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

Converging Evidence Points to BDNF as Biomarker of Depressive Symptoms in Schizophrenia-Spectrum Disorders

Brain-derived neurotrophic factor (BDNF) is a key modulator of neuroplasticity and has an important role in determining the susceptibility to severe psychiatric disorder with a significant neurodevelopmental component such as major psychoses. Indeed, a potential association between BDNF serum levels and schizophrenia (SCZ) and schizoaffective disorder (SAD) has been tested in diverse studies and a considerable amount of them found reduced BDNF levels in these disorders. Here, we aimed at testing the association of BDNF serum levels with several demographic, clinical, and psychometric measures in 105 patients with SCZ and SAD, assessing the moderating effect of genetic variants within the BDNF gene. We also verified whether peripheral BDNF levels differed between patients with SCZ and SAD. Our findings revealed that BDNF serum levels are significantly lower in patients affected by SCZ and SAD presenting more severe depressive symptomatology. This finding awaits replication in future independent studies and points to BDNF as a possible prognostic indicator in major psychoses.

Symptom remission at 12-weeks strongly predicts long-term recovery from the first episode of psychosis

BACKGROUND

To determine the baseline individual characteristics that predicted symptom recovery and functional recovery at 10-years following the first episode of psychosis.

METHODS

AESOP-10 is a 10-year follow up of an epidemiological, naturalistic population-based cohort of individuals recruited at the time of their first episode of psychosis in two areas in the UK (South East London and Nottingham). Detailed information on demographic, clinical, and social factors was examined to identify which factors predicted symptom and functional remission and recovery over 10-year follow-up. The study included 557 individuals with a first episode psychosis. The main study outcomes were symptom recovery and functional recovery at 10-year follow-up.

RESULTS

At 10 years, 46.2% (n = 140 of 303) of patients achieved symptom recovery and 40.9% (n = 117) achieved functional recovery. The strongest predictor of symptom recovery at 10 years was symptom remission at 12 weeks (adj OR 4.47; CI 2.60-7.67); followed by a diagnosis of depression with psychotic symptoms (adj OR 2.68; CI 1.02-7.05). Symptom remission at 12 weeks was also a strong predictor of functional recovery at 10 years (adj OR 2.75; CI 1.23-6.11), together with being from Nottingham study centre (adj OR 3.23; CI 1.25-8.30) and having a diagnosis of mania (adj OR 8.17; CI 1.61-41.42).

CONCLUSIONS

Symptom remission at 12 weeks is an important predictor of both symptom and functional recovery at 10 years, with implications for illness management. The concepts of clinical and functional recovery overlap but should be considered separately.

Recent physical conditions and health service utilization in people with common mental disorders and severe mental illness in England: Comparative cross-sectional data from a nationally representative sample

Background.

Policies addressing the physical health of people with mental disorders have historically focused on those with severe mental illness (SMI), giving less prominence to the more prevalent common mental disorders (CMDs). Little is known about the comparative physical health outcomes of these patient groups. We aimed to first compare the: (a) number of past-year chronic physical conditions and (b) recent physical health service utilization between CMDs vs. SMI, and secondly compare these outcomes between people with CMDs vs. people without mental disorders.

Methods.

We analyzed cross-sectional data from the third Adult Psychiatric Morbidity Survey, a representative sample of the English population. We determined the presence of physical conditions and health service utilization by self-report and performed logistic regression models to examine associations of these outcomes between participant groups.

Results.

Past-year physical conditions were reported by the majority of participants (CMDs, n = 815, 62.1%; SMI = 27, 63.1%) with no variation in the adjusted odds of at least one physical condition between diagnoses (odds ratio [OR] = 0.96, 95% confidence intervals [CI] 0.42–1.98, p = 0.784). People with CMDs were significantly more likely to be recently hospitalized relative to with those with SMI (OR = 6.33, 95% CI 5.50–9.01, p < 0.05). Having a CMD was associated with significantly higher odds of past-year physical conditions and recent health service utilization (all p < 0.001) compared with the general population.

Conclusions.

People with CMDs experience excess physical health morbidities in a similar pattern to those found among people with SMI, while their somatic hospitalization rates are even more elevated. Findings highlight the importance of recalibrating existing public health strategies to bring equity to the physical health needs of this patient group.

Transcriptional changes in the stress pathway are related to symptoms in schizophrenia and to mood in schizoaffective disorder

Altered levels of stress-signalling transcripts have been identified in post-mortem brains of people with schizophrenia, and since stress effects may be expressed throughout the body, there should be similar changes in peripheral cells. However, the extent to which these markers are altered in peripheral white blood cells of people with schizophrenia is not known. Furthermore, how peripheral cortisol and stress-related mRNA are associated with negative symptom severity and emotional states in people with schizophrenia versus schizoaffective disorder has not been determined. Whole blood samples were collected from 86 patients with either schizophrenia or schizoaffective disorder (56 people with schizophrenia and 30 people with schizoaffective disorder), and 77 healthy controls. Total RNA was isolated, cDNA was synthesized, and stress-signalling mRNA levels (for NR3C1, FKBP5, FKBP4, PTGES3 and BAG1) were determined. Stress and symptom severity scores were measured by the Depression, Anxiety and Stress Scale, and the Positive and Negative Syndrome Scale, respectively. We found increased FKBP5 mRNA, Z(156) = 2.5, p = 0.01, decreased FKBP4 mRNA, t(155) = 3.5, p ≤ 0.001, and decreased PTGES3 mRNA, t(153) = 3.0, p ≤ 0.01, in schizophrenia and schizoaffective disorder cohorts combined compared to healthy controls. Stress-related peripheral mRNA levels were differentially correlated with negative emotional states and symptom severity in schizoaffective disorder (β's = -0.45-0.56, p's = 0.05-0.001) and schizophrenia (β's = -0.34-0.38, p's = 0.04-0.03), respectively. Therefore, molecules of the stress-signalling pathway appear to differentially contribute to clinical features of schizophrenia versus schizoaffective disorder.

