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Montes JM, Agüera-Ortiz L, Mané A, Martinez-Raga J, Gutiérrez-Rojas L. Clinical decision-making before discharge in hospitalized persons with schizophrenia: a Spanish Delphi expert consensus. Front Psychiatry 2024; 15:1412637. [PMID: 38915849 PMCID: PMC11194714 DOI: 10.3389/fpsyt.2024.1412637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 05/22/2024] [Indexed: 06/26/2024] Open
Abstract
Introduction The care of people with schizophrenia (PWS) is usually provided in an outpatient setting by community mental health teams. However, PWS frequently require inpatient treatment because of a wide array of clinical, personal and/or social situations. Unfortunately, to our knowledge, there are no guidelines available to help psychiatrists in the decision-making process on hospital discharge for PWS. The aim of this project was to develop an expert consensus on discharge criteria for PWS after their stay in an acute inpatient psychiatric unit. Methods Using a modified Delphi method a group of 42 psychiatrists throughout Spain evaluated four areas of interest regarding this issue: clinical symptomatology, treatment-related factors, follow-up health care units after discharge, and physical health and monitoring. Results After two rounds, among the 64 statements, a consensus was reached for 59 (92.2%) statements. In three (17.7%) of the 17 statements on 'clinical symptomatology' and 2 (13.3%) of the 15 statements on 'follow-up health care units after discharge', a consensus was not reached; in contrast, a consensus was reached for all statements concerning 'treatment-related factors' and those concerning 'physical health and monitoring'. The consensus results highlight the importance for discharge of the control of symptoms rather than their suppression during admission and of tolerability in the selection of anantipsychotic. Discussion Although there is a lack of relevant data for guiding the discharge of PWS after hospitalization in an acute inpatient psychiatric unit, we expect that this consensus based on expert opinion may help clinicians to take appropriate decisions.
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Affiliation(s)
- José Manuel Montes
- Psychiatry Department, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Madrid, Spain
- Centro de Investigación en Red de Salud Mental, CIBERSAM, Instituto de Salud Carlos III, Madrid, Spain
| | - Luis Agüera-Ortiz
- Centro de Investigación en Red de Salud Mental, CIBERSAM, Instituto de Salud Carlos III, Madrid, Spain
- Department of Psychiatry, Instituto de Investigación Sanitaria (imas12), Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Anna Mané
- Centro de Investigación en Red de Salud Mental, CIBERSAM, Instituto de Salud Carlos III, Madrid, Spain
- Psychiatry Department, Parc de Salut Mar, Barcelona, Spain; Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Jose Martinez-Raga
- Psychiatry Department, Hospital Universitario Doctor Peset & Universitat de Valencia, Valencia, Spain
| | - Luis Gutiérrez-Rojas
- Department of Psychiatry, University of Granada, Granada, Spain
- Psychiatry Department, Hospital Clínico San Cecilio, Granada, Spain
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2
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Dernbach MR, Carpenter JE. Case Files of the Emory University Medical Toxicology Fellowship: A Patient Presents to the Outpatient Toxicology Clinic with Delusions of Being Poisoned. J Med Toxicol 2024; 20:233-244. [PMID: 38378951 PMCID: PMC10959915 DOI: 10.1007/s13181-024-00995-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 02/05/2024] [Accepted: 02/08/2024] [Indexed: 02/22/2024] Open
Affiliation(s)
- Matthew Robert Dernbach
- Department of Emergency Medicine, Emory University, 50 Hurt Plaza SE, Suite 600, Atlanta, GA, 30303, USA.
- Georgia Poison Center, Atlanta, GA, USA.
