A prospective 1-5 year outcome study in first-admitted and readmitted schizophrenic patients; relationship to heredity, premorbid adjustment, duration of disease and education level at index admission and neuroleptic treatment

Clinical Recovery Among Individuals With a First-Episode Schizophrenia an Updated Systematic Review and Meta-Analysis

BACKGROUND AND HYPOTHESIS

Through decades the clinical recovery outcomes among individuals diagnosed with schizophrenia have been highly inconsistent ranging from 13.5% to 57%. The primary objective of this updated examination was to report the pooled estimate and explore various moderators to improve the understanding of the course of schizophrenia.

STUDY DESIGN

A systematic literature search was set up on PubMed, PsycInfo, and EMBASE until January 13th, 2022. Both observational and interventional studies among cohorts of individuals with the first episode of schizophrenia reporting on clinical recovery were included. The PRISMA 2020 statement was used and data was extracted for a random-effects meta-analysis, meta-regression, and sensitivity analyses. Risk of bias was assessed using The Newcastle-Ottawa Scale.

STUDY RESULTS

A 20.8% (95% CI = 17.3 to 24.8) recovery rate was found among 26 unique study samples (mean trial duration, 9.5 years) including 3877 individuals (mean age, 26.4 years). In meta-regression none of the following study characteristics could uncover the diverse reported recovery rates; age at inclusion (P = .84), year of inclusion (P = .93), follow-up time (P = .99), drop-out rate (P = .07), or strictness of the recovery criteria (P = .35). Furthermore, no differences in recovery were found between early intervention services (EIS; 19.5%; 95% CI = 15.0 to 24.8) compared to other interventions (21%; 95% CI = 16.9 to 25.8), P = .65.

CONCLUSIONS

A clinical recovery rate of approximately 21% was found with minimum impact from various moderators. The rate was not different comparing EIS with other interventions implying that new initiatives are needed to improve the rate of recovery.

A 10-year mirror-image study of effectiveness and cost of long-acting paliperidone palmitate injectable in patients with schizophrenia or schizoaffective disorder

Acute episodes of Schizophrenia and Schizoaffective Disorder often require hospitalizations and/or psychiatry emergency room (PER) visits, with significant economic burden. Long-acting injectables (LAI), such as the once-monthly Palmitate Paliperidone LAI (1MPP) are effective in suppressing symptoms and raise treatment adherence. This study is the first aimed at evaluating long-term efficacy of initiation of 1MPP. This was a mirror-image study with a total 10 year observational length. Sample was divided into five different groups according to time span of observation: 2,4,6,8, and 10 years. Number of participants per group was 162, 129, 95, 77 and 35, respectively. Main outcomes were number and length of hospitalizations and number of PER visit. Significant reductions in these outcomes after initiation of 1MPP were found in all groups. Subgroups consisting only of patients with full adherence were evaluated, and these had better outcomes. A cost evaluation was also performed, which demonstrated decreases every year, for all main outcomes. Sensitivity analysis in the 2-year group showed results in this time-frame are independent of gender, diagnosis, previous LAI or 1MPP initiation setting. Initiation of 1MPP reduces number and length of hospitalizations up to 5 years, decreasing associated costs. This study increases evidence supporting use of 1MPP in patients with Schizophrenia or Schizoaffective disorder.

Immune environment of the brain in schizophrenia and during the psychotic episode: A human post-mortem study

A causal relationship between immune dysregulation and schizophrenia has been supported by genome-wide association studies and epidemiological evidence. It remains unclear to what extent the brain immune environment is implicated in this hypothesis. We investigated the immunophenotype of microglia and the presence of perivascular macrophages and T lymphocytes in post-mortem brain tissue. Dorsal prefrontal cortex of 40 controls (22F:18M) and 37 (10F:27M) schizophrenia cases, of whom 16 had active psychotic symptoms at the time of death, was immunostained for seven markers of microglia (CD16, CD32a, CD64, CD68, HLA-DR, Iba1 and P2RY12), two markers for perivascular macrophages (CD163 and CD206) and T-lymphocytes (CD3). Automated quantification was blinded to the case designation and performed separately on the grey and white matter. 3D reconstruction of Iba1-positive microglia was performed in selected cases. An increased cortical expression of microglial Fcγ receptors (CD64 F = 7.92, p = 0.007; CD64/HLA-DR ratio F = 5.02, p = 0.029) highlights the importance of communication between the central and peripheral immune systems in schizophrenia. Patients in whom psychotic symptoms were present at death demonstrated an age-dependent increase of Iba1 and increased CD64/HLA-DR ratios relative to patients without psychotic symptoms. Microglia in schizophrenia demonstrated a primed/reactive morphology. A potential role for T-lymphocytes was observed, but we did not confirm the presence of recruited macrophages in the brains of schizophrenia patients. Taking in account the limitations of a post-mortem study, our findings support the hypothesis of an alteration of the brain immune environment in schizophrenia, with symptomatic state- and age-dependent effects.

Employment and relationship outcomes in first-episode psychosis: A systematic review and meta-analysis of longitudinal studies

As employment and relationship status are important long-term outcomes in individuals with a diagnosis of first episode psychosis (FEP) disorders, there is a need to elucidate more accurately the extent of these social deficits in people with FEP. This in turn can aid treatment planning and policy development ultimately ensuring more complete and sustainable recoveries. We carried out a systematic review and meta-analysis of longitudinal studies in FEP reporting on employment and relationship status during the illness course. Random effects meta-analyses and meta-regression analyses were employed. Seventy-four studies were included with a sample totalling 15,272 (range = 20-1724) FEP cases with an average follow-up duration of 8.3 years (SD = 7.2). 32.5% (95%CI = 28.5-36.9) of people with a diagnosis of FEP disorders were employed and 21.3% (95%CI = 16.5-27.1) were in a relationship at the end of follow-up. Studies from high-income countries and Europe had a higher proportion of people in employment at the end of follow-up compared to middle-income nations and non-European countries. The inverse was found for relationship status. The proportion of people with a diagnosis of FEP in employment decreased significantly with longer follow-up. Living with family, being in a relationship at first contact and Black and White ethnicities were identified as significant moderators of these outcomes. These findings highlight marked functional recovery deficits for people with FEP, although cultural factors need to be considered. They support the need for interventions to improve employment opportunities, and social functioning, both in early psychosis and during the longitudinal illness course.

The relationship between patients' educational level and therapeutic process in an acute patient therapeutic community

Traditional custodial care in mental hospitals has given way to brief hospitalizations and a variety of active inpatient treatment milieus, eg, therapeutic communities. But can only well-educated patients utilize this kind of complex, even demanding form of psychosocial care? A total of 1,538 patients and their first admissions from 1977 to 1993 at a closed therapeutic community ward at the Department of Psychiatry, University of Oulu (Finland) were assessed to analyze the association of the patient's educational level with some treatment and outcome characteristics. Educational levels were non-professional education (46% of all patients), lower professional (39%) and higher professional education (15%). There were no statistically significant differences in the treatment and outcome variables of patients in any educational level. The result indicates the achievement of one treatment goal on the therapeutic community model, ie, patient equality in spite of different educational status. This result may be especially important for less educated persons.

Lead-Time Bias Confounds Association Between Duration of Untreated Psychosis and Illness Course in Schizophrenia

OBJECTIVE

At first hospitalization, a long duration of untreated psychosis (DUP) predicts illness severity and worse treatment outcomes. The mechanism of this association, however, remains unclear. It has been hypothesized that lengthy untreated psychosis is toxic or that it reflects a more severe form of schizophrenia. Alternatively, the association may be an artifact of lead-time bias. These hypotheses are tested in a longitudinal study of schizophrenia with 2,137 observations spanning from childhood to 20 years after first admission.