Clinical implication of smoking among patients with schizophrenia at a Tertiary Institution in South East Nigeria

Background

The chronic and debilitating nature of schizophrenia creates a disease with marked clinical and economic consequences. Smoking in schizophrenia appears to be associated with increased psychopathology and disability.

Objective

The aim of this study was to determine if cigarette smoking in schizophrenia is associated with increased disability and psychopathology.

Materials and methods

This was a cross-sectional descriptive study in which 367 out-patients with International Classification of Diseases (ICD) 10 diagnosis of schizophrenia were recruited. Socio-demographic questionnaire, Present State Examination (PSE) 10, Positive And Negative Syndrome Scale (PANSS) and World Health Organization Disability Assessment Schedule (WHODAS) were administered. Data was analyzed using a software package SPSS version 15.

Results

There was no significant difference in the mean PANSS scores of smokers and non-smokers. Current smoking was associated with increased disability (F=5.39, p=0.02). Total PANSS score significantly predicted disability F(3,71=5.60, p=0.002, R2=0.19). There was no significant association between positive or negative symptoms and being a smoker or non-smoker.

Conclusion

The results of this study revealed that smoking in Nigerian schizophrenia patients is associated with significant disability. Measures should be put in place to discourage cigarette smoking among Nigerian patients with schizophrenia.

Neuropsychological and neuroimaging underpinnings of schizoaffective disorder: a systematic review

OBJECTIVES

The neurobiological basis and nosological status of schizoaffective disorder remains elusive and controversial. This study provides a systematic review of neurocognitive and neuroimaging findings in the disorder.

METHODS

A comprehensive literature search was conducted via PubMed, ScienceDirect, Scopus and Web of Knowledge (from 1949 to 31st March 2015) using the keyword 'schizoaffective disorder' and any of the following terms: 'neuropsychology', 'cognition', 'structural neuroimaging', 'functional neuroimaging', 'multimodal', 'DTI' and 'VBM'. Only studies that explicitly examined a well defined sample, or subsample, of patients with schizoaffective disorder were included.

RESULTS

Twenty-two of 43 neuropsychological and 19 of 51 neuroimaging articles fulfilled inclusion criteria. We found a general trend towards schizophrenia and schizoaffective disorder being related to worse cognitive performance than bipolar disorder. Grey matter volume loss in schizoaffective disorder is also more comparable to schizophrenia than to bipolar disorder which seems consistent across further neuroimaging techniques.

CONCLUSIONS

Neurocognitive and neuroimaging abnormalities in schizoaffective disorder resemble more schizophrenia than bipolar disorder. This is suggestive for schizoaffective disorder being a subtype of schizophrenia or being part of the continuum spectrum model of psychosis, with schizoaffective disorder being more skewed towards schizophrenia than bipolar disorder.

A critical appraisal of paliperidone long-acting injection in the treatment of schizoaffective disorder

Schizoaffective disorder (SCA) is a chronic and disabling mental illness that presents with mixed symptoms of schizophrenia and affective disorders. SCA is recognized as a discrete disorder, but with greater heterogeneity and symptom overlap, leading to difficulty and delay in diagnosis. Although the overall prognosis is intermediate between schizophrenia and mood disorders, SCA is associated with higher rates of suicide and hospitalization than schizophrenia. No treatment guidelines exist for SCA, and treatment is frequently complex, involving off-label use and polypharmacy (typically combinations of antipsychotics, mood stabilizers, and antidepressants). Oral paliperidone extended-release was the first agent to be approved for the treatment of SCA. As in schizophrenia and bipolar disorder, adherence to oral medications is poor, further contributing to suboptimal outcomes. The use of an antipsychotic in a long-acting injection (LAI) addresses adherence issues, thus potentially reducing relapse. Paliperidone palmitate represents the LAI formulation of paliperidone. In a long-term, double-blind, randomized, controlled trial of adult patients (n=334; intent-to-treat [ITT]) with SCA, paliperidone long-acting injection (PLAI) significantly delayed risk of relapse compared to placebo (hazard ratio 2.49, 95% confidence interval, 1.55–3.99; P<0.001). This study demonstrated the efficacy and safety of PLAI when used as either monotherapy or adjunctive therapy for the maintenance treatment of SCA. The results are consistent with a similarly designed study conducted in patients with schizophrenia, which suggests a benefit in the long-term control of not only psychotic but also affective symptoms. No new safety signals were observed. When used in monotherapy, PLAI simplifies treatment by reducing complex pharmacotherapy and obviating the necessity for daily oral medications. PLAI is the second agent, and the first LAI, to be approved for the treatment of SCA; as an LAI formulation, there is the advantage of improved adherence and simplified treatment in the long-term management of SCA.