| | - Joseph E Carpenter
- Department of Emergency Medicine, Emory University, 50 Hurt Plaza SE, Suite 600, Atlanta, GA, 30303, USA
- Georgia Poison Center, Atlanta, GA, USA
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3
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Dissaux N, Neyme P, Kim-Dufor DH, Lavenne-Collot N, Marsh JJ, Berrouiguet S, Walter M, Lemey C. Psychosis Caused by a Somatic Condition: How to Make the Diagnosis? A Systematic Literature Review. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1439. [PMID: 37761400 PMCID: PMC10529854 DOI: 10.3390/children10091439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 08/14/2023] [Accepted: 08/18/2023] [Indexed: 09/29/2023]
Abstract
BACKGROUND First episode of psychosis (FEP) is a clinical condition that usually occurs during adolescence or early adulthood and is often a sign of a future psychiatric disease. However, these symptoms are not specific, and psychosis can be caused by a physical disease in at least 5% of cases. Timely detection of these diseases, the first signs of which may appear in childhood, is of particular importance, as a curable treatment exists in most cases. However, there is no consensus in academic societies to offer recommendations for a comprehensive medical assessment to eliminate somatic causes. METHODS We conducted a systematic literature search using a two-fold research strategy to: (1) identify physical diseases that can be differentially diagnosed for psychosis; and (2) determine the paraclinical exams allowing us to exclude these pathologies. RESULTS We identified 85 articles describing the autoimmune, metabolic, neurologic, infectious, and genetic differential diagnoses of psychosis. Clinical presentations are described, and a complete list of laboratory and imaging features required to identify and confirm these diseases is provided. CONCLUSION This systematic review shows that most differential diagnoses of psychosis should be considered in the case of a FEP and could be identified by providing a systematic checkup with a laboratory test that includes ammonemia, antinuclear and anti-NMDA antibodies, and HIV testing; brain magnetic resonance imaging and lumbar puncture should be considered according to the clinical presentation. Genetic research could be of interest to patients presenting with physical or developmental symptoms associated with psychiatric manifestations.
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Affiliation(s)
- Nolwenn Dissaux
- Centre Hospitalier Régional et Universitaire de Brest, 2 Avenue Foch, 29200 Brest, France
- Unité de Recherche EA 7479 SPURBO, Université de Bretagne Occidentale, 29200 Brest, France
| | - Pierre Neyme
- Fondation du Bon Sauveur d’Alby, 30 Avenue du Colonel Teyssier, 81000 Albi, France
| | - Deok-Hee Kim-Dufor
- Centre Hospitalier Régional et Universitaire de Brest, 2 Avenue Foch, 29200 Brest, France
| | - Nathalie Lavenne-Collot
- Centre Hospitalier Régional et Universitaire de Brest, 2 Avenue Foch, 29200 Brest, France
- Laboratoire du Traitement de l’Information Médicale, Inserm U1101, 29200 Brest, France
| | - Jonathan J. Marsh
- Graduate School of Social Service, Fordham University, 113 West 60th Street, New York, NY 10023, USA
| | - Sofian Berrouiguet
- Centre Hospitalier Régional et Universitaire de Brest, 2 Avenue Foch, 29200 Brest, France
- Unité de Recherche EA 7479 SPURBO, Université de Bretagne Occidentale, 29200 Brest, France
| | - Michel Walter
- Centre Hospitalier Régional et Universitaire de Brest, 2 Avenue Foch, 29200 Brest, France
- Unité de Recherche EA 7479 SPURBO, Université de Bretagne Occidentale, 29200 Brest, France
| | - Christophe Lemey
- Centre Hospitalier Régional et Universitaire de Brest, 2 Avenue Foch, 29200 Brest, France
- Unité de Recherche EA 7479 SPURBO, Université de Bretagne Occidentale, 29200 Brest, France
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4
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Approach to New-Onset Psychosis in Pediatrics: A Review of Current Practice and an Interdisciplinary Consensus-Driven Clinical Pathway at a Single-Center Institution. J Child Neurol 2023; 38:216-222. [PMID: 37165651 DOI: 10.1177/08830738231156804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
New-onset psychosis in the pediatric population poses many diagnostic challenges. Given the diversity of underlying causes, which fall under the purview of multiple medical specialties, a timely, targeted, yet thorough workup requires a systematic and coordinated approach. A committee of expert pediatric physicians from the divisions of emergency medicine, psychiatry, neurology, hospitalist medicine, and radiology convened to create and implement a novel clinical pathway and approach to the pediatric patient presenting with new-onset psychosis. Here we provide background and review the evidence supporting the investigations recommended in our pathway to screen for a comprehensive range of etiologies of pediatric psychosis.
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5
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Schizophrenia Misdiagnosis after Capgras and Cotard Delusions in a Patient with Infantile Cystinosis, Cavum Septi Pellucidi, Cavum Vergae and Cavum Veli Interpositi. Behav Sci (Basel) 2023; 13:bs13020157. [PMID: 36829386 PMCID: PMC9952842 DOI: 10.3390/bs13020157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 02/09/2023] [Accepted: 02/10/2023] [Indexed: 02/15/2023] Open
Abstract
How many patients with psychosis secondary to genetic conditions or congenital brain malformation have been diagnosed with schizophrenia, since its initial conception more than one hundred years ago? A case report of a young man, with antecedents of Capgras and Cotard syndromes, sent to a schizophrenia treatment-resistant outpatient clinic is presented. Instead of true, primary, idiopathic schizophrenia, a diagnosis of secondary schizophrenia (pseudo-schizophrenia or schizophrenia-like psychosis) was made, corresponding to a secondary psychotic syndrome, with hallucinations and delusions due to congenital cavum septi pellucidi, cavum vergae, cavum veli interpositi and progressive brain atrophy due to cystinosis. Extreme caution is recommended when diagnosing schizophrenia in severely psychotic patients independent of their acute or chronic condition. Schizophrenia shall never be forgotten as the great imitated of medicine.