METHODS

Data were from the Suffolk County Mental Health Project. The cohort included 287 individuals with schizophrenia or schizoaffective disorder. DUP was defined as days from first psychotic symptom to first psychiatric hospitalization. Psychosocial function was assessed using the Premorbid Adjustment Scale and the Global Assessment of Functioning Scale. Psychosocial function trajectories were estimated using multilevel spline regression models adjusted for gender, occupational status, race, and antipsychotic medication.

RESULTS

Both long- and short-DUP patients experienced similar declines in psychosocial function, but declines occurred at different times relative to first admission. Long-DUP patients experienced most of these declines prior to first admission, while short-DUP patients experienced declines after first admission. When psychosocial function was analyzed relative to psychosis onset, DUP did not predict illness course.

CONCLUSIONS

The association between DUP and psychosocial function may be an artifact of early detection, creating the illusion that early intervention is associated with improved outcomes. In other words, DUP may be better understood as an indicator of illness stage than a predictor of course.

Early predictors of poor treatment response in patients with schizophrenia treated with atypical antipsychotics

BACKGROUND

The aims of this study were to explore the relationship between early reduction in psychotic symptoms and the ultimate response in patients with schizophrenia treated by atypical antipsychotics, and to determine the best time to switch or maitain the regimen. We also explore the possible predictors for the clinical response.

METHODS

One hundred eleven inpatients with acutely exacerbated schizophrenia were randomized to give optimal therapy of olanzapine, risperidone, and paliperidone in one-week run-in period and 12 weeks' intervention. All participants were assessed using Positive and Negative Syndrome Scale (PANSS). Early Response, defined as reduction of 25% in PANSS score, was examined at weeks 1, 2, 3, 4 and 8, and these ratings were used to predict ultimate response (25% PANSS reduction) at week 12. We hypothesized that early treatment response at Week 1 or 2 could predict Week 12's treatment outcome.

RESULTS

The early treatment response at Week 2 had a greater negative prediction value (NPV, 93.6%) than did the response at Week 1 (NPV, 69.7%), Week 3 (NPV, 91.5%), Week 4 (NPV, 90.7%) and Week 8 (NPV, 87.2%). The positive predictive value became more acceptable (65%) until Week 4. There was no any other potential predictors, including types of antipsychotics medication and treatment dosage, were associated with ultimate response in this study.

CONCLUSION

The treatment non-response at Week 2 optimally predicted the ultimate (Week 12) non-response, in terms of negative predictive value (NPV). These finding suggests that the revision of treatment strategy should be considered t if patients with schizophrenia was not responsive to them after 2 weeks' treatment, and for those who are responders at Week 2, another two weeks are needed to further evaluate whether they will be continuously responsive.

TRIAL REGISTRATION

NCT03730857 at ClinicalTrial.gov . Date of registration: 30/Oct/2018.

Brain morphology in antipsychotic-naïve schizophrenia: A study of multiple brain structures

Background

Although brain volume changes are found in schizophrenia, only a limited number of structural magnetic resonance imaging studies have exclusively examined antipsychotic-naïve patients.

Aims

To comprehensively investigate multiple brain structures in a single sample of patients who were antipsychotic-naïve.

Method

Twenty antipsychotic-naïve patients with first-episode schizophrenia and 20 healthy comparison subjects were included. Intracranial, total brain, frontal lobe, grey and white matter, cerebellar, hippocampal, parahippocampal, thalamic, caudate nucleus and lateral and third ventricular volumes were measured. Repeated-measures analyses of (co)variance were conducted with intracranial volume as covariate.

Results

Third ventricle volume enlargement was found in patients compared with the healthy subjects. No differences were found in other brain regions.

Conclusions

These findings suggest that some brain abnormalities are present in the early stages of schizophrenia. Moreover, it suggests that brain abnormalities reported in patients with chronic schizophrenia develop in a later stage of the disease and/or are medication induced.

Patient Characteristics, Length of Stay, and Functional Improvement for Schizophrenia Spectrum Disorders: A Population Study of Inpatient Care in Ontario 2005 to 2015

OBJECTIVES

Schizophrenia and associated illnesses account for a large proportion of mental illness burden and health care expenditures, with the majority of expense involving inpatient care. To date, the literature exploring factors associated with length of stay (LOS) and functional improvement during inpatient care is underdeveloped. In response, this study examined the association between patient characteristics, LOS, and functional improvement using Ontario Mental Health Reporting System (OMHRS) data from 2005 to 2015.

METHODS

The associations of patient characteristics (including key demographics, psychosocial variables, reasons for admission, and service use history) and 2 outcome measures (LOS and Global Assessment of Functioning [GAF]) were analysed with generalised linear mixed modelling (GLMM). From 2005 to 2015, a total of 48,498 episodes for distinct patients from 18 psychiatric hospitals and 57 general hospitals in Ontario were included.

RESULTS

For psychiatric and general hospitals, mean LOS was 96.6 and 20.5 days, and mean GAF improvement was 14.8 and 16.1, respectively. The majority of associations probed demonstrated a high degree of significance with similar patterns across general and tertiary facility contexts. Older age and more recent readmission following a psychiatric discharge were associated with longer LOS and less GAF improvement. Recent experience of adverse life events and substance misuse were associated with shorter LOS.

CONCLUSIONS

While the findings of this exploratory cross-sectional analysis will require further inquiry with respect to validity and reliability, they suggest that a different service pathway is likely required for individuals with greater psychosocial challenge and extensive service use histories.

Gender differences in susceptibility to schizophrenia: Potential implication of neurosteroids

Past research has indicated gender differences in the clinical characteristics and course of schizophrenia. In this study, we investigated whether gender differences in the manifestation of schizophrenia are correlated with neurosteroids, including dehydroepiandrosterone (DHEA), dehydroepiandrosterone sulfate (DHEA-S), and pregnenolone. We further explored the potential relationship between the aforementioned neurosteroids and psychopathology. We recruited 65 schizophrenic patients (36 males and 29 females) and 103 healthy control subjects (47 males and 56 females) and obtained blood samples from the subjects in the morning while in a fasting state to determine the serum levels of DHEA, DHEA-S, and pregnenolone. The psychopathology and mood symptoms of patients with schizophrenia were evaluated using the Positive and Negative Syndrome Scale (PANSS) and 17-item Hamilton Depression Rating Scale, respectively. Compared to the male control subjects, male patients with schizophrenia had significantly lower serum levels of DHEA and pregnenolone. In males with schizophrenia, the serum levels of DHEA and DHEA-S were associated with the age of onset and the duration of illness, while pregnenolone levels were associated with general symptoms of the PANSS. However, none of the neurosteroid levels were different between the female patients with schizophrenia and the female controls, and no significant correlation between neurosteroid levels and psychopathology evaluations was found among the schizophrenic females. Neurosteroids, including DHEA, DHEA-S, and pregnenolone, are involved in the pathophysiology of schizophrenia in male patients, but not in female ones. Therefore, our findings suggest that neurosteroids may be associated with gender differences in susceptibility to schizophrenia.

Gender differences in one-year outcomes of first-presentation psychosis patients in inner-city UK Early Intervention Services

AIM

Men and women have historically been shown to differ in their presentation and outcome of psychotic disorders and thus are likely to have different treatment needs. It is unclear whether Early Intervention Services (EIS) are able to provide equitable care for both men and women presenting for the first time with psychosis. The main aim of this study was to explore gender differences for first-presentation psychosis patients at the time of their referral to inner-city EIS and their outcomes 1 year later.

METHODS

Audit data were utilized from 1098 first-presentation psychosis patients from seven EIS across London, UK, collected via the computerized MiData package. Binary logistic regression was employed to detect potential associations between gender and (i) initial clinical presentation (including duration of untreated psychosis, pathways to care, risk behaviours); and (ii) 1-year clinical and functional outcomes.

RESULTS

At entry to EIS, male patients presented with more violent behaviour whereas female patients had more suicide attempts. Following 1 year of EIS care, men still presented as more violent towards others whereas women were more likely to have been admitted to a psychiatric ward.