Brain structural changes in schizoaffective disorder compared to schizophrenia and bipolar disorder

OBJECTIVE

Brain structural changes in schizoaffective disorder, and how far they resemble those seen in schizophrenia and bipolar disorder, have only been studied to a limited extent.

METHOD

Forty-five patients meeting DSM-IV and RDC criteria for schizoaffective disorder, groups of patients with 45 matched schizophrenia and bipolar disorder, and 45 matched healthy controls were examined using voxel-based morphometry (VBM).

RESULTS

Analyses comparing each patient group with the healthy control subjects found that the patients with schizoaffective disorder and the patients with schizophrenia showed widespread and overlapping areas of significant volume reduction, but the patients with bipolar disorder did not. A subsequent analysis compared the combined group of patients with the controls followed by extraction of clusters. In regions where the patients differed significantly from the controls, no significant differences in mean volume between patients with schizoaffective disorder and patients with schizophrenia in any of five regions of volume reduction were found, but mean volumes in the patients with bipolar disorder were significantly smaller in three of five.

CONCLUSION

The findings provide evidence that, in terms of structural gray matter brain abnormality, schizoaffective disorder resembles schizophrenia more than bipolar disorder.

Social functioning and age across affective and nonaffective psychoses

Both nonaffective and affective psychoses are associated with deficits in social functioning across the course of the illness. However, it is not clear how social functioning varies among diagnostic groups as a function of age. The current study examined the relationship between social functioning and age in schizophrenia (SZ), schizoaffective disorder (SZA), and psychotic bipolar disorder (PBD). We found that individuals with PBD had the highest functioning, whereas individuals with SZ had the poorest. The functioning of individuals with SZA fell in between those of other groups. We also found that older ages were associated with poorer functioning. Although there was not a significant diagnostic group by age interaction, visual inspection of our data suggests a subtly steeper trajectory of decline in PBD. Overall, these results indicate that early interventions targeting social functioning may benefit individuals with either non-affective or affective psychoses to slow a projected decline.

Social class, social mobility and risk of psychiatric disorder--a population-based longitudinal study

Objectives

This study explored how adult social class and social mobility between parental and own adult social class is related to psychiatric disorder.

Material and Methods

In this prospective cohort study, over 1 million employed Swedes born in 1949-1959 were included. Information on parental class (1960) and own mid-life social class (1980 and 1990) was retrieved from the censuses and categorised as High Non-manual, Low Non-manual, High Manual, Low Manual and Self-employed. After identifying adult class, individuals were followed for psychiatric disorder by first admission of schizophrenia, alcoholism and drug dependency, affective psychosis and neurosis or personality disorder (N=24 659) from the Swedish Patient Register. We used Poisson regression analysis to estimate first admission rates of psychiatric disorder per 100 000 person-years and relative risks (RR) by adult social class (treated as a time-varying covariate). The RRs of psychiatric disorder among the Non-manual and Manual classes were also estimated by magnitude of social mobility.

Results

The rate of psychiatric disorder was significantly higher among individuals belonging to the Low manual class as compared with the High Non-manual class. Compared to High Non-manual class, the risk for psychiatric disorder ranged from 2.07 (Low Manual class) to 1.38 (Low Non-manual class). Parental class had a minor impact on these estimates. Among the Non-manual and Manual classes, downward mobility was associated with increased risk and upward mobility with decreased risk of psychiatric disorder. In addition, downward mobility was inversely associated with the magnitude of social mobility, independent of parental class.

Conclusions

Independently of parental social class, the risk of psychiatric disorder increases with increased downward social mobility and decreases with increased upward mobility.

Psychopathological long-term outcome of schizophrenia -- a review

OBJECTIVE

In the past, the comparability of empirical studies that examined the course and outcome of schizophrenia was limited by their use of different diagnostic systems. Focussing on the psychopathological long-term outcome, the present article aims to review follow-up studies that used modern operationalized diagnostic criteria for schizophrenia (DSM-III, DSM-III-R, DSM-IV and ICD-10).

METHOD

We searched MEDLINE, the Cochrane Central Register of Controlled Trials, EMBASE, PsycINFO and PSYNDEX for relevant studies up to the year 2011. Twenty-one studies were included in the final analysis.

RESULTS

The long-term outcome of schizophrenia was heterogeneous and included full remissions as well as severe chronic states. Schizophrenia, however, showed a considerably more unfavourable outcome than other diagnostic groups such as schizoaffective or affective disorders. Psychopathological symptoms remained relatively stable in the course of illness. Several predictors for a poor outcome were identified, such as male gender or pronounced negative symptoms.

CONCLUSION

Recent studies using modern diagnostic systems largely confirm the results of earlier studies. Current diagnostic criteria for schizophrenia identify a heterogeneous sample of patients. The influence of therapeutic interventions on long-term outcome remains unclear.