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Universal healthcare coverage for first episode of schizophrenia-spectrum disorders in Chile: analysis of the administrative database. Eur Arch Psychiatry Clin Neurosci 2022; 272:129-138. [PMID: 33772320 DOI: 10.1007/s00406-021-01254-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Accepted: 03/16/2021] [Indexed: 10/21/2022]
Abstract
Aim of the study was to analyse the Ministry of Health's (MINSAL) administrative database of the Universal Health Coverage (UHC) program for First Episode of Schizophrenia Spectrum Disorders (FEP-SSD). The database included every case registered in the program between 2004 and 2017. According to the timeframes established for permanence in the program, cases were defined as Suspected, FEP in diagnostic observation and FEP-SSD. Only first registers were analysed. We compared gender, age at entry, level of care and region where the case was registered. Denominator data for estimation of incidence rates were obtained from the last census. We adjusted incidence rate ratios by age, gender, and region. During the studied period, 33.207 suspected cases were registered. 27.006 (81%) were confirmed as FEP and after 6-month follow-up, 22.701 (68%) were confirmed as FEP-SSD. The median age at entry was 24 years, males entering at younger age. Male proportion was higher than female in all groups. 46.9% of all cases were detected in primary care. FEP-SSD cases were six years younger and had a higher proportion of males than discarded cases (62.6 vs 53.2%). During 169.4 million person-years at risk, crude incidence for suspected cases was 19.58 per 100.000 person-years; for FEP, 15.92 per 100.000 person-years and for FEP-SSD, 13.38 per 100.000 person-years. Chile has lower incidence of FEP-SSD compared to current world estimations but gender proportions are comparable. This UHC program has allowed early access through the integration of mental health to the health network at all levels of care.
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Pattaravimonporn N, Chaikijurajai T, Chamroonrat W, Sriphrapradang C. Myxedema Psychosis after Levothyroxine Withdrawal in Radioactive Iodine Treatment of Differentiated Thyroid Cancer: A Case Report. Case Rep Oncol 2021; 14:1596-1600. [PMID: 34950002 PMCID: PMC8647114 DOI: 10.1159/000520128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 10/04/2021] [Indexed: 11/19/2022] Open
Abstract
Neuropsychiatric symptoms, especially acute psychosis (often referred to as myxedema madness or psychosis), are rare but possible clinical presentations of patients with hypothyroidism. A 42-year-old woman with papillary thyroid carcinoma and recent total thyroidectomy had developed flat affect, paranoid delusion, and visual and auditory hallucination during inpatient admission for elective radioactive iodine treatment. On admission, her history and physical exam did not reveal symptoms and signs of significant hypothyroidism. Other medical causes of acute psychosis were excluded, and the patient was immediately treated with thyroid hormone replacement therapy. Subsequently, her thyroid function normalized, and her psychotic symptoms gradually improved. Although there is a lack of classic signs and symptoms of hypothyroidism, myxedema madness should be recognized as one of the potentially treatable causes of acute psychosis.