CONCLUSION

Gender differences in clinical outcome, service use and risk behaviours were apparent within the first year of specialist psychosis care. This may be partly due to the different pathways to care taken by men and women and differences in clinical presentation. Greater focus on the specific needs of each gender by EIS in detection and intervention is required to improve equality of outcome.

Sex/gender differences in the brain and cognition in schizophrenia

The early conceptualizations of schizophrenia have noted some sex/gender differences in epidemiology and clinical expression of the disorder. Over the past few decades, the interest in differences between male and female patients has expanded to encompass brain morphology and neurocognitive function. Despite some variability and methodological shortcomings, a few patterns emerge from the available literature. Most studies of gross neuroanatomy show more enlarged ventricles and smaller frontal lobes in men than in women with schizophrenia; finding reflecting normal sexual dimorphism. In comparison, studies of brain asymmetry and specific corticolimbic structures, suggest a disturbance in normal sexual dimorphism. The neurocognitive findings are somewhat consistent with this picture. Studies of cognitive functions mediated by the lateral frontal network tend to show sex differences in patients which are in the same direction as those observed in the general population, whereas studies of processes mediated by the corticolimbic system more frequently reveal reversal of normal sexual dimorphisms. These trends are faint and future research would need to delineate neurocognitive differences between men and women with various subtypes of schizophrenia (e.g., early versus late onset), while taking into consideration hormonal status and gender of tested participants.

Predictors of psychiatric rehospitalization among elderly patients

The population of Hong Kong and the proportion of elderly people have been increasing rapidly. The aim of this retrospective cohort study is to determine predictive factors for psychiatric rehospitalization within 2 years among elderly patients who were discharged from psychiatric wards, in attempt to reduce their rehospitalization rate and to reintegrate them into the community. Patients aged 65 and over, who were discharged from psychiatric wards of Pamela Youde Nethersole Eastern Hospital from 1 March 2010 to 29 February 2012, were identified. Rehospitalization within 2 years after discharge was the primary outcome measure, and the time to rehospitalization was measured as the secondary outcome. Patients were subgrouped into readmitted and non-readmitted groups. Logistic regression and Cox regression analyses were applied to the potential predictive factors with odds ratios and hazard ratios obtained, respectively, for the significant findings. Kaplan-Meier survival curves were plotted for graphical representation of the study results in survival analysis. 368 individuals satisfying the study criteria were identified. The same four factors were shown to be significantly associated with rehospitalization in both multiple logistic regression and Cox regression survival analysis. Referral to other psychiatric disciplines upon discharge (p< 0.001, OR=0.325, HR=0.405) was associated with a lower rehospitalization risk and correlated to a longer time to rehospitalization. History of suicidal behaviors (p< 0.001, OR=4.906, HR=3.161), history of violent behaviors (p< 0.001, OR=5.443, HR=3.935) and greater number of previous psychiatric admissions (p< 0.001, OR=1.250, HR=1.121)  were associated with a higher rehospitalization risk and predicted earlier rehospitalization. The rehospitalization rate of elderly patients was 5.2% at 1 month, 9.5% at 3 months, 15.0% at 6 months, 17.1% at 1 year, 18.8% at 1.5 year and 20.9% at 2 years.

The Use of Continuous Treatment Versus Placebo or Intermittent Treatment Strategies in Stabilized Patients with Schizophrenia: A Systematic Review and Meta-Analysis of Randomized Controlled Trials with First- and Second-Generation Antipsychotics

BACKGROUND

Although continuous treatment with antipsychotics is still recommended as the gold standard treatment paradigm for all patients with schizophrenia, some clinicians question whether continuous antipsychotic treatment is necessary, or even justified, for every patient with schizophrenia who has been stabilized on antipsychotics.

OBJECTIVE

The primary objectives of this systematic review and meta-analysis were (i) to compare relapse/hospitalization risks of stabilized patients with schizophrenia under active versus intermittent or placebo treatment conditions; (ii) to examine the role of several study characteristics, possibly intervening in the relationship between relapse risk and treatment condition; and (iii) to examine whether time to relapse is associated with antipsychotic treatment duration.

METHODS

A systematic literature search, using the MEDLINE database (1950 until November 2014), was conducted for English-language published randomized controlled trials, covering a follow-up time period of at least 6 months, and investigating relapse/rehospitalization and/or time-to-relapse rates with placebo or intermittent treatment strategies versus continuous treatment with oral and long-acting injectable first- or second-generation antipsychotics (FGAs/SGAs) in stabilized patients with schizophrenia. Additional studies were identified through searches of reference lists of other identified systematic reviews and Cochrane reports. Two meta-analyses (placebo versus continuous and intermittent versus continuous treatment) were performed to obtain an optimal estimation of the relapse/hospitalization risks of stabilized patients with schizophrenia under these treatment conditions and to assess the role of study characteristics. For time-to-relapse data, a descriptive analysis was performed.

RESULTS

Forty-eight reports were selected as potentially eligible for our meta-analysis. Of these, 21 met the inclusion criteria. Twenty-five records, identified through Cochrane and other systematic reviews and fulfilling the inclusion criteria, were added, resulting in a total of 46 records. Stabilized patients with schizophrenia who have been exposed for at least 6 months to intermittent or placebo strategies, respectively, have a 3 (odds ratio [OR] 3.36; 95% CI 2.36-5.45; p < 0.0001) to 6 (OR 5.64; 95% CI 4.47-7.11; p < 0.0001) times increased risk of relapse, compared with patients on continuous treatment. The availability of rescue medication (p = 0.0102) was the only study characteristic explaining systematic differences in the OR for relapse between placebo versus continuous treatment across studies. Studies reporting time-to-relapse data show that the time to (impending) relapse is always significantly delayed with continuous treatment, compared with placebo or intermittent treatment strategies. Although the interval between treatment discontinuation and symptom recurrence can be highly variable, mean time-to-relapse data seem to indicate a failure of clinical stability before 7-14 months with intermittent and before 5 months with placebo treatment strategies. For all reports included in this systematic review, median time-to-relapse rates in the continuous treatment group were not estimable as <50% of the patients in this treatment condition relapsed before the end of the study.

CONCLUSIONS

With continuous treatment, patients have a lower risk of relapse and remain relapse free for a longer period of time compared with placebo and intermittent treatment strategies. Moreover, 'success rates' in the intermittent treatment conditions are expected to be an overestimate of actual outcome rates. Therefore, continuous treatment remains the 'gold standard' for good clinical practice, particularly as, until now, only a few and rather general valid predictors for relapse in schizophrenia are known and subsequent relapses may contribute to functional deterioration as well as treatment resistance in patients with schizophrenia.

Demographic correlates of attenuated positive psychotic symptoms

It is now well established that the utilization of standardized clinical criteria can enhance prediction of psychosis. These criteria are primarily concerned with the presence and severity of attenuated positive symptoms. Because these symptom criteria are used to derive algorithms for designating clinical high risk (CHR) status and for maximizing prediction of psychosis risk, it is important to know whether the symptom ratings vary as a function of demographic factors that have previously been linked with symptoms in diagnosed psychotic patients. Using a sample of 356 CHR individuals from the NAPLS-II multi-site study, we examined the relation of three sex, age, and educational level, with the severity of attenuated positive symptom scores from the Scale of Prodromal Symptoms (SOPS). Demographic factors accounted for little of the variance in symptom ratings (5-6%). Older CHR individuals manifested more severe suspiciousness, and female CHR participants reported more unusual perceptual experiences than male participants. Contrary to prediction, higher educational level was associated with more severe ratings of unusual thought content, but less severe perceptual abnormalities. Overall, sex, age and education were modestly related to unusual thought content and perceptual abnormalities, only, suggesting minimal implication for designating CHR status and predicting psychosis-risk.

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.