The Munich 15-year follow-up study (MUFUSSAD) on first-hospitalized patients with schizophrenic or affective disorders: assessing courses, types and time stability of diagnostic classification

OBJECTIVE

In the context of the development of DSM-V and ICD-11 it appears to be useful to get further data on the validity of the diagnostic differentiation between schizophrenic and affective disorders. This study investigated the relevance of the main diagnostic groups schizophrenia, schizoaffective psychosis and affective disorder in the context of different diagnostic systems (ICD-9, ICD-10, DSM -IV), assessing their time stability, long-term courses, types and functional outcome.

METHODS

A total of 323 first hospitalized inpatients of the Psychiatric Department of the University Munich were recruited at index time. The full follow-up evaluation including standardized assessment procedures could be performed in 197 patients.

RESULTS

The re-diagnosis of the patients' disorders shows that with the transition from ICD-9 to ICD-10 or DSM-IV, the group of affective disorders increased numerically while the diagnostic groups of schizophrenia and schizoaffective disorders decreased in size. The structured clinical interview for DSM-IV (SCID) analysis showed that altogether ICD-10 and DSM-IV had a relatively high diagnostic stability. Of the patients with an ICD-10 diagnosis of schizophrenia, 57% had a chronic course; 61% of the patients with a DSM-IV diagnosis of schizophrenia. Patients with affective disorders, according either to ICD-10 or DSM-IV, had in more than 90% of the cases an episodic-remitting course. In terms of prediction of long-term outcome regarding the differentiation between chronic and non-chronic course, the ICD-10 diagnoses did give a slightly better predictive result than a dimensional approach based on the key psychopathological syndrome scores.

CONCLUSIONS

The differentiation between schizophrenic and affective disorders seems meaningful especially under predictive aspects. A dimensional syndromatological description does not exceed the predictive power of the investigated main diagnostic categories, but might increase the clinically relevant information.

The Munich 15-year follow-up study (MUFUSSAD) on first-hospitalized patients with schizophrenic or affective disorders: comparison of psychopathological and psychosocial course and outcome and prediction of chronicity

Given the limited explanatory power of the available neurobiological findings, results of long-term follow-up studies should still be considered as one criterion among others in the development of psychiatric classification systems regarding schizophrenia and affective disorders. A total of 323 first hospitalized inpatients of the Psychiatric Department of the University Munich were recruited at index time and followed up after 15 years. The full follow-up evaluation including several standardized assessment procedures (AMDP, PANSS, SANS, DAS, GAS) could be performed in 197 patients. The patients originally diagnosed according to ICD-9 were re-diagnosed according to ICD-10 and DSM-IV, using SCID among others. Schizophrenic patients had a much poorer outcome than affective or schizoaffective patients in terms of negative syndrome, deficit syndrome, psychosocial impairments and GAS results, and a higher prevalence of a chronic course. The logistic regression analyses performed to find optimized predictor combinations for the prognosis of a chronic course found, for example, the total Strauss-Carpenter Scale score, male gender and several other psychopathological syndromes to be relevant predictors. The findings reflect some long-term related validity for the differentiation between schizophrenia and affective disorders. The Strauss-Carpenter Scale, male gender as well as several psychopathological syndromes are the most relevant predictors for chronicity.

Schizoaffective disorder--an ongoing challenge for psychiatric nosology

OBJECTIVE

Schizoaffective disorder is a common diagnosis in mental health services. The present article aims to provide an overview of diagnostic reliability, symptomatology, outcome, neurobiology and treatment of schizoaffective disorder.

METHOD

Literature was identified by searches in "Medline" and "Cochrane Library".

RESULTS

The diagnosis of schizoaffective disorder has a low reliability. There are marked differences between the current diagnostic systems. With respect to psychopathological symptoms, no clear boundaries were found between schizophrenia, schizoaffective disorder and affective disorders. Common neurobiological factors were found across the traditional diagnostic categories. Schizoaffective disorder according to ICD-10 criteria, but not to DSM-IV criteria, shows a more favorable outcome than schizophrenia. With regard to treatment, only a small and heterogeneous database exists.

CONCLUSION

Due to the low reliability and questionable validity there is a substantial need for revision and unification of the current diagnostic concepts of schizoaffective disorder. If future diagnostic systems return to Kraepelin's dichotomous classification of non-organic psychosis or adopt a dimensional diagnostic approach, schizoaffective disorder will disappear from the psychiatric nomenclature. A nosological model with multiple diagnostic entities, however, would be compatible with retaining the diagnostic category of schizoaffective disorder.

Predicting the course and outcome of bipolar disorder: a review

Despite of advances in pharmacological and non-pharmacological treatments, bipolar disorder often entails multiple relapses and impaired psychological functioning. The extent to which modern treatments have influenced the natural course of a mental disorder is uncertain. Prediction of the course and outcome of bipolar disorders continues to be challenging, despite the multiple research efforts worldwide. Due to a lack of laboratory diagnostic tests and biomarkers, psychiatric interview and examination provide the basis for outcome prediction. While considered to have more favorable prognosis than schizophrenia, it is not uncommon for bipolar disorder to include persisting alterations of psychosocial functioning. Although long-term symptomatic remission does not guarantee functional recovery, it may have a favorable impact on long-term overall prognosis. The high degree of treatment resistance in patients with bipolar disorder highlights the need to develop better identification of outcome predictors, prognosis and treatment intervention, designed to reverse or prevent this illness burden. This review summarizes the main factors involved in predicting the course and outcome of bipolar disorder.