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Affiliation(s)
- Nutnicha Pattaravimonporn
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Thanat Chaikijurajai
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.,Internal Medicine Residency Program, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Wichana Chamroonrat
- Division of Nuclear Medicine, Department of Radiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Chutintorn Sriphrapradang
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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8
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Dorney K, Murphy M. Recommendations for the medical work-up of first episode psychosis, including specific relevance to Indigenous Australians: A narrative review. Early Interv Psychiatry 2021; 15:423-438. [PMID: 32543124 DOI: 10.1111/eip.12980] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Revised: 03/24/2020] [Accepted: 04/28/2020] [Indexed: 12/15/2022]
Abstract
AIMS To collate existing literature for busy practicing psychiatrists about the medical work-up for first-episode psychosis (FEP). Therefore, (a) to review current guidelines for the medical work-up of first episode psychosis. (b) To examine whether any specific recommendations for Indigenous Australians exist. (c) To produce an easy reference table of evidence based investigations. METHOD A multi-part narrative review process was undertaken. Step 1 "Source identification and summary": identified key existing national and international guidelines and expert opinions related to the medical work-up of FEP and summarised these suggestions. Step 2 "Exploration of each investigation": examined each of the identified investigations for its importance. Step 3 "Relevance to Indigenous Australians": reviewed any particular relevance to the Indigenous Australian population. Step 4 "Clinician guide": involved presenting recommended investigations in a simple table. RESULTS Multiple guidelines were identified. There was clear consensus for many aspects. However, there were also differences in the approach for some investigations. Clinical reasoning for the proposed investigations was commonly absent. There were limited specific recommendations for Indigenous Australians. Evidence and importance was explored for each investigation and auseful table for the practicing psychiatrist was constructed. Investigations were stratified into those considered to be "universal," "low yield," or "unecessary." CONCLUSION A narrative review of multiple guidelines relating to the medical work-up of FEP identified many similarities and some differences to their approach. Little additional information exists for the Indigenous Australian context. A clinician friendly worksheet for everyday use may be helpful to busy clinicians.
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Affiliation(s)
- Kiernan Dorney
- Department of Psychiatry, Northern Sydney Local Health District, Sydney, New South Wales, Australia
| | - Michael Murphy
- Department of Psychiatry, University of New South Wales, Sydney, New South Wales, Australia
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9
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Hua LL, Alderman EM, Chung RJ, Grubb LK, Lee J, Powers ME, Upadhya KK, Wallace SB. Collaborative Care in the Identification and Management of Psychosis in Adolescents and Young Adults. Pediatrics 2021; 147:peds.2021-051486. [PMID: 34031232 DOI: 10.1542/peds.2021-051486] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Pediatricians are often the first physicians to encounter adolescents and young adults presenting with psychotic symptoms. Although pediatricians would ideally be able to refer these patients immediately into psychiatric care, the shortage of child and adolescent psychiatry services may sometimes require pediatricians to make an initial assessment or continue care after recommendations are made by a specialist. Knowing how to identify and further evaluate these symptoms in pediatric patients and how to collaborate with and refer to specialty care is critical in helping to minimize the duration of untreated psychosis and to optimize outcomes. Because not all patients presenting with psychotic-like symptoms will convert to a psychotic disorder, pediatricians should avoid prematurely assigning a diagnosis when possible. Other contributing factors, such as co-occurring substance abuse or trauma, should also be considered. This clinical report describes psychotic and psychotic-like symptoms in the pediatric age group as well as etiology, risk factors, and recommendations for pediatricians, who may be among the first health care providers to identify youth at risk.
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Affiliation(s)
- Liwei L. Hua
- Catholic Charities of Baltimore, Baltimore, Maryland
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10
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Ross EL, Becker JE, Linnoila JJ, Soeteman DI. Cost-Effectiveness of Routine Screening for Autoimmune Encephalitis in Patients With First-Episode Psychosis in the United States. J Clin Psychiatry 2020; 82:19m13168. [PMID: 33211912 PMCID: PMC7919384 DOI: 10.4088/jcp.19m13168] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 05/18/2020] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Autoimmune encephalitis (AE) is a highly treatable neurologic condition that can cause psychosis. Screening for AE is not currently recommended in routine workup for first-episode psychosis (FEP), owing partly to the high cost of testing for AE-associated neuronal autoantibodies. METHODS This study used a decision-analytic model to estimate the cost-effectiveness of routine serum screening for AE compared with clinically targeted screening in patients with FEP. Model parameters drawn from prior published literature included the prevalence of neuronal autoantibodies in FEP (4.5%), serum autoantibody panel cost (US $291), remission probability with antipsychotics (0.58), and remission probability with immunotherapy for patients diagnosed with AE (0.85). Outcomes included quality-adjusted life-years (QALYs), costs, and incremental cost-effectiveness ratios (ICERs), assessed over a 5-year horizon from the US health care sector and societal perspectives. ICER thresholds of $50,000/QALY to $150,000/QALY were used to define cost-effectiveness. The analysis was conducted between June 2018 and January 2020. RESULTS Routine screening led to mean QALY gains of 0.008 among all patients and 0.174 among the subgroup of patients with neuronal autoantibodies. Mean costs increased by $780 from a societal perspective and $1,150 from a health care sector perspective, resulting in ICERs of $99,330/QALY and $147,460/QALY, respectively. Incorporating joint input data uncertainty, the likelihood routine screening has an ICER ≤ $150,000/QALY was 55% from a societal perspective and 37% from a health care sector perspective. The model parameter with the greatest contribution to overall uncertainty was the effectiveness of immunotherapy relative to antipsychotics. CONCLUSIONS Routine screening for AE in patients with FEP may be cost-effective in the United States. As further immunotherapy effectiveness data become available, a more definitive recommendation to perform routine screening could be warranted.
