Long-term course and outcome in unipolar affective and schizoaffective psychoses

Psychotic major depression: challenges in clinical practice and research

Psychotic major depression is an under-researched and under-identified disorder. We highlight the major challenges both in clinical practice and in conducting research with people with this disorder. We also suggest which major issues need addressing to move treatment and knowledge of this disorder forward. Declaration of interest M.H. and A.H.Y. both report grants from the National Institute for Health Research (NIHR).

Characteristics and Service Use of Older Adults with Schizoaffective Disorder Versus Older Adults with Schizophrenia and Bipolar Disorder

OBJECTIVE

The purpose of this study was to determine if schizoaffective disorder in older adults is differentiated from schizophrenia and bipolar disorder with respect to community functioning, cognitive functioning, psychiatric symptoms, and service use.

DESIGN

Secondary analysis of baseline data collected from the Helping Older People Experience Success psychosocial skills training and health management study.

SETTING

Three community mental health centers in New Hampshire and Massachusetts.

PARTICIPANTS

Adults over the age of 50 (N = 139, mean age: 59.7 years, SD: 7.4 years) with persistent functional impairment and a diagnosis of schizoaffective disorder (N = 52), schizophrenia (N = 51), or bipolar disorder (N = 36).

MEASUREMENTS

Health status (36-Item Short Form Health Survey [SF-36]), performance-based community living skills (UCSD Performance-Based Skills Assessment), neuropsychological functioning (Delis-Kaplan Executive Functioning subtests), psychiatric symptoms (Brief Psychiatric Rating Scale, Center for Epidemiologic Studies Depression Scale, Scale for the Assessment of Negative Symptoms), medical severity (Charlson comorbidity index), and acute service use.

RESULTS

Older adults with schizoaffective disorder had depressive symptoms of similar severity to bipolar disorder, and thought disorder symptoms of similar severity to schizophrenia. Schizoaffective disorder compared with schizophrenia was associated with better community functioning, but poorer subjective physical and mental health functioning as measured by the SF-36. Older adults with schizoaffective disorder had greater acute hospitalization compared with adults with schizophrenia, though their use of acute care services was comparable to individuals with bipolar disorder.

CONCLUSIONS

Findings from this study suggest that schizoaffective disorder in older adults occupies a distinct profile from either schizophrenia or bipolar disorder with respect to community functional status, symptom profile, and acute services utilization.

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

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

Characteristics and heterogeneity of schizoaffective disorder compared with unipolar depression and schizophrenia - a systematic literature review and meta-analysis

BACKGROUND

Comparisons of illness characteristics between patients with schizoaffective disorder (SAD) patients and unipolar depression (UD) are rare, even though UD is one of the most important differential diagnoses of SAD. Also, the variability of illness characteristics (heterogeneity) has not been compared. We compared illness characteristics and their heterogeneity among SAD, UD, and - as another important differential diagnosis - schizophrenia (S).

METHODS

In order to reduce sampling bias we systematically searched for studies simultaneously comparing samples of patients with SAD, UD, and S. Using random effects and Mantel-Haenszel models we estimated and compared demographic, illness course and psychopathology parameters, using pooled standard deviations as a measurement of heterogeneity.

RESULTS

Out of 155 articles found by an earlier meta-analysis, 765 screened in Medline, 2738 screened in EMBASE, and 855 screened in PsycINFO we selected 24 studies, covering 3714 patients diagnosed according to RDC, DSM-III, DSM-IIIR, DSM-IV, or ICD-10. In almost all key characteristics, samples with schizoaffective disorders fell between unipolar depression and schizophrenia, with a tendency towards schizophrenia. On average, UD patients were significantly older at illness onset (33.0 years, SAD: 25.2, S: 23.4), more often women (59% vs. 57% vs. 39%) and more often married (53% vs. 39% vs. 27%). Their psychopathology was also less severe, as measured by BPRS, GAS, and HAMD. In demographic and clinical variables heterogeneity was roughly 5% larger in UD than in SAD, and samples of patients with schizophrenia had the lowest pooled heterogeneity. A similar picture emerged in a sensitivity analysis with coefficient of variation as the measurement of heterogeneity.

LIMITATIONS

Relative to bipolar disorder there are fewer studies including unipolar patients. No studies based on DSM-5 could be included.

CONCLUSIONS

Regarding unipolar affective disorder this study confirms what we have shown for bipolar disorders in earlier studies: schizoaffective disorder falls between schizophrenia and affective disorders, and there are relevant quantitative differences in key illness characteristics, which supports the validity of the schizoaffective disorder concept. Contrary to our expectations heterogeneity is not larger in SAD than in UD and not substantially higher than in S. Lower reliability of the diagnosis of SAD therefore cannot be ascribed to higher variability of illness characteristics in SAD.