The management of individuals with bipolar disorder: a review of the evidence and its integration into clinical practice

Bipolar disorder is a common, debilitating, chronic illness that emerges early in life and has serious consequences such as long-term unemployment and suicide. It confers considerable functional disability to the individual, their family and society as a whole and yet it is often undetected, misdiagnosed and treated poorly. In the past decade, many new treatment strategies have been trialled in the management of bipolar disorder with variable success. The emerging evidence, for pharmacological agents in particular, is promising but when considered alone does not directly translate to real-world clinical populations of bipolar disorder. Data from drug trials are largely based on findings that identify differences between groups determined in a time-limited manner, whereas clinical management concerns the treatment of individuals over the life-long course of the illness. Considering the findings in the context of the individual and their particular needs perhaps best bridges the gap between the evidence from research studies and their application in clinical practice. Specifically, only lithium and valproate have moderate or strong evidence for use across all three phases of bipolar disorder. Anticonvulsants, such as lamotrigine, have strong evidence in maintenance; whereas antipsychotics largely have strong evidence in acute mania, with the exception of quetiapine, which has strong evidence in bipolar depression. Maintenance data for antipsychotics is emerging but at present remains weak. Combinations have strong evidence in acute phases of illness but maintenance data is urgently needed. Conventional antidepressants only have weak evidence in bipolar depression and do not have a role in maintenance therapy. Therefore, this paper summarizes the efficacy data for treating bipolar disorder and also applies clinical considerations to these data when formulating recommendations for the management of bipolar disorder.

Social disability in schizophrenic, schizoaffective and affective disorders 15 years after first admission

BACKGROUND

Interest in social functioning of people suffering from mental illnesses has been increasing over the last few years. Only few studies have investigated differences in social functioning in affective, schizoaffective and schizophrenic patients in the long-term and in a comparative approach.

METHOD

The present study is part of a 15 year follow-up study on patients suffering from severe mental illness. The here reported findings refer to the data of a sample of 177 patients with life-time diagnoses belonging to the schizophrenic, schizoaffective or affective spectrum according to the ICD-10 criteria. Psychopathological, socio-demographic and other illness-related variables were assessed at the index hospitalisation and at the 15 year follow-up evaluation by using the assessment system published by the Association for Methodology and Documentation in Psychiatry (AMDP-system). Information about patients' social disability was assessed by using a modified and further developed version of the WHO disability assessment scale, the (Mannheim) Disability Assessment Schedule (DAS-M scale). Prevalence rates of social disability and differences in the severity of social disability between different groups of mental illnesses were evaluated. And the association between social disability, diagnoses and psychopathology was analysed.

RESULTS

Compared to affective and schizoaffective patients, schizophrenic patients showed significantly higher levels of social disability in almost all domains. Severe to very severe levels of disability were found in 64% of schizophrenic patients and only in 19% of schizoaffective patients and 5% of affective patients. However, on a descriptive level all three diagnostic groups presented with similar maxima and minima in their profiles of social disability. Multiple regression analyses revealed that the apathy syndrome had the highest impact on the presence of severe social disability with all other psychopathological syndromes, gender, age and diagnosis having no statistically significant influence.

CONCLUSION

Findings indicate that patients' disabilities in different diagnostic groups seem to be of a similar quality and nature despite differences in their severity. The impact of psychopathology on disability seems to be more important than the one of diagnosis per se.

Prospective evaluation of the effect of major depression on working status in a population sample

OBJECTIVE

Numerous surveys have reported associations between major depressive episodes (MDEs) and occupational status, but cross-sectional studies cannot quantify the risks of employment transitions nor clarify their temporal direction. The goal of our study was to estimate the impact of MDE on subsequent employment status in a longitudinal community cohort.

METHODS

Data from the National Population Health Survey (NPHS) were used. Proportional hazard models and logistic regression were employed to evaluate the effect of MDE on working status during the 1994 to 2004 interval among respondents who reported working at a job or business at baseline.

RESULTS

MDE was associated with an increased risk of movement to nonworking status. People aged 26 to 45 years with MDEs have more than double the risk of this transition (HR = 2.6; 95% CI 1.8 to 3.6, P < 0.001). The probability of transition to nonworking status was higher, but the relative effect was smaller in people aged 46 to 65 years (HR = 1.2; 95% CI 0.7 to 2.0, P = 0.47). Retirement or perceived lack of availability of work did not contribute to the association.

CONCLUSIONS

MDE is associated with an elevated risk of transition from working to nonworking status, especially in people aged 26 to 45 years.