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Affiliation(s)
- Eric L. Ross
- Department of Psychiatry, McLean Hospital, Belmont, MA,Department of Psychiatry, Massachusetts General Hospital, Boston, MA,Department of Psychiatry, Harvard Medical School, Boston, MA
| | - Jessica E. Becker
- Department of Psychiatry, McLean Hospital, Belmont, MA,Department of Psychiatry, Massachusetts General Hospital, Boston, MA,Department of Psychiatry, Harvard Medical School, Boston, MA
| | - Jenny J. Linnoila
- Department of Neurology, Massachusetts General Hospital, Boston, MA,Department of Neurology, Harvard Medical School, Boston, MA
| | - Djøra I. Soeteman
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA
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11
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Electroconvulsive Therapy in Children and Adolescents: Clinical Indications and Special Considerations. Harv Rev Psychiatry 2020; 27:354-358. [PMID: 31714466 DOI: 10.1097/hrp.0000000000000236] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Electroconvulsive therapy (ECT) is a well-tolerated, well-established, and efficacious treatment in adults, particularly in the setting of severe mood and psychotic disorders. In children and adolescents, however, ECT is infrequently administered and likely underutilized. Results from older studies evaluating the utility of ECT in children and adolescents were mixed, but recent studies have supported ECT treatment success in these patients, with particularly high response rates for treating depression. In this Perspectives, we discuss the current clinical indications for ECT in managing mood and psychotic disorders in children and adolescents. We then review the pretreatment evaluation and management of patients receiving ECT and examine the efficacy of ECT for those indications. We also address issues unique to children and adolescents, versus adults, that need to be considered when determining whether treatment with ECT is appropriate for a patient in this age group. Included in this context are the distinct side-effect profile in children and adolescents, ethical issues regarding informed consent, incorporating the child into the decision-making process when developmentally appropriate, and the need to take into account differing state jurisdictional processes.
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12
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Skikic M, Arriola JA. First Episode Psychosis Medical Workup: Evidence-Informed Recommendations and Introduction to a Clinically Guided Approach. Child Adolesc Psychiatr Clin N Am 2020; 29:15-28. [PMID: 31708044 DOI: 10.1016/j.chc.2019.08.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Evaluating the patient with first episode psychosis (FEP) requires a careful assessment that includes a thorough history, examination, and workup. This begins with a thoughtful consideration of the differential diagnoses and is followed and supported by laboratory, encephalographic, and imaging studies where appropriate. This article presents some of the diagnostic considerations for a patient presenting with psychosis with an emphasis on the secondary causes and proposes a tiered approach to the workup of FEP that is clinically guided.
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Affiliation(s)
- Maja Skikic
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, 1601 23rd Avenue South, Nashville, TN 37212, USA.
| | - Jose Alberto Arriola
- Department of Psychiatry and Behavioral Sciences, Consult-Liaison Psychiatry, Vanderbilt University Medical Center, 1601 23rd Avenue South, Nashville, TN 37212, USA
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Keshavan MS, Collin G, Guimond S, Kelly S, Prasad KM, Lizano P. Neuroimaging in Schizophrenia. Neuroimaging Clin N Am 2019; 30:73-83. [PMID: 31759574 DOI: 10.1016/j.nic.2019.09.007] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
Schizophrenia is a chronic psychotic disorder with a lifetime prevalence of about 1%. Onset is typically in adolescence or early adulthood; characteristic symptoms include positive symptoms, negative symptoms, and impairments in cognition. Neuroimaging studies have shown substantive evidence of brain structural, functional, and neurochemical alterations that are more pronounced in the association cortex and subcortical regions. These abnormalities are not sufficiently specific to be of diagnostic value, but there may be a role for imaging techniques to provide predictions of outcome. Incorporating multimodal imaging datasets using machine learning approaches may offer better diagnostic and predictive value in schizophrenia.