Neuropeptide Y, social function and long-term outcome in schizophrenia

There is a lack of biomarkers in schizophrenia and the mechanisms underlying the observed deficits in social functioning are poorly understood. This cohort study aimed to explore whether neurotransmitter neuropeptide Y (NPY) in cerebrospinal fluid (CSF) from patients with schizophrenia is correlated to social function and clinical variables. A further aim was to determine whether baseline levels of NPY were associated with subsequent 3-year outcome. Fifty-six consecutively admitted patients with schizophrenia were included and underwent lumbar puncture and symptom ratings before antipsychotic treatment. NPY levels in CSF were determined by radioimmunoassay. Social function (Social Competence and Social Interest) was assessed by Nurses' Observation Scale for Inpatient Evaluation while psychiatric symptoms were rated using the Comprehensive Psychopathological Rating Scale. Three-year outcome was assessed with the Strauss-Carpenter Outcome Scale. Cross-sectional analysis showed a correlation between level of NPY and Social Competence at index admission (r(s)=0.37, p<0.05). The longitudinal analysis (i.e., at the 3-year follow-up) indicated that, for each standard deviation increase in baseline NPY, there was an increased risk of being unemployed (odds ratio [OR] 2.02, 95% confidence interval [CI] 1.07-3.82), having moderate or severe symptoms (OR 3.09, CI 1.30-7.32) or being hospitalized at least 6 months the previous year (OR 3.24, CI 1.09-9.64). However, NPY was not correlated to Social Interest or clinical variables at index admission. In conclusion, NPY levels in CSF are correlated to Social Competence and seem to predict some aspects of longitudinal outcome in schizophrenia.

The revolving door phenomenon revisited: time to readmission in 17’145 [corrected] patients with 37'697 hospitalisations at a German psychiatric hospital

Objective

Despite the recurring nature of the disease process in many psychiatric patients, individual careers and time to readmission rarely have been analysed by statistical models that incorporate sequence and velocity of recurrent hospitalisations. This study aims at comparing four statistical models specifically designed for recurrent event history analysis and evaluating the potential impact of predictor variables from different sources (patient, treatment process, social environment).

Method

The so called Andersen-Gil counting process model, two variants of the conditional models of Prentice, Williams, and Peterson (gap time model, conditional probability model), and the so called frailty model were applied to a dataset of 17’415 patients observed during a 12 years period starting from 1996 and leading to 37’697 psychiatric hospitalisations. Potential prognostic factors stem from a standardized patient documentation form.

Results

Estimated regression coefficients over different models were highly similar, but the frailty model best represented the sequentiality of individual treatment careers and differing velocities of disease progression. It also avoided otherwise likely misinterpretations of the impact of gender, partnership, historical time and length of stay. A widespread notion of psychiatric diseases as inevitably chronic and worsening could be rejected. Time in community was found to increase over historical time for all patients. Most important protective factors beyond diagnosis were employment, partnership, and sheltered living situation. Risky conditions were urban living and a concurrent substance use disorder.

Conclusion

Prognostic factors for course of diseases should be determined only by statistical models capable of adequately incorporating the recurrent nature of psychiatric illnesses.

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.

Psychosocial outcome in patients at clinical high risk of psychosis: a prospective follow-up

PURPOSE

In patients at clinical high risk (CHR) of psychosis, transition to psychosis has been the focus of recent studies. Their broader outcome has received less attention. We studied psychosocial state and outcome in CHR patients.

METHODS

In the European Prediction of Psychosis Study, 244 young help-seeking CHR patients were assessed with the Strauss and Carpenter Prognostic Scale (SCPS) at baseline, and 149 (61.1%) of them were assessed for the second time at the 18-month follow-up. The followed patients were classified into poor and good outcome groups.

RESULTS

Female gender, ever-married/cohabitating relationship, and good working/studying situation were associated with good baseline SCPS scores. During follow-up, patients' SCPS scores improved significantly. Good follow-up SCPS scores were predicted by higher level of education, good working/studying status at baseline, and white ethnicity. One-third of the followed CHR patients had poor global outcome. Poor working/studying situation and lower level of education were associated with poor global outcome. Transition to psychosis was associated with baseline, but not with follow-up SCPS scores or with global outcome.

CONCLUSION

The majority of CHR patients experience good short-term recovery, but one-third have poor psychosocial outcome. Good working situation is the major indicator of good outcome, while low level of education and non-white ethnicity seem to be associated with poor outcome. Transition to psychosis has little effect on psychosocial outcome in CHR patients. In treating CHR patients, clinicians should focus their attention on a broader outcome, and not only on preventing transition to psychosis.

Gender difference in age at onset of schizophrenia: a meta-analysis

BACKGROUND

Most studies reporting the gender difference in age at onset of schizophrenia show an earlier onset in males, but vary considerably in their estimates of the difference. This may be due to variations in study design, setting and diagnostic criteria. In particular, several studies conducted in developing countries have found no difference or a reversed effect whereby females have an earlier onset. The aim of the study was to investigate gender differences in age of onset, and the impact of study design and setting on estimates thereof.

METHOD

Study methods were a systematic literature search, meta-analysis and meta-regression.

RESULTS

A total of 46 studies with 29,218 males and 19,402 females fulfilled the inclusion criteria and were entered into a meta-analysis. A random-effects model gave a pooled estimate of the gender difference of 1.07 years (95% confidence interval 0.21-1.93) for age at first admission of schizophrenia, with males having earlier onset. The gender difference in age at onset was not significantly different between developed and developing countries. Studies using diagnostic and statistical manual of mental disorders (DSM) criteria showed a significantly greater gender difference in age at onset than studies using International Classification Of Diseases (ICD) criteria, the latter showing no difference.

CONCLUSIONS

The gender difference in age of onset in schizophrenia is smaller than previously thought, and appears absent in studies using ICD. There is no evidence that the gender difference differs between developed and developing countries.

Treatment-refractory schizophrenia

Between one-third and one-half of the individuals who meet diagnostic criteria for schizophrenia remain actively ill despite optimal pharmacological treatment. These individuals tend to progressively deteriorate in terms of social and vocational functioning despite major public and private investments in their rehabilitation. For patients who do not respond to the first prescribed antipsychotic drug, current clinical practice is to switch to a second and a third drug, and eventually to clozapine, the only antipsychotic drug proven to be effective in treatment-refractory schizophrenia (TRS). Occasionally, two antipsychotics are given concomitantly or psychotropic drugs are added to antipsychotic drugs; however, very few empirical data exist to support this practice. Although there are many exceptions, patients who do not benefit from the first prescribed drug will not benefit from any pharmacological intervention. Therefore, efforts are under way to determine the reason for lack of response to available treatments and devise novel, more effective treatments. To be successful these efforts must result in a more specific definition of TRS, as well as in a better understanding of the illness pathophysiology and the mechanism of action of the drugs.

Patient predictors of symptom and functional outcome following cognitive behaviour therapy or befriending in first-episode psychosis

BACKGROUND

Cognitive behaviour therapy (CBT) is an effective treatment for many, but not all, individuals with psychosis. An important goal is identifying individuals more likely to benefit from CBT to ensure appropriate delivery. The current study aimed to examine patient-related predictors of symptom and functional outcome following CBT and Befriending in first-episode psychosis (FEP).

METHOD

Our original randomized controlled trial compared 14 weeks of CBT (n=31) and Befriending (n=31) in FEP (Jackson et al. 2008). A series of regressions were conducted separately for each group to examine demographic, cognitive, symptoms/illness and functioning variables in predicting positive symptoms (BPRS Psychotic), negative symptoms (SANS Total) and functioning (SOFAS) at 1-year follow-up.

RESULTS

In the CBT group, higher baseline functioning (SOFAS) predicted lower levels of positive symptoms (R(2)=0.19; p=0.023), higher educational achievement and lower levels of avolition symptoms (SANS Avolition) predicted lower levels of total negative symptoms (R(2)=0.38; p=0.003), and working/studying at baseline predicted higher functional outcome (R(2)=0.35; p=0.004) at 1 year. In the Befriending group, premorbid adjustment (PAS Average) was the only variable that predicted 1-year positive symptom (R(2)=0.26; p=0.010), negative symptom (R(2)=0.35; p=0.016) and functional (R(2)=0.48; p=0.002) outcome.