Is schizoaffective disorder a distinct categorical diagnosis? A critical review of the literature

Considerable debate surrounds the inclusion of schizoaffective disorder in psychiatric nosology. Schizoaffective disorder may be a variant of schizophrenia in which mood symptoms are unusually prominent but not unusual in type. This condition may instead reflect a severe form of either major depressive or bipolar disorder in which episode-related psychotic symptoms fail to remit completely between mood episodes. Alternatively, schizoaffective disorder may reflect the co-occurrence of two relatively common psychiatric illnesses, schizophrenia and a mood disorder (major depressive or bipolar disorder). Each of these formulations of schizoaffective disorder presents nosological challenges because the signs and symptoms of this condition cross conventional categorical diagnostic boundaries between psychotic disorders and mood disorders. The study, evaluation, and treatment of persons presently diagnosed with schizoaffective may be more usefully informed by a dimensional approach. It is in this context that this article reviews and contrasts the categorical and dimensional approaches to its description, neurobiology, and treatment. Based on this review, an argument for the study and treatment of this condition using a dimensional approach is offered.

One-year outcome and its prediction in first-episode schizophrenia--a naturalistic study

BACKGROUND

The literature suggests that the early course of schizophrenia is a strong predictor of long-term outcome. We sought to test this notion in a sample of first-episode patients.

SAMPLING AND METHODS

Forty patients with a first episode of DSM-IV diagnoses of schizophrenia, schizoaffective, or schizophreniform disorder were assessed with well-established instruments such as the Positive and Negative Syndrome Scale and the Strauss-Carpenter Scale. Reassessment was performed 14 months later and included the Global Assessment of Functioning Scale in addition to the aforementioned instruments and a psychiatric interview. Regression analyses for the Global Assessment of Functioning Scale and symptomatology were used to identify outcome predictors.

RESULTS

At follow-up, 27 patients (67.5%) were in remission. Women's outcome was significantly better with respect to intimate relationships and domiciliary independence. Although symptomatology of the whole group remained stable during the follow-up period, a subgroup of patients experienced a significant decrease in symptom levels whereas symptoms increased in another subgroup. The most important predictor of outcome was compliance with atypical antipsychotic medication during the follow-up period.

CONCLUSIONS

These results suggest that there is a prognostic divide early in the course of the disease, that compliance with medication is of overriding importance towards 1-year outcome, and that for the individual patient the question of chronicity may be answered very early in the course of the disease.

Relationship between diagnosis and disposition of patients admitted to a state psychiatric hospital

The lifetime outcome for individuals diagnosed with affective disorders is generally more favorable than for those diagnosed with a schizophrenic disorder. We determined if a similar differential outcome could be detected among 139 patients hospitalized on the admissions unit of a state psychiatric facility between 1998 and 2001, and diagnosed with a Schizophrenic, Schizoaffective or Affective Disorder. The placement of each patient on discharge was categorized as an outpatient environment, a minimum-security treatment unit, a locked ward, or a highly secure forensic facility. Patients with an affective disorder were significantly less likely than the other two groups to have a co-occurring diagnosis of substance abuse, and they performed better on the neuropsychological assessments. However, the groups did not differ in their discharge placements, or in their length of stay. These findings suggest that resolution of more acute symptomatology may be unrelated to factors associated with long-term outcome for individuals suffering from severe and persistent mental illness.

Fifteen-year follow-up of ICD-10 schizoaffective disorders compared with schizophrenia and affective disorders

OBJECTIVE

The nosological status of schizoaffective disorders is still unclear. The aim of the present study was to compare ICD-10 schizoaffective disorders to schizophrenia and affective disorders with respect to the clinical picture and the long-term outcome.

METHOD

Two hundred and forty-one first-admitted inpatients from the years 1980-1982 who fulfilled the ICD-10 criteria for schizophrenia, schizoaffective or affective disorders were included. Patients were examined at the time of first hospitalization and then followed-up after 15 years.

RESULTS

With respect to the clinical picture at the time of first hospitalization ICD-10 schizoaffective disorders were distinguishable from both schizophrenia and affective disorders. However, with respect to the long-term outcome ICD-10 schizoaffective disorders had a prognosis similar to that of affective disorders.

CONCLUSION

Differing prognosis implies that schizoaffective disorders should be distinguished from schizophrenia and suggests their subcategorization under affective disorders.

[Disability in schizophrenia. Intrinsic factors and prediction of psychosocial outcome. An analysis of literature]

OBJECTIVE

Many different factors, both related to the individual and illness ("intrinsic" factors) and to the environment ("extrinsic" factors), contribute in different ways to the development of disability. Basing on data of literature, this review focuses the main "intrinsic" factors predicting disability in schizophrenia.

METHOD

A systematic search on Mediline of all papers published during the period 1965-2001 was performed, using "schizophrenia", "outcome", "psychosocial outcome", "social disability" and "social adjustment" as key words. Only papers reporting specifically data about predictive factors and psychosocial outcome variables were considered; prospective follow-up studies were considered, but retrospective and cross-sectional studies were also taken into account when data deriving from prospective studies were inconsistent.

RESULTS

Male sex predicts a higher disability among demographic factors; lower social and occupational adjustment are premorbid personality factors associated with higher disability; among factors related to illness, younger age at onset of illness, "nuclear", "non paranoid" and in particular "deficit" forms of schizophrenia seem to predict more disability. The latter seems to be predicted also by higher levels of negative symptoms and neuropsychological deficits; the role of depressive symptoms seems to be less supported by follow-up data; a continuous course of the illness predicts more disability, although some evidences show a progressive reduction of disability, at least in the long term.