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Affiliation(s)
- Matcheri S Keshavan
- Beth Israel Deaconess Medical Center, Harvard Medical School, 75 Fenwood Road, Boston, MA 02115, USA.
| | - Guusje Collin
- McGovern Institute for Brain Research, Massachusetts Institute of Technology, 43 Vassar St, Cambridge, MA 02139, USA; University Medical Center Utrecht Brain Center, Heidelberglaan 100, Postbus 85500, 3508 GA, Utrecht, the Netherlands
| | - Synthia Guimond
- Department of Psychiatry, The Royal's Institute of Mental Health Research, University of Ottawa, 1145 Carling Avenue, Ottawa, ON K1Z 7K4, Canada
| | - Sinead Kelly
- Beth Israel Deaconess Medical Center, Harvard Medical School, 75 Fenwood Road, Boston, MA 02115, USA
| | - Konasale M Prasad
- University of Pittsburgh School of Medicine, Suite 279, 3811 O'Hara St, Pittsburgh, PA 15213, USA; Swanson School of Engineering, University of Pittsburgh, Pittsburgh, PA, USA; Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Paulo Lizano
- Beth Israel Deaconess Medical Center, Harvard Medical School, 75 Fenwood Road, Boston, MA 02115, USA
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14
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Forbes M, Stefler D, Velakoulis D, Stuckey S, Trudel JF, Eyre H, Boyd M, Kisely S. The clinical utility of structural neuroimaging in first-episode psychosis: A systematic review. Aust N Z J Psychiatry 2019; 53:1093-1104. [PMID: 31113237 DOI: 10.1177/0004867419848035] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Australian and US guidelines recommend routine brain imaging, either computed tomography or magnetic resonance imaging, to exclude structural lesions in presentations for first-episode psychosis. The aim of this review was to examine the evidence for the appropriateness and clinical utility of this recommendation by assessing the frequency of abnormal radiological findings in computed tomography and magnetic resonance imaging scans among patients with first-episode psychosis. METHODS PubMed and Embase database were searched from inception to April 2018 using appropriate MeSH or Emtree terms. Studies were included in the review if they reported data on computed tomography or magnetic resonance imaging scan findings of individuals with first-episode psychosis. No restriction on the geographical location of the study or the age of participants was applied. We calculated the percentage of abnormal radiological findings in each study, separately by the two diagnostic methods. RESULTS There were 16 suitable studies published between 1988 and 2017, reporting data on an overall 2312 patients with first-episode psychosis. Most were observational studies with a retrospective design and the majority examined patients with computed tomography. While structural abnormalities were a relatively common finding, these rarely required clinical intervention (range across studies: 0-60.7%; median: 3.5%) and were very rarely the cause of the psychotic symptoms (range: 0-3.3%; median: 0%). Only 2 of the 16 studies concluded that brain imaging should be routinely ordered in first-episode psychosis. CONCLUSION There is insufficient evidence to suggest that brain imaging should be routinely ordered for patients presenting with first-episode psychosis without associated neurological or cognitive impairment. The appropriate screening procedure for structural brain lesions is conventional history-taking, mental status and neurological examination. If intracranial pathology is suspected clinically, a magnetic resonance imaging or computed tomography scan should be performed depending on the clinical signs, the acuity and the suspected pathology. National guidelines should reflect evidence-based data.
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Affiliation(s)
- Malcolm Forbes
- Department of Psychiatry, University of Melbourne, Parkville, VIC, Australia
| | - Denes Stefler
- Department of Epidemiology and Public Health, University College London, London, UK
| | - Dennis Velakoulis
- Neuropsychiatry Unit, Royal Melbourne Hospital, Parkville, VIC, Australia.,Melbourne Neuropsychiatry Centre, University of Melbourne and Melbourne Health, Parkville, VIC, Australia
| | - Stephen Stuckey
- Monash Imaging, Diagnostic Neuroradiology and MRI, Monash Health, Clayton, VIC, Australia.,Department of Imaging, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia
| | | | - Harris Eyre
- Department of Psychiatry, University of Melbourne, Parkville, VIC, Australia.,Innovation Institute, Texas Medical Centre, Houston, TX, USA
| | - Melinda Boyd
- School of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Steve Kisely
- Innovation Institute, Texas Medical Centre, Houston, TX, USA
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15
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Goutte J, Killian M, Antoine JC, Massoubre C, Fakra E, Cathébras P. [First-episode psychosis as primary manifestation of medical disease: An update]. Rev Med Interne 2019; 40:742-749. [PMID: 31421899 DOI: 10.1016/j.revmed.2019.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 06/09/2019] [Accepted: 07/17/2019] [Indexed: 11/15/2022]
Abstract
A huge variety of medical diseases may potentially present with isolated psychotic symptoms, and disease-specific treatment or management is available for a significant part of them. The initial medical work-up of a first-episode psychosis (FEP) is of crucial importance. This literature review aimed to identify medical conditions potentially revealed by FEP, to list the warning signs of secondary psychosis, and to discuss a screening strategy. Underlying organic conditions may be drugs and medications, neurologic diseases, infections, inflammatory and/or autoimmune pathologies, and metabolic disorders whether of hereditary origin. Each patient presenting with a first-episode psychosis should be evaluated with a precise anamnesis, a careful clinical examination, and routine laboratory tests. Brain imaging and tests (depending on the context) should be performed in the presence of atypical clinical features or "red flags", leading to suspect an organic disease.
