of psychosis (psychosis proneness) may become abnormally persistent (persistence) and subsequently clinically relevant (impairment), depending on the degree of environmental risk the person is additionally exposed to. The psychosis proneness-persistence-impairment model considers genetic background factors impacting on a broadly distributed and transitory population expression of psychosis during development, poor prognosis of which, in terms of persistence and clinical need, is predicted by environmental exposure interacting with genetic risk.

An observational, "real life" trial of the introduction of assertive community treatment in a geographically defined area using clinical rather than service use outcome criteria

INTRODUCTION

Assertive outreach methods of service delivery hold promise, but have been evaluated mostly in the context of short-lived experiments of limited sustainability and a focus on service use outcomes. The aim of the current investigation was to conduct an observational, "real life", pre-post comparison of the introduction of assertive outreach in a geographically defined area using clinical rather than service use outcome criteria.

METHOD

Assertive outreach was implemented in 2002 in a catchment area of 250,000, where cumulative routine outcome measurements had been in place since 1998. Clinical outcome, defined as making a transition to meeting the recently introduced remission criterion, was compared for two non-overlapping cohorts of patients treated in the period 1998-2001 and in the period 2002-2005.

RESULTS

The proportion of patients that made the transition to remission increased from 19% in the period before the introduction of assertive outreach, to 31% in the period after (OR = 2.21, 95% CI 1.03-4.78).

CONCLUSION

Assertive outreach in real life routine clinical practice brings about detectable changes in clinical outcome. ACT may bring improvement to the lives of patients living in countries characterised by fragmented and hospital-based mental health services.

Social disadvantage and schizophrenia. A combined neighbourhood and individual-level analysis

OBJECTIVE

To study, in a geographically defined area, associations between the neighbourhood social environment and individual socioeconomic status on the one hand, and treated incidence of schizophrenia and level of subsequent service use on the other.

METHOD

A combined data set of (i) patients with a case register diagnosis of schizophrenia and (ii) population controls was subjected to multilevel analyses, including neighbourhood exposures (neighbourhood socioeconomic disadvantage and social capital) and individual level confounders. Separate analyses were conducted for inpatient and outpatient psychiatric service consumption as indexed by the case register.

RESULTS

Neighbourhood socioeconomic disadvantage and neighbourhood social capital did not impact on the treated incidence of schizophrenia, but quantity of inpatient service consumption was higher in neighbourhoods with higher level of social control (i.e. where it is more likely that neighbours intervene in neighbourhood-threatening situations). In addition, most indicators of lower individual socioeconomic status were associated with higher treated incidence, while treated incidence was lower when individual educational status was low.

CONCLUSION

Residents of high social control neighbourhoods may seek greater levels of resolution of psychiatric disorder in patient-residents, and by consequence may induce greater levels of inpatient service consumption in patients diagnosed with schizophrenia. Individual-level indicators of social disadvantage are associated with higher risk of treated psychotic disorder, with the exception of lower educational status, which may confer a lower probability of treatment given the presence of psychotic disorder.

The wider social environment and mental health service use

OBJECTIVE

Previous studies associating neighbourhood context with mental health service use typically included limited sets of confounders.

METHOD

A data set including patients registered in a Case Register and population controls was subjected to multilevel analyses, including neighbourhood exposures and individual level confounders. In addition, days of care consumption of patients was addressed.

RESULTS

The association between socioeconomic deprivation and social capital on the one hand and mental health service use rates on the other could be attributed to individual level differences. However, number of days of service consumption was higher in neighbourhoods with more informal social control. In residentially stable neighbourhoods only, socioeconomic deprivation was associated with lower levels of service consumption.

CONCLUSION

Higher levels of social control may induce patients to remain in contact with mental health services. Furthermore, higher levels of deprivation in neighbourhoods with little population mobility may result in reduced expectations of recovery and/or increased tolerance.

Early intervention in psychosis: a new evidence based paradigm

OBJECTIVE

Even in countries whose mental health services are comparatively well resourced, the care offered to those in the early stages of psychotic illnesses is not what it could be. Patients often have to progress to chronicity before receiving adequate interventions, by which stage there has been great potential for harm, not only through the psychosis, but also to the quality of life of the individual who has often missed or not completed adequately, several important developmental tasks. Further, evidence indicates that delay in treatment is positively associated with poorer outcome. This paper puts the case for early intervention in psychosis.