CONCLUSIONS

Disability shows a largely autonomous course respect to symptoms and has to be considered an independent parameter of outcome. Few intrinsic factors show a predictive role also in the long term.

Duration of untreated psychosis in first-episode schizophrenia: marker or determinant of course?

The natural history of schizophrenia is often chronic and debilitating, an enduring fact that draws attention to the first episode and early course of the disorder when neurobiological deficits apparently form. Many recent studies have focused on the duration of untreated psychosis (DUP) in first-episode patients for reasons that are reviewed here. DUP is often months or years in length, making it a major public mental health problem. Reducing DUP through early detection may be possible from a service systems perspective. This may be very important because earlier treatment not only reduces acute psychotic symptoms, but may also improve long-term prognosis by attenuating the deficit processes active at this time; processes that are either signaled by or a product of DUP. Finally, DUP appears to influence sampling in first-episode research in that longer DUP is associated with higher recruitment refusal rates to studies. For all of these reasons, DUP should be added to the battery of descriptive variables routinely collected on all patients with schizophrenia, whether for treatment or research.

Some fairly obvious distinctions between schizophrenia and bipolar disorder

In examining the ratio of 'famous' individuals with bipolar disorder to those with schizophrenia, it is evident that the ratio greatly favors those with bipolar disorder, suggesting that schizophrenia somehow precludes expert performance or high-level accomplishment. Why might this be so? One possible explanation lies in neurocognitive findings. In this review, I suggest that patients with schizophrenia perform consistently worse than patients with bipolar disorder on a variety of higher level cognitive tasks (though bipolar patients themselves often evince impairment in comparison to healthy controls). Working memory, in particular, appears to discriminate between the groups. However, questions remain, including the effects of state and medications, and the conclusion that I reach does not exclude the possibility that the two disorders share some but not all etiologic or pathophysiologic features.

The varied outcomes of schizophrenia

OBJECTIVE

To review variations in outcomes in schizophrenia across individual, historical, and cross-cultural boundaries, as well as within specific domains of functioning.

METHOD

Research literature on the outcomes of schizophrenia appearing within the last 8 years was reviewed.

RESULTS

First, a review of follow-up studies published in the developed world suggests that heterogeneity in outcome across individuals with schizophrenia remains the rule, with affective symptoms, later and acute onset, and responsiveness to biological treatments predictive of good outcome. Negative symptoms are associated with poor outcome, cognitive impairments, and incapacity in social and work domains. Deterioration appears to occur within the first few months of onset if not already in the prodrome, with recent early-course studies finding longer duration of untreated psychosis associated with insidious onset, negative symptoms, social and work incapacity, and poor outcome. Second, a review of recent cross-cultural and historical studies provides evidence that outcome varies across time and place, schizophrenia having a more favourable outcome in the developing world and becoming a more benign disorder over the course of this century. Third, a review of studies of the domains of functioning within individuals identifies 4 relatively independent dimensions of depression and negative, psychotic, and disorganized symptoms. Cognitive deficits, which are associated with negative symptoms, also constitute a relatively stable dimension over time, showing neither marked deterioration nor improvement once established early in the course of disorder.

CONCLUSIONS

The early appearance and stability over time of negative symptoms and cognitive impairments call for assertive intervention efforts early in the course of disorder to prevent chronicity and prolonged disability.

Predictors of clinical and social outcomes after hospitalization in schizophrenia

A prospective cohort study of schizophrenia was carried out in Sao Paulo, Brazil, in order to investigate clinical and social outcomes in schizophrenia and related psychoses after hospitalization. A sample of 124 individuals who were living in a defined catchment area and had been consecutively admitted to psychiatric hospitals in that area with clinical diagnoses of non-affective functional psychoses was followed up for 2 years. Assessments of clinical status and social adjustment at inclusion and at 2-year follow-up were carried out by means of standardized instruments, the PSE and the DAS. At the end of the follow-up period, 120 subjects (96.8%) were traced, and 103 (83.1%) were re-assessed. At the second assessment, the proportion of subjects with a nuclear syndrome of schizophrenia had halved (from 68.3% to 32.7%), 23.8% were symptom free and 60.2% showed at least one psychotic symptom. Presence of psychotic symptoms at follow-up was best predicted by educational level (less than 4 years of formal education) and an initial DSM-III-R diagnosis of schizophrenia. The distribution of global social adjustment levels at 2-year follow-up was similar to that observed at the outset, with approximately one third of subjects showing good, one third showing intermediate and one third showing poor global social adjustment. Social disability was best predicted by longer duration of illness, worse social adjustment levels at inclusion and lower educational level.

Socio-economic mobility among patients with schizophrenia or major affective disorder. A 17-year retrospective follow-up

BACKGROUND

Social mobility among patients with schizophrenia or major affective disorder was compared with that among the general population.

METHOD

Mobility was studied retrospectively from 1970 to 1987. Socio-economic status (SES) was defined by occupation as in the population census (upper white-collar, lower white-collar, blue-collar, entrepreneur, farmer, unemployed). All patients aged 30-60 years at discharge (2901 men and 3620 women) in 1987-88 in Finland were included in the study. The SES structure of the general population was used for comparisons.