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Affiliation(s)
- J Goutte
- Service de médecine interne, CHU de Saint-Étienne, 42055 Saint-Étienne Cedex 2, France.
| | - M Killian
- Service de médecine interne, CHU de Saint-Étienne, 42055 Saint-Étienne Cedex 2, France.
| | - J C Antoine
- Service de neurologie, CHU de Saint-Étienne, 42055 Saint-Étienne Cedex 2, France.
| | - C Massoubre
- Service de psychiatrie, CHU de Saint-Étienne, 42055 Saint-Étienne Cedex 2, France.
| | - E Fakra
- Service de psychiatrie, CHU de Saint-Étienne, 42055 Saint-Étienne Cedex 2, France.
| | - P Cathébras
- Service de médecine interne, CHU de Saint-Étienne, 42055 Saint-Étienne Cedex 2, France.
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16
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Harris G, Xiang H, Tan I, Randhawa V. How often does computed tomography (CT) of the brain demonstrate a cause for psychosis? A 7-year retrospective study at a tertiary metropolitan hospital. Australas Psychiatry 2019; 27:183-186. [PMID: 30474379 DOI: 10.1177/1039856218815761] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES The aim of the study was to determine the diagnostic yield of computed tomography (CT) of the brain for the investigation of psychosis. METHODS CT brain requests describing psychosis over a 7-year period at a 500-bed major metropolitan hospital were identified retrospectively. Patients were excluded if they were aged greater than 50 years or if the CT request described focal neurological findings on examination, trauma/falls or known brain tumour, demyelinating disorder, encephalopathy, seizure disorder, congenital brain anomaly, stroke or traumatic brain injury. RESULTS A total of 805 patients meeting the inclusion and exclusion criteria were identified, representing the largest published study on this topic. Only 0.4% of patients (3 out of 805) had a potential cause for psychosis demonstrated on CT. None of these patients had their management altered as a result. An additional 0.6% of patients (5 out of 805) had significant pathology that was deemed unrelated to their psychosis. CONCLUSIONS The diagnostic value of CT in the setting of psychosis was found to be extremely low in patients meeting the inclusion and exclusion criteria. Given the risk of ionising radiation and the expenditure of time and cost, more judicious use of CT is suggested.
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Affiliation(s)
- Guy Harris
- Radiology Registrar, Radiology Department, Concord Repatriation General Hospital, Sydney, NSW, Australia
| | - Hao Xiang
- Radiology Registrar, Radiology Department, Concord Repatriation General Hospital, Sydney, NSW, Australia
| | - Irene Tan
- Radiology Staff Specialist, Fellowship Trained Neuroradiologist, Radiology Department, Concord Repatriation General Hospital, Sydney, NSW, Australia
| | - Varundeep Randhawa
- Emergency Senior Resident Medical Officer, Emergency Department, Canterbury Hospital, Sydney, NSW, Australia
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17
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Hogan C, Little BP, Carlson JCT, Freudenreich O, Ivkovic A, Baron JM. Case 5-2019: A 48-Year-Old Woman with Delusional Thinking and Paresthesia of the Right Hand. N Engl J Med 2019; 380:665-674. [PMID: 30763197 DOI: 10.1056/nejmcpc1807495] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Charlotte Hogan
- From the Departments of Psychiatry (C.H., O.F., A.I.), Radiology (B.P.L.), Hematology (J.C.T.C.), and Pathology (J.M.B.), Massachusetts General Hospital, and the Departments of Psychiatry (C.H., O.F., A.I.), Radiology (B.P.L.), Hematology (J.C.T.C.), and Pathology (J.M.B.), Harvard Medical School - both in Boston
| | - Brent P Little
- From the Departments of Psychiatry (C.H., O.F., A.I.), Radiology (B.P.L.), Hematology (J.C.T.C.), and Pathology (J.M.B.), Massachusetts General Hospital, and the Departments of Psychiatry (C.H., O.F., A.I.), Radiology (B.P.L.), Hematology (J.C.T.C.), and Pathology (J.M.B.), Harvard Medical School - both in Boston
| | - Jonathan C T Carlson