CONCLUSIONS

FEP individuals with higher baseline functioning may benefit more from CBT than those with poorer functioning. Individuals with functional difficulties may benefit from alternative treatments initially, such as supported education or employment.

Association of demographic characteristics, symptomatology, retrospective and prospective memory, executive functioning and intelligence with social functioning in schizophrenia

OBJECTIVE

The objective of this study was to explore the influence of socio-demographic and clinical factors and neurocognitive variables (i.e. prospective and retrospective memory, executive functioning, and intelligence) on social functioning in Chinese schizophrenia patients.

METHODS

The study sample comprised 110 Chinese schizophrenia patients. Their clinical condition and social functioning were evaluated with the Brief Psychiatric Rating Scale (BPRS) and the Functional Needs Assessment (FNA), respectively. Three prospective memory (PM) tasks (time-, event-, and activity-based), three tests of executive functioning (the Design Fluency Test [DFT], Tower of London [TOL], and Wisconsin Card Sorting Test [WCST]), one test of intelligence (Raven's Progressive Matrices), and two retrospective memory (RM) tasks (the immediate and delayed recall conditions of the Logical Memory subtest of the Wechsler Memory Scales-Revised [WMS-R]) were administered to all patients.

RESULTS

In correlation analyses higher education and better performance on the WCST (categories completed) and the Logical Memory subtests (delayed and immediate) of the WMS-R are significantly correlated with better social functioning, whereas a lower WCST score (perseverative errors) and more severe negative symptoms are associated with poorer social functioning. Multiple linear regression analysis revealed that higher education and a lower WCST score (perseverative errors) independently contribute to better social functioning.

CONCLUSIONS

Unexpectedly, most socio-demographic and clinical factors do not seem to have a significant impact on social functioning of Chinese schizophrenia patients living in a Chinese society. Negative symptoms and certain cognitive deficits were the main predictors of social functioning and they should be the main targets for antipsychotic treatment and psychosocial interventions to improve social adjustment in Chinese schizophrenia patients.

Beyond the first episode: candidate factors for a risk prediction model of schizophrenia

Many early psychosis services are financially compromised and cannot offer a full tenure of care to all patients. To maintain viability of services it is important that those with schizophrenia are identified early to maximize long-term outcomes, as are those with better prognoses who can be discharged early. The duration of untreated psychosis remains the mainstay in determining those who will benefit from extended care, yet its ability to inform on prognosis is modest in both the short and medium term. There are a number of known or putative genetic and environmental risk factors that have the potential to improve prognostication, though a multivariate risk prediction model combining them with clinical characteristics has yet to be developed. Candidate risk factors for such a model are presented, with an emphasis on environmental risk factors. More work is needed to corroborate many putative factors and to determine which of the established factors are salient and which are merely proxy measures. Future research should help clarify how gene-environment and environment-environment interactions occur and whether risk factors are dose-dependent, or if they act additively or synergistically, or are redundant in the presence (or absence) of other factors.

Knowledge and insight in relation to functional remission in patients with long-term psychotic disorders

BACKGROUND

Patients with psychotic symptoms often respond poorly to treatment. Outcomes can be affected by biological, physiological and psychological factors according to the vulnerability-stress model. The patient's coping strategies and beliefs have been correlated with outcomes.

OBJECTIVES

To investigate the knowledge and insight in relation to treatment response.

METHODS

A naturalistic study was performed using patient interviews and information gathered from patient drug charts. Apart from the rating scales used for classification of treatment response (CANSEPT method), the SPKS knowledge of illness and drugs rating scale was utilized.

RESULTS

In the group of patients in functional remission (FR; n = 38), 37% had insight into their illness as compared to 10% among those not in functional remission (non-FR; n = 78; P < 0.01). As much as 23% of the non-FR group had no strategy for responding to warning signs versus 8% in the FR group (P < 0.05).

CONCLUSIONS

Better treatment outcomes appear to be associated with better insight into illness, higher knowledge of warning signs and better coping strategies.

Treatment response in psychotic patients classified according to social and clinical needs, drug side effects, and previous treatment; a method to identify functional remission

BACKGROUND

Various approaches have been made over the years to classify psychotic patients according to inadequate treatment response, using terms such as treatment resistant or treatment refractory. Existing classifications have been criticized for overestimating positive symptoms; underestimating residual symptoms, negative symptoms, and side effects; or being to open for individual interpretation. The aim of this study was to present and evaluate a new method of classification according to treatment response and, thus, to identify patients in functional remission.

METHOD

A naturalistic, cross-sectional study was performed using patient interviews and information from patient files. The new classification method CANSEPT, which combines the Camberwell Assessment of Need rating scale, the Udvalg for Kliniske Undersøgelser side effect rating scale (SE), and the patient's previous treatment history (PT), was used to group the patients according to treatment response. CANSEPT was evaluated by comparison of expected and observed results.

RESULTS

In the patient population (n = 123), the patients in functional remission, as defined by CANSEPT, had higher quality of life, fewer hospitalizations, fewer psychotic symptoms, and higher rate of workers than those with the worst treatment outcome.

CONCLUSION

In the evaluation, CANSEPT showed validity in discriminating the patients of interest and was well tolerated by the patients. CANSEPT could secure inclusion of correct patients in the clinic or in research.

Predictors of 10-year outcome of first-episode psychosis

BACKGROUND

Predictors of outcome for psychosis are poorly understood. Duration of untreated psychosis (DUP) appears to predict short-term outcome although its medium- to long-term role remains unclear. Neurodevelopmental indices such as pre-morbid function and/or neurological soft signs may predict longer-term outcome. We aimed to assess the impact of a range of clinical and demographic variables on long-term outcome of a geographically defined, epidemiological first-episode psychosis cohort.

METHOD

A 10-year follow-up was undertaken of a consecutively presenting sample of 109 cases of first-episode psychosis aged 16-50 years. Baseline assessments included positive, negative and depression symptoms, DUP, neurological soft signs and pre-morbid functioning. Multi-dimensional outcomes were assessed blind to baseline data.

RESULTS

All participants were traced at a mean of 10.5 years post-index admission: 11 had died, 10 from non-natural causes. Of the surviving cases, 70% were comprehensively re-assessed by interview. Summary data on the remainder were collected from their family practitioner and chart review. Poor 10-year outcomes were predicted independently by poor pre-morbid functioning, baseline negative symptoms and longer DUP. The same measures, plus neurological soft signs, appeared to predict outcomes in a DSM-IV schizophrenia/schizo-affective subgroup.

CONCLUSIONS

Poor pre-morbid functioning, baseline symptoms, DUP and neurological soft signs at onset independently predict poor long-term outcome in first-episode psychosis.

[Meta-analysis of clinical trials on family intervention in schizophrenia]

The present study aimed to assess the efficacy of cognitive-behavioral family interventions by relatives of schizophrenic patients under community care, specifically targeting relapse and family burden as outcomes. Independent researchers conducted the analyses of the pertinence and quality of trials identified through a search strategy, following a previously developed protocol. Eleven randomized or quasi-randomized trials were selected. The summary relative risk of relapse using the fixed effects model was favorable to family intervention, with estimated efficacy reaching nearly 60% (50%-70%). Summary relative risk in the cognitive-behavioral therapy trials subgroup [RR = 0.43 (0.28-0.67)] was equivalent to that of the behavioral therapy subgroup [RR = 0.37 (0.23-0.60)] and the "pragmatic" subgroup [RR = 0.37 (0.21-0.66)], although the "pragmatic" trials were generally analyzed for effective treatment. The difference in summary overall risk of relapse was nearly 30% using the random effects model. Only four trials analyzed family burden as outcome, including different dimensions of burden. Results of individual trials were generally favorable to family intervention, for both the objective and subjective dimensions.