RESULTS

Among patients with schizophrenia there was a constant downward drift, commonly to unemployment. This risk was higher among men than women. In the youngest age group a marked decline from the parents' social status was observed. Among patients with major affective disorder the distribution of SES in 1970 was similar to that of the general population. By 1987, a downward drift was again observed, mainly to unemployment regardless of the initial SES group. The number of patients in occupational categories were usually 30-50% lower than expected.

CONCLUSIONS

Schizophrenic patients had a high risk of social drop-out. Among patients with major affective disorder the downward drift was much less.

Lower socioeconomic status and shorter survival following HIV infection

We studied the association between socioeconomic status and survival in a prospective study of 364 HIV-infected homosexual men who were recruited during 1982-84. The participants were divided by annual income; those earning above Canadian $10,000 (high-income; n = 274) and those below $10,000 (low-income; n = 90) at recruitment. The latter threshold closely approximated to the poverty level for this population. Low income men were significantly younger than high income men but the groups were similar with respect to baseline CD4 counts, subsequent use of anti-retrovirals and prophylaxis against Pneumocystis carinii pneumonia (PCP), and number of visits attended during follow-up. Subjects were followed for a median of 9.5 years (range 1.8-13.1). By Dec 31, 1993, there were 135 deaths yielding a cumulative mortality rate of mean 45% (SD 4.0) at 11.5 years. Men aged 30 or more at infection had poorer survival than those under 30 (mortality risk ratio 1.56; 95% CI 1.09-2.24; p = 0.015), and longer survival was significantly associated with a higher CD4 count at the earliest seropositive visit. The age-adjusted mortality risk ratio for low income men compared with high income men was significantly increased at 1.63 (95% CI 1.11-2.40; p = 0.013). The significant risk of death for low income men persisted despite adjustment for age at infection, CD4 count, use of zidovudine, dideoxyinosine, and dideoxycytidine, use of PCP prophylaxis, and year of infection. We cannot attribute our findings to income loss as a result of more rapid HIV progression because the same effect was present in people who provided income data before seroconversion. Similarly, our findings are not due to differential access to care because the study was done within the context of a universal health care system, and the two income groups received treatments equally. This finding is consistent with the association of lower socioeconomic status with increased morbidity and mortality observed within large populations and in other diseases.

Predicting the long-term outcome of affective disorders

Factors influencing the long-term outcome of affective disorders were investigated in 106 patients with an average length of course of 28 years. Univariate statistical analyses, stepwise multiple discriminance analyses and path analysis were applied. A direct unfavourable influence on the frequency of persisting alteration (evaluated according to the Global Assessment Scale) was found to have the low self-confident premorbid personality and a higher number of episodes during course, whereas only the variable "male" had such an influence on the social consequences of the illness. The variable "manic episode" (bipolarity) and "age at onset" had only an indirect influence, in that bipolar patients had more episodes, and younger patients more frequently had a bipolar course and therefore had more episodes. The unfavourable long-term outcome was due in those cases to the higher number of episodes.

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.

Specific skills and social competence in schizophrenia

Generalization of skills is a major problem in social skills training for schizophrenic patients. Assessment of skills is mostly not based on objective indices of specific skill deficits. The results of this study show that global competence of schizophrenics can be differentiated from specific competence. Global competence was found to be related to symptoms, whereas specific competence was not. No support was found for the assumption that social dysfunctions are caused by negative symptoms. Social perception and positive symptoms did explain a substantial part of the variance of global competence. It is therefore concluded that neither global incompetence nor negative symptoms should be used as an indication for social skills training.

Course of schizoaffective psychosis: further data from a retrospective study

This study investigated the clinical course and outcome of 72 patients, diagnosed as suffering from schizoaffective psychosis (according to ICD-9 criteria) who also satisfied Research Diagnostic Criteria for schizoaffective disorder. The current overall functioning of these patients was related to the number and frequency of episodes, regardless of the duration of the illness: the lesser the number or frequency of relapses, the better the overall functioning. In addition, there were no statistically significant differences in psychosocial impairment between bipolar and unipolar schizoaffective disorder.

Schizoaffective disorders with and without onset in the puerperium

The premorbid and sociodemographic features, long-term course and long-term outcome (on average 23.8 resp. 26.8 years after onset of illness) were compared in 30 female schizoaffective patients with onset of their illness during the puerperium and 60 female schizoaffective patients with onset at other times. The majority of premorbid and sociodemographic variables as well as course parameters were similar in the two groups. Most of the few differences (in age at first manifestation, marital state at onset, presence of stable heterosexual relationship before onset, acuteness of onset, presence of life events) are closely connected with the inclusion and exclusion criteria applied for the puerperal disorders (exclusion of patients with preexisting illness or psychiatric symptoms during pregnancy, inclusion only if onset was within 6 weeks of parturition). The puerperal schizoaffective disorders began more frequently with a schizomanic episode and less frequently with a schizodepressive episode than did the non-puerperal schizoaffective disorders, a finding which perhaps reflected the "pathoplastic" role of the puerperium on psychotic disorders. Several significant differences were found regarding the long-term outcome (frequency of persistent alterations, level of global functioning and disability, non-achievement of the expected social development, loss of autarky), confirming earlier findings that puerperal disorders generally have a better outcome than other psychotic disorders.