Heterogeneity of schizoaffective disorder compared with schizophrenia and bipolar disorder

OBJECTIVE

Low diagnostic reliability, the need to meet criteria of two disorders, and its status as residual diagnosis in clinical practice led us to hypothesize that schizoaffective disorder (SAD) is characterized by considerable heterogeneity, particularly in comparison with schizophrenia (SZ) and bipolar disorder (BD). As this has not been investigated the aim of this study is to test whether heterogeneity is larger in SAD than in SZ and BD.

METHOD

Systematic search for studies simultaneously comparing all three diagnoses regarding demographic, clinical, psychometric (clinical rating scales and IQ tests), and biological parameters; comparison of heterogeneity as measured by standard deviation (SD).

RESULTS

Standard deviation of SAD samples (N = 47) was smaller than in both differential diagnoses. SDs were 7% higher in BD than in SAD (SZ: 2% higher); in studies employing DSM-IIIR/-IV pooled SD was 4% higher in BD (8% lower in SZ). Differences between diagnoses were limited to the comparison of SAD and BD, and became smaller when only psychotic BD was considered.

CONCLUSION

Heterogeneity of SZ and BD is not smaller than that of SAD. SAD seems not to be more diverse than other functional psychoses. Results are preliminary because of the novelty of the approach and to the small number of studies.

Symptomatic and functional remission in patients with first-episode psychosis

OBJECTIVE

For patients suffering from psychotic disorders and their caregivers, 'recovery' remains important. Our study aims to examine the rates of both symptomatic and functional remission in first-episode psychosis (FEP) patients at 2 years and identify sociodemographic and clinical factors associated with recovery.

METHOD

In this naturalistic study, all consecutive FEP patients presenting to an early psychosis intervention programme were recruited. Symptomatic remission was defined by the Schizophrenia Working Group's criteria; functional remission was defined as a Global Assessment of Functioning (GAF) disability score of ≥61 with engagement in age-appropriate vocation. Simple and multiple logistic regressions using stepwise method were used.

RESULTS

Out of 1175 patients, 636 (54.1%) met criteria for symptomatic remission, 686 (58.4%) for functional remission, while 345 (29.4%) met for both. Multiple logistic regression revealed female gender (OR 1.47; 95%CI, 1.12-1.93), those married (OR 1.49; 95%CI, 1.02-2.18), younger age (OR 0.98; 95%CI, 0.95-0.99), tertiary education (OR 1.56; 95%CI, 1.02-2.38), shorter DUP (OR 0.99; 95%CI, 0.98-0.99), lower baseline PANSS negative scores (OR 0.97; 95%CI, 0.95-0.99), and early response at month 3 (OR 1.78; 95%CI, 1.31-2.42), as significant predictors of recovery at year 2.

CONCLUSION

Our results indicate that strategies to reduce DUP and achieve early response could improve remission rates in FEP patients.

Schizoaffective disorders are psychotic mood disorders; there are no schizoaffective disorders

Schizoaffective disorder (SA D/O), introduced in 1933 by Dr. Jacob Kasanin, represented a first, modest change in our concept about the diagnoses of psychotic patients away from the beliefs of E. Bleuler, i.e., that hallucinations and delusions define schizophrenia, and toward the recognition of a significant role for mood disorders. SA D/O established a connection between schizophrenia and mood disorders, traditionally considered mutually exclusive, a connection that has strengthened progressively toward the diagnostic unity of all three disorders. A basic tenet of medicine holds that if discrepant symptoms can be explained by one disease instead of two or more, it is likely there is only one disease. The scientific justification for SA D/O and schizophrenia as disorders distinct from a psychotic mood disorder has been questioned. The "schizo" prefix in SA D/O rests upon the presumption that the diagnostic symptoms for schizophrenia are disease specific. They are not, since patients with severe mood disorders can evince any or all of the "schizophrenic" symptoms. "Schizophrenic" symptoms mean "psychotic" and not any specific disease. These data and a very low interrater reliability for SA D/O suggest that the concepts of SA D/O and schizophrenia as valid diagnoses are flawed. Clinically SA D/O remains popular because it encompasses both schizophrenia and psychotic mood disorder when there is a diagnostic question. We present a review of the literature in table form based on an assignment of each article assigned to one of five categories that describe the possible relationships between SA D/O, schizophrenia and psychotic mood disorders. We conclude that the data overall are compatible with the hypothesis that a single disease, a mood disorder, with a broad spectrum of severity, rather than three different disorders, accounts for the functional psychoses.

Bipolar disorder, schizoaffective disorder and schizophrenia: epidemiologic, clinical and prognostic differences

The validity and nosologic status of schizoaffective disorder is still a controversial issue. This study was conducted to analyze the demographic, clinical and prognostic variables that determine the validity of the diagnosis of schizoaffective disorder bipolar type. We analyzed and compared 138 outpatients: 67 with type I bipolar disorder, 34 with schizoaffective disorder bipolar type and 37 with schizophrenia. They were all diagnosed following research diagnostic criteria and assessed according to the Schedule for Affective Disorders and Schizophrenia. Schizoaffective unipolar patients were excluded. The results reaffirmed that, from the standpoints of demographics, clinical features and prognosis, schizoaffective disorders bipolar type can be classified as a phenotypic form at an intermediate point between bipolar I disorder and schizophrenia. These results emphasize the importance of longitudinal follow-up in the diagnosis and assessment of psychotic syndromes. Although cross-sectional symptoms were closer to the schizophrenia spectrum, the course of the illness resembled more that of bipolar patients, resulting in an intermediate outcome.