A symptom self-rating scale for schizophrenia (4S): psychometric properties, reliability and validity

The objective of the study was to validate a self-administrated symptom rating scale for use in patients with schizophrenia spectrum disorders by item analysis, exploration of factor structure, and analyses of reliability and validity. Data on 151 patients, initially treated by risperidone, obtained within the framework of a naturalistic Phase IV longitudinal study, were analysed by comparing patient and clinician ratings of symptoms, side-effects and global indices of illness. The Symptom Self-rating Scale for Schizophrenia (4S) is psychometrically adequate (item analysis, internal consistency, factor structure). Side-effect ratings were reliable. Symptom ratings displayed consistent associations with clinicians' ratings of corresponding symptom dimensions, suggesting construct validity. Patients had most difficulties assessing negative symptom items. Patients were well able to assess their own symptoms and drug side-effects. The factor structure of symptom ratings differs between patients and clinicians as well as how they construe global indices of illness. Clinicians focus on psychotic, patients on affective symptoms. Use of symptom self-ratings is one way to improve communication and thereby strengthen the therapeutic alliance and increase treatment adherence.

Gene polymorphism influencing treatment response in psychotic patients in a naturalistic setting

RATIONALE

Many patients with psychotic symptoms respond poorly to treatment. Factors possibly affecting treatment response include the presence of polymorphisms in genes coding for various receptor populations, drug-metabolizing enzymes or transport proteins.

OBJECTIVES

To investigate whether genetic polymorphisms could be indicators of treatment response to antipsychotic drugs. The genes of interest were the dopamine D2 receptor gene (DRD2), the serotonin 2A and 2C receptor genes (HTR2A and HTR2C), the P-glycoprotein gene (ABCB1 or MDR1) and the drug-metabolizing cytochrome P450 2D6 gene (CYP2D6).

MATERIAL AND METHODS

Data for this naturalistic, cross-sectional study of patients requiring antipsychotic drugs and attending the Psychosis Outpatient Care clinic in Jönköping, Sweden were obtained from patient interviews, blood samples and information from patient files. Blood samples were genotyped for DRD2 Taq1 A, Ins/Del and Ser311Cys, HTR2A T102C, HTR2C Cys23Ser, ABCB1 1236C>T, 2677G>T/A, 3435C>T and genetic variants of CYP2D6. The patients (n=116) were grouped according to the CANSEPT method regarding significant social and clinical needs and significant side effects.

RESULTS

Patients on olanzapine homozygous for ABCB1 3435T, had more significant social and clinical needs than others. Patients with one or two DRD2 Taq1 A1 alleles had a greater risk of significant side effects, particularly if they were male, Caucasian, had a schizophrenic or delusional disorder or were taking strong dopamine D2-receptor antagonistic drugs.

CONCLUSION

If these results are confirmed, patients carrying the DRD2 Taq1 A1 allele would benefit from using drugs without strong dopamine D2 receptor antagonistic properties.

Predictors of outcome in first-episode schizophrenia over the first 4 years of illness

BACKGROUND

The outcome of schizophrenia appears to be more favourable than once thought. However, methodological issues, including the reliance on diagnosis at first presentation have limited the validity of outcome studies to date.

METHOD

We conducted a first-episode follow-up study of 97 patients with DSM-IV schizophrenia over the first 4 years of illness. First presentation and follow-up assessments were compared using paired t tests and a forced-entry regression analysis was used to determine prognostic variables.

RESULTS

There were significant improvements in positive and negative symptoms and global assessment of functioning between first presentation and follow-up. At first presentation, fewer negative symptoms (t=-3.40, p<0.01), more years spent in education (t=3.25, p<0.01), and a shorter duration of untreated psychosis (DUP) (t=-2.77, p<0.01) significantly predicted a better outcome at follow-up.

CONCLUSIONS

The outcome of schizophrenia may not be as pessimistic as once thought and most patients did not display a downward deteriorating course of illness. This study supports the relationship between DUP and outcome beyond the early stages of illness.

The significance of family history in first-episode schizophrenia spectrum disorder

There have been inconsistent findings regarding the significance of family history of schizophrenia spectrum disorders in relation to presentation and course of illness. There has been little research relevant to this issue from first-episode patients. We examined the differences in premorbid adjustment, symptoms, and intellectual functioning between 28 first-episode schizophrenia spectrum patients with a history of such illness in first degree relatives and 28 matched patients without such a family history. The results indicate that whereas the 2 groups did not differ in presenting symptoms, those with a positive family history showed poorer intellectual functioning and less reduction in symptoms at 2 and 3 year follow-up and greater likelihood of abnormal electroencephalogram findings. The findings provide evidence that presence of a positive family history in first-episode patients is associated with a more pernicious form of illness.

Premorbid behavioral and intellectual functioning in schizophrenia patients with poor response to treatment with antipsychotic drugs

INTRODUCTION

Approximately one third of schizophrenia patients show partial or no response to pharmacotherapy. Despite intensive investigations, the phenomenological and biological characteristics of such patients are far from elucidated. This study examined the premorbid behavioral and intellectual functioning of schizophrenia patients who showed poor response to antipsychotic treatment.

METHOD

One hundred twenty-nine schizophrenia patients who showed poor response to treatment were ascertained from a national register and matched by gender, age and education to 129 patients who showed adequate response. The groups were compared on premorbid measures of behavioral and intellectual functions.

RESULTS

As a group, treatment-resistant male patients had significantly lower (worse) social functioning [p=0.002], and individual autonomy [p<0.0001] scores before the onset of the illness compared to treatment non-resistant patients. Male and female treatment-resistant patients did not differ from non-resistant patients in premorbid intellectual functioning [p>0.1].

CONCLUSIONS

Low premorbid social functioning and individual autonomy, but not intellectual functioning, could serve as predictors of poor treatment response in schizophrenia.

Premorbid adjustment in schizophrenia--an important aspect of phenotype definition

Schizophrenia is a heterogeneous disorder, and early signs of disorder such as poor premorbid adjustment (PMA) are often present before the onset of diagnosable illness. Differences in PMA between patients may be suggestive of differing aetiological pathways. Poor PMA in schizophrenia has repeatedly been reported to be associated with male sex, earlier age at onset, illness severity, negative symptoms, and poor outcome. Studies of schizophrenia patients systematically assessed for PMA have used small patient samples and have rarely used controls.

OBJECTIVE

To investigate possible correlations of PMA, as measured with the Cannon-Spoor Premorbid Adjustment Scale (PAS), with such meaningful clinical characteristics as sex, age at onset, negative symptoms etc. using one of the largest samples of schizophrenia inpatients as well as controls characterised for PMA to date.

METHOD

PMA, diagnosis and lifetime symptoms were assessed in 316 inpatients with schizophrenia and 137 population based controls using the PAS and the Structured Clinical Interview for DSM.

RESULTS

Controls demonstrated better PAS scores than inpatients with schizophrenia. Earlier age at onset and negative symptoms were found to be associated with poorer PAS scores. There was no difference in PAS ratings between males and females in patients with schizophrenia. Among the control probands, females showed significantly better PAS scores than males.

CONCLUSION

PAS scores are worse in individuals who eventually develop schizophrenia, and the distribution of these scores among schizophrenia inpatients is correlated with specific clinical features. Earlier findings, which had reported an association with age at onset and negative symptoms in small patient samples, were substantiated. The widely reported association of poor PMA with male sex, if genuinely present, does not appear to be disease specific. Our findings suggest that PMA is in itself a valuable phenotype characteristic and that it may represent a specific biological phenotype which may be of value in sub-sample selection.