METHOD

Based on the experience of the Early Psychosis Prevention and Intervention Centre in Melbourne, the paper reviews the evidence for and the criticisms of, early intervention. Using the concept of indicated prevention, it suggests ways in which clinicians can improve the interventions available to those experiencing the onset of psychosis and suggests that pre-psychotic intervention may be possible.

RESULTS

Evidence discussed in this paper indicates that the development of mental illness is a major health issue in young people; that there is a positive correlation between duration of untreated psychosis and outcome; that it is possible to identify a proportion of those at high risk of developing mental illness; that through intervention it may be possible to reduce the transition rate to illness.

CONCLUSION

Primary prevention is beyond the capacity of our present knowledge. Indicated prevention in the form of early intervention and optimal, sustained treatment is a paradigm for which there is increasing supportive evidence. It is a paradigm which is appealing to clinicians, patients, families and which has the potential to reduce the secondary impact of serious mental illness such as suicide, stigma, isolation and reduction in social status.

The continuity of psychotic experiences in the general population

Schizophrenia is a severe mental illness that affects 1% of the population. The diagnosis is made according to current diagnostic systems of DSM-IV (American Psychiatric Association, 1994) and ICD-10 (World Health Association, 1992) on the basis of characteristic 'positive' and 'negative' symptoms. The traditional medical model assumes a categorical view of the schizophrenia syndrome and its core symptoms, in which differences between psychotic symptoms and their normal counterparts are considered to be qualitative. An alternative, dimensional approach assumes that schizophrenia is not a discrete illness entity, but that psychotic symptoms differ in quantitative ways from normal experiences and behaviours. This paper reviews evidence for the continuity of psychotic symptoms with normal experiences, focusing on the symptoms of hallucinations and delusions. It concludes by discussing the theoretical and treatment implications of such a continuum.

Schizophrenia is not disappearing in south-west Scotland

BACKGROUND

Recent work has reported a decline in the incidence of schizophrenia, but it is unclear if these findings reflect a true decrease in its incidence or are an artefact arising from methodological difficulties.

AIMS

To take account of these methodological difficulties and report service-based incidence rates for schizophrenia in Dumfries and Galloway in south-west Scotland for 1979-98.

METHOD

Using both clinical diagnoses and diagnoses generated from the Operational Checklist for Psychotic Disorders (OPCRIT) computer algorithm for ICD-10 and DSM-IV schizophrenia, we measured change in the incidence rates over time. We used indirect standardisation techniques and Poisson models to measure the rate ratio linear trend.

RESULTS

There was a monotonic and statistically significant decline in clinically diagnosed schizophrenia. The summary rate ratio linear trend was 0.77. However, using OPCRIT-generated ICD-10 and DSM-IV diagnoses, there was no significant difference over time.

CONCLUSIONS

OPCRIT-generated consistent diagnoses revealed no significant fall in the incidence of schizophrenia. Changes in diagnostic practice have caused the declining rates of clinically diagnosed schizophrenia in Dumfries and Galloway.

Neighbourhood variation in incidence of schizophrenia. Evidence for person-environment interaction

BACKGROUND

Neighbourhood characteristics may influence the risk of psychosis, independently of their individual-level equivalents.

AIMS

To examine these issues in a multi-level model of schizophrenia incidence.

METHOD

Cases of schizophrenia, incident between 1986 and 1997, were identified from the Maastricht Mental Health Case Register. A multi-level analysis was conducted to examine the independent effects of individual-level and neighbourhood-level variables in 35 neighbourhoods.

RESULTS

Independent of individual-level single and divorced marital status, an effect of the proportion of single persons and proportion of divorced persons in a neighbourhood was apparent (per 1% increase respectively: RR = 1.02; 95% CI 1.00-1.03; and RR = 1.12, 95% CI 1.04-1.21). Single marital status interacted with the neighbourhood proportion of single persons, the effect being stronger in neighbourhoods with fewer single-person households.

CONCLUSIONS

The neighbourhood environment modifies the individual risk for schizophrenia. Premorbid vulnerability resulting in single marital status may be more likely to progress to overt disease in an environment with a higher perceived level of social isolation.