Outcome of depression in psychiatric settings

We reviewed follow-up studies of adults with depressive disorders seen in psychiatric settings, and noted outcomes in terms of recovery, recurrence, and persistent depression, at six months, one year, two to five years, and ten or more years after an index episode of depression. Recovery increased with time: about half recovered at least briefly by six months, and a large majority did so in the long term. Only about a quarter recovered from an index episode and remained well more than ten years thereafter. A quarter of patients suffered recurrence of depression within a year of an index episode, and three-quarters did so at least once during follow-up periods lasting more than ten years. For more than one in ten patients, the depression proved persistent, the proportion affected remaining relatively stable over time. The review highlighted a relative paucity of conclusive investigations on the outcome of the commonest psychiatric disorder in clinical settings.

Social conditions in a total population with long-term functional psychosis in three different areas of Stockholm County

A number of social conditions regarding interpersonal relations, housing and employment were studied in a total population of individuals with long-term functional psychosis (n = 341) drawn from the population aged 18-64 years inhabiting three different areas of Stockholm County, altogether about 57,000 inhabitants. Individuals were included irrespective of whether they had a psychiatric treatment contact or not. They were mostly unmarried (57%) and living alone (64%). Most were unemployed (69%) and over half received a disability pension. However, 76% had their own flat and a reasonable financial standard, not deteriorating with illness duration. The diagnosis of schizophrenia led to poorer social conditions, as did early age at onset, male sex and co-morbidity of substance abuse. A larger number of individuals lived in an institution in the urban area while a greater number lived with relatives in the rural area.

A review of schizoaffective disorder: I. Current concepts

This paper reviews recent literature on schizoaffective disorder. Research studies of diagnosis, clinical course and outcome and family history are evaluated. It is concluded that schizoaffective disorder is a heterogeneous category which includes patients with bipolar disorder, schizophrenia, a genetically distinct psychosis and a genetic disposition to both schizophrenia and bipolar disorder.

Long-term clinical outcome of schizophrenia with special reference to gender differences

A sample of 94 first-admitted schizophrenics and 47 patients with schizophreniform disorder (DSM-III) was personally re-examined after a mean of 10 years (by Retterstöl), and 110 of the patients after a mean of 31 years (by the author). Nearly half of the patients were admitted in 1946-1948 (long-term) and the remaining in 1958-1961 (short-term). Average outcome was significantly more favourable for short-term than for long-term patients. Single marital status and no, minimal or mild psychosocial stressor at onset (Axis IV) predicted poor long-term outcome. At 10-year follow-up there was no difference between men and women in clinical outcome. No substantial change was revealed in men at last follow-up, whereas on average women had clearly deteriorated.

Psychopathological and social status of patients with affective, schizophrenic and schizoaffective disorders after long-term course

A total of 106 affective, 101 schizoaffective and 148 schizophrenic disorders were investigated after a long-term course of illness (mean follow-up period 25.1 years), employing narrow definitions and using reliable international instruments of evaluation. In addition, the social consequences of the illness were evaluated (upward and downward social and occupational drift, premature retirement and achievement of the expected social development). Considering all aspects of outcome, schizophrenic patients (narrow defined, slightly modified DSM-III criteria) had persistent alterations in several aspects of social life, communication and cognitive functions, in some cases to a very high degree. Although the outcome of affective disorders is not always favourable, it is significantly more favourable than that of schizophrenia. Schizoaffective disorders occupy a position between affective and schizophrenic disorders regarding outcome, but with more similarities to that of affective than to that of schizophrenic disorders.

Delusional disorders. I. Comparative long-term outcome

Of 301 first-admitted patients with delusional psychoses, 94 met DSM-III criteria of schizophrenia (S), 53 paranoid disorder (PD), 47 schizophreniform disorder (SFD), 35 schizoaffective disorder (SAD), 54 major affective disorder (AD), and 18 other disorders (OD). Retterstöl selected the patients and personally interviewed them after 5-18 years, and later the author interviewed them after 22-39 (mean 30) years. At last follow-up good functioning was noticed in 42%, moderate symptoms in 22%, severe defect in 20%, and very severe defect in 16%; 40% were still delusional. On average S patients did poorest, and OD patients slightly better. AD patients had superior outcome, while PD, SFD and SAD patients showed an intermediate position, but a little closer to AD than to S. However, heterogeneous course and outcome was noticed in all diagnostic groups.