Epidemiology of Completed Suicides in Singapore for 2001 and 2002

Abstract. This study provides an analysis of 640 completed suicide cases in Singapore for the years 2001 and 2002, compared to previous years and in relation to demographic and socioeconomic factors, as well as to the characteristics of a subgroup of suicide victims with prior psychiatric illness. There was little change in the suicide pattern over the 2 years studied compared to previous years. The sex ratio was constant at 1.5. Population-adjusted ratios were 1 for Chinese, 0.5 for Malays, and > 1 for both Indians and other ethnic groups. Falling from heights ranked first in terms of method adopted for both years. A disproportionately higher number of suicides were recorded for the 25-34 and the ≥ 75-year-old age groups. A total of 47 (17.2%) in 2001 and 74 (20.2%) in 2002 of the cases had a history of prior psychiatric illness, with psychotic disorders being the most common diagnostic category. There was also a statistically significant correlation between unemployment and incidence rates. Although the overall rate of elderly suicides had gone down since the 1990s, prevention strategy should focus on the elderly as this rate is still about 3-4 times the national average.

Validity and Stability of Performance-Based Estimates of Premorbid Educational Functioning in Older Patients with Schizophrenia

This paper presents the results of two studies of the validity of word-recognition reading as an indicator of premorbid functioning in schizophrenia. The first examined the stability over a 6-year follow-up period of word recognition reading compared to other aspects of cognitive functioning, including verbal learning and delayed recall, verbal fluency, constructional skills, and naming ability. The second study examined the relative predictive power of indicators of premorbid functioning as compared to current cognitive functioning for the prediction of current social and self-care skills. In the first study 218 patients with chronic schizophrenia participated. For the second study, 231 male veterans with schizophrenia were assessed for cognitive functioning, indicators of premorbid adjustment, and current functional status. Analyses of the differences between correlations indicated that word recognition reading ability was significantly more stable than other aspects of cognitive functioning over a six-year period during which decline in some other aspects of performance was found. In the second study, premorbid educational and social attainment, word recognition reading skill, and current cognitive functioning were all significantly related to current functional status, defined by correlations with ratings of current functional status. Path analyses indicated, however, that current cognitive functioning was the only significant predictor of current functional status when the intercorrelations of the variables were considered. In sum, Premorbid functioning estimated with word-recognition reading was stable over time (study 1) and correlated with both current cognitive and functional status (study 2). The results of these two studies suggest that word-recognition reading skills are useful screening instruments to estimate premorbid functioning even in deteriorated patients with schizophrenia.

Clinical correlates of childhood and adolescent adjustment in adult patients with bipolar disorder

Impaired psychosocial functioning has been well documented in bipolar disorder, although there is little information linking premorbid adjustment with adult functional outcome. Childhood and adolescent functioning in school, peer relations, and personal interests was evaluated by standardized interviews with 56 adult-onset DSM-IV bipolar I (N = 46), II (N = 7), or not otherwise specified (N = 3) patients, with collaboration by collateral historians, and assessed relative to current work functioning and overall illness features. Poor childhood or adolescent adjustment was associated with subsequent alcohol or drug abuse or dependence (p <.05), insidious onset of bipolar disorder (p <.02), and increased suicide attempts (p <.02). Poor adjustment in childhood was related to the lifetime development of rapid cycling. Poor premorbid adjustment may be linked with the potential to develop substance abuse comorbidity and an increased risk for suicide attempts and rapid cycling in bipolar patients. The prognostic significance of maladaptive childhood or adolescent behaviors may bear directly on clinical components of outcome in bipolar disorder.

Prevalence and course of schizophrenia in a Chinese rural area

OBJECTIVE

To assess the characteristics and factors affecting course of schizophrenia in a Chinese rural area.

METHOD

An epidemiological investigation was conducted to identify all the patients with schizophrenia among 149 231 people in Xinjin County, Chengdu.

RESULTS

The total prevalence of schizophrenia was 4.13 per 1000 population. Males had an earlier mean age of onset (29.6 years) than females (32.3 years). Duration of illness before treatment and the total duration of illness were found to be significantly associated with level of remission. The status of treatment, family economy, housing, and families' care of patients had a significant effect on the clinical course of the illness.

CONCLUSIONS

Duration of illness before treatment may be an important predictor of course in schizophrenia. Early treatment for the patients may produce higher level of improvement in prognosis. Education intervention and community-based service are urgent priorities for these patients.

One-year outcome in first episode psychosis patients in the Swedish Parachute project

OBJECTIVE

Implementing a system designed to treat first episode psychotic (FEP) patients.

METHOD

Every FEP patient (n=253) from a catchment area of 1.5 million inhabitants were asked to participate in this 5-year project. One historical (n=71) and one prospective (n=64) FEP group were used for comparisons.

RESULTS

A total of 175 patients (69%) were followed up through the first year of treatment. Global Assessment of Functioning (GAF) values were significantly higher than in the historical comparison group but similar to the prospective group. Psychiatric in-patient care was lower as was prescription of neuroleptic medication. Satisfaction with care was generally high in the Parachute group. Access to a small overnight crisis home was associated with higher GAF.

CONCLUSION

It is possible to successfully treat FEP patients with fewer in-patient days and less neuroleptic medication than is usually recommended, when combined with intensive psychosocial treatment and support.

Influences of patient-related variables on risperidone efficacy for acutely exacerbated schizophrenia: analyses with rigorous statistics

Response predictors of risperidone or other newer atypical antipsychotics for schizophrenia treatment remain unclear. This study aimed to investigate the influence of patient demographics on risperidone efficacy for schizophrenia. One hundred twenty-one newly hospitalized patients who had schizophrenia with acute exacerbation entered this prospective, 6-week risperidone trial. The target dose was 6 mg/day, or lower in case of side effects. Consequently, the mean +/- SD dose remained quite stable after week 2 and reached 4.4 +/- 1.3 mg/day at week 6. Efficacy and side effect assessments were conducted biweekly. The mean total score of the Positive and Negative Syndrome Scale (PANSS) declined during the trial, particularly within the first 4 weeks. Further, of the various efficacy scores (and their natural logarithm values) collected, only the logarithm of the PANSS total score was selected to serve as the response value, because it was normally distributed and thus suitable for regression analyses. After adjusting the effects of treatment duration (weeks 0-6) and other patient-related variables with the generalized estimating equation method, each 1-week increase in duration of prior hospitalizations raised the PANSS total by 0.04% (p = 0.002) and each 1-year increment in the education duration decreased the PANSS by 0.94% (p = 0.04). Gender, age, age at illness onset, duration of illness, diagnosis subtype, or number of prior hospitalizations, however, did not significantly impact the response value. These preliminary results suggest that longer hospitalization duration and shorter education predict higher symptomatology. Further studies with longer observation and larger samples in not only acutely ill patients but also other populations (e.g., first-episode patients) are warranted.

Gender differences in premorbid adjustment of patients with first episode psychosis

Gender differences in premorbid adjustment, clinical presentation, and longitudinal course have been considered increasingly in explanatory models of psychotic disorders, such as the schizophrenias. Indeed, findings of a male propensity to poor premorbid adjustment, negative and non-affective symptoms, and poor outcome relative to their female counterparts, has led to suggestions that males are more prone to an early-onset dementia praecox type of schizophrenic disorder. The current study investigated a sample of 38 male and 20 female patients presenting with their first episode of psychosis (broadly defined, but excluding obvious drug-induced disorders) from a defined catchment area population, which had been systematically ascertained without prejudice to diagnostic subtype or illness duration. The study investigated gender, diagnosis and interaction of gender and diagnosis on differences within the three developmental age categories of childhood, early adolescence and late adolescence, to identify where, within these age categories, differences lie. The second part of the study was to investigate the relationship between premorbid adjustment, gender, and psychopathology as measured by the PANSS and SCL-90. General linear modelling revealed that males were reported to have had poorer premorbid adjustment in late adolescence when compared to females, notably in items examining school performance, adaptation to school, social interests and sociosexual development. Males were observed to have higher levels of negative symptoms but not for positive or general symptoms on the PANSS. This finding is independent from the effect of diagnosis or of the interaction effect between gender and diagnosis on premorbid adjustment. There were no gender effects for the self reported global indices on the SCL-90. The results suggest that in comparison with their female counterparts, males who develop a psychotic illness have significantly poorer premorbid adjustment at the late adolescent stage and that this may contribute to higher levels of negative symptoms.

Prospektive Studie zum Krankheitsverlauf schizophrener Psychosen:

Zusammenfassung. Theoretischer Hintergrund: Es existieren zwar viele Studien zu Verlauf und Outcome schizophrener Psychosen, doch in nur wenigen werden ersthospitalisierte Patienten prospektiv über einen hinreichend langen Zeitraum untersucht. Fragestellung: Wie verändern sich Symptomatik und soziales Funktionsniveau im Frühverlauf schizophrener Psychosen? Welche prognostischen Implikationen ergeben sich aus einer DSM-III-R-Diagnose (Schizophrenie versus andere Psychosen) bei Ersthospitalisierung? Methode: 5-Jahres-Verlauf und Outcome einer Follow-up-Stichprobe von 121 ersthospitalisierten schizophrenen Patienten (nach ICD-9) wurden mit standardisierten Instrumenten untersucht. Ergebnisse: Zum 5-Jahres-Follow-up erreichte die Hälfte der Patienten nur einen ungünstigen Outcome in der Negativsymptomatik (49%), der sozialen Behinderung (51%), den Sozialkontakten (61%) und dem Beschäftigungsniveau (51%). Nur wenige Patienten (20%) wiesen einen durchgängig günstigen Krankheitsverlauf auf, 42% zeigten eine wechselhaften und 38% einen chronischen Verlauf. Patienten, die die engen Schizophrenie-Kriterien nach DSM-III-R erfüllten, hatten signifikant ungünstigere Outcomes. Schlussfolgerungen: Der frühe Krankheitsverlauf schizophrener Psychosen ist immer noch relativ ungünstig.

First-episode psychosis: a comparative review of diagnostic evolution and predictive variables in adolescents versus adults

OBJECTIVE

To review the diagnostic evolution and predictive variables of diagnosis and outcome in first-episode psychosis in adolescents (age 13-19 years) and adults.

METHOD

Literature was reviewed through MEDLINE, Psycinfo, and PubMed, and supplemented by selected bibliographies.

RESULTS

First-episode psychosis in the adolescent population has greater diagnostic instability than in adults. We identified trends in the predictive variables of diagnosis and outcome: 1) Premorbid adjustment (that is, personality) in adolescents and Global Assessment of Functioning (GAF) both before and after first-episode psychosis in adolescents and adults are the best predictors of diagnosis; 2) GAF (before and after) is the best predictor of outcome in both adolescents and adults.

CONCLUSION

Adolescent-onset psychosis appears to be in continuity with adult-onset psychosis. The greater diagnostic instability in adolescents and the absence of significant data on predictive variables suggest a need for specialized and continuous care and research in the adolescent population.

The relationship between dopamine D2 receptor polymorphism at the Taq1 A locus and therapeutic response to nemonapride, a selective dopamine antagonist, in schizophrenic patients

Previous studies have demonstrated that subjects with one or two A1 alleles of dopamine D2 receptor (DRD2) polymorphism at the Taq1 A locus have lower DRD2 density than those with no A1 allele. The present study aimed to examine whether the Taq1 A DRD2 genotypes are related to therapeutic response to nemonapride, a selective dopamine antagonist, in schizophrenic patients. The subjects were 25 acutely exacerbated schizophrenic inpatients who had received no medication for at least 1 month before the study. The fixed dose (18 mg/day) of nemonapride was administered to each patient for 3 weeks. The clinical status was prospectively monitored by the Brief Psychiatric Rating Scale (BPRS) before, and 3 weeks after, the treatment. The Taq1 A genotypes (A1 and A2 alleles) were determined by the polymerase chain reaction method. Three patients were homozygous for the A1 allele, 11 were heterozygous for the A1 and A2 alleles, and 11 were homozygous for the A2 allele. The patients with one or two A1 alleles (n = 14) showed significantly higher percentage improvement in total BPRS and positive symptoms than those with no A1 allele (n = 11) after 3-week treatment while the percentage improvement in other subgrouped symptoms (negative, anxiety-depression, excitement and cognitive symptoms) was similar between the two genotype groups. The present results suggest that the Taq1 A DRD2 polymorphism is related to early therapeutic response to nemonapride in schizophrenic patients, possibly by modifying the efficiency of DRD2 antagonism of the drug in the central nervous system.

Cognitive and functional changes with aging in schizophrenia

The variation in functional outcome in schizophrenia appears to be exaggerated in late life. The cognitive and functional deficits commonly seen in younger schizophrenic patients appear to worsen in some cases in late life, while others patients appear to have a stable course of illness without functional decline, and still other patients have been reported to have essentially no residual symptoms in their later years. Cognitive and functional deficits appear to worsen more significantly in patients with a lifetime course of severe functional deficit. Despite the profound functional and cognitive deficits in these patients, neuropathologic studies have found no evidence of typical causes of severe cognitive impairments. This paper reviews the current findings on cognitive and functional changes in aging in schizophrenia, with a specific focus on patients with a poor lifetime functional outcome.

Cantabria first-episode schizophrenia study: three-year follow-up

BACKGROUND

We present the findings from the three-year follow-up of all first episodes of schizophrenia occurring during a two-year period in Cantabria (in Spain).

AIMS

(a) To describe the clinical characteristics of the illness from the early stages of the disease, and (b) to study the long-term psychosocial adjustment and psychopathological evolution of these patients, identifying predictors for the course of the illness.

METHOD

Of the original cohort of 86 patients, 76 (88.3%) were fully evaluated at three-year follow-up. Psychiatric assessment was performed (PSE-9 and SANS/SAPS). Social adjustment was evaluated using the Disability Assessment Schedule (DAS). Information regarding the clinical evolution and use of health resources was also gathered.

RESULTS

The majority of patients with a first-contact diagnosis of schizophrenia failed to meet the criteria for a CATEGO diagnosis at follow-up. The SANS/SAPS assessments revealed a doubling in the proportion of patients with 'negative schizophrenia'. The pattern of clinical course was also evaluated, with 24 (31.5%) of the patients having a good outcome. Being male and having low social class tended to be associated with poor clinical outcome

CONCLUSIONS

The outcome of schizophrenia is less pessimistic than was originally thought.

CSF levels of HVA and 5-HIAA in drug-free schizophrenic patients and healthy controls: a prospective study focused on their predictive value for outcome in schizophrenia

The CSF levels of HVA and 5-HIAA were determined in 90 drug-free DSM-III-R schizophrenic patients and 47 healthy control subjects, and their predictive value for 5-year outcome was evaluated. CSF was collected by lumbar puncture at index admission, and in 37 of the patients a second sample was drawn after approx. 7 weeks of neuroleptic treatment. Outcome was rated prospectively 5 years after index admission by means of the Strauss-Carpenter outcome scale. Schizophrenic patients had significantly lower levels of HVA in the CSF than the control group, but no difference was found for 5-HIAA. The CSF-amine metabolite levels were not correlated with age at admission, age at first symptoms or duration of the disorder. Neither HVA nor 5-HIAA correlated with the total outcome scores at a 1- and 5-year follow-up evaluation. First-admitted previously untreated patients with the poorest 5-year outcome had significantly lower HVA/5-HIAA quotients than those with a good outcome. Furthermore, patients still having a low HVA/5-HIAA quotient after treatment with neuroleptics had a poorer 5-year outcome than patients with an increased quotient. The data indicate that both HVA and 5-HIAA in the CSF, and especially their sensitivity to neuroleptic treatment, have a predictive value for the prognosis in schizophrenia.