- From the Departments of Psychiatry (C.H., O.F., A.I.), Radiology (B.P.L.), Hematology (J.C.T.C.), and Pathology (J.M.B.), Massachusetts General Hospital, and the Departments of Psychiatry (C.H., O.F., A.I.), Radiology (B.P.L.), Hematology (J.C.T.C.), and Pathology (J.M.B.), Harvard Medical School - both in Boston
| | - Oliver Freudenreich
- From the Departments of Psychiatry (C.H., O.F., A.I.), Radiology (B.P.L.), Hematology (J.C.T.C.), and Pathology (J.M.B.), Massachusetts General Hospital, and the Departments of Psychiatry (C.H., O.F., A.I.), Radiology (B.P.L.), Hematology (J.C.T.C.), and Pathology (J.M.B.), Harvard Medical School - both in Boston
| | - Ana Ivkovic
- From the Departments of Psychiatry (C.H., O.F., A.I.), Radiology (B.P.L.), Hematology (J.C.T.C.), and Pathology (J.M.B.), Massachusetts General Hospital, and the Departments of Psychiatry (C.H., O.F., A.I.), Radiology (B.P.L.), Hematology (J.C.T.C.), and Pathology (J.M.B.), Harvard Medical School - both in Boston
| | - Jason M Baron
- From the Departments of Psychiatry (C.H., O.F., A.I.), Radiology (B.P.L.), Hematology (J.C.T.C.), and Pathology (J.M.B.), Massachusetts General Hospital, and the Departments of Psychiatry (C.H., O.F., A.I.), Radiology (B.P.L.), Hematology (J.C.T.C.), and Pathology (J.M.B.), Harvard Medical School - both in Boston
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Tampi RR, Young J, Hoq R, Resnick K, Tampi DJ. Psychotic disorders in late life: a narrative review. Ther Adv Psychopharmacol 2019; 9:2045125319882798. [PMID: 31662846 PMCID: PMC6796200 DOI: 10.1177/2045125319882798] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Accepted: 09/25/2019] [Indexed: 11/25/2022] Open
Abstract
Psychotic disorders are not uncommon in late life. These disorders often have varied etiologies, different clinical presentations, and are associated with significant morbidity and mortality among the older adult population. Psychotic disorders in late life develop due to the complex interaction between various biological, psychological, social, and environmental factors. Given the significant morbidity and mortality associated with psychotic disorders in late life, a comprehensive work-up should be conducted when they are encountered. The assessment should not only identify the potential etiologies for the psychotic disorders, but also recognize factors that predicts possible outcomes for these disorders. Treatment approaches for psychotic disorders in late life should include a combination of nonpharmacological management strategies with the judicious use of psychotropic medications. When antipsychotic medications are necessary, they should be used cautiously with the goal of optimizing outcomes with regular monitoring of their efficacy and adverse effects.
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Affiliation(s)
- Rajesh R Tampi
- Department of Psychiatry and Behavioral Sciences, Cleveland Clinic Akron General, Akron, OH 44307, USA
| | - Juan Young
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Rakin Hoq
- NeoMed/Summa Psychiatry Residency Program, Akron, OH, USA
| | - Kyle Resnick
- NeoMed/Summa Psychiatry Residency Program, Akron, OH, USA
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19
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Heads Up: The Presentation of Schizoaffective Disorder in an Elite College Soccer Player with Prior Concussion. Harv Rev Psychiatry 2018; 25:302-310. [PMID: 29117025 DOI: 10.1097/hrp.0000000000000147] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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20
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Moe AM, Breitborde NJ. Psychosis in Emerging Adulthood: Phenomenological, Diagnostic, and Clinical Considerations. ACTA ACUST UNITED AC 2018. [DOI: 10.1080/23794925.2018.1509032] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- Aubrey M. Moe
- Department of Psychiatry and Behavioral Health, The Ohio State University, Columbus, OH, USA
| | - Nicholas J.K. Breitborde
- Departments of Psychiatry and Behavioral Health and Psychology, The Ohio State University, Columbus, OH, USA
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21
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Dominguez MDG, Garralda ME. Assessing and managing hallucinations in children and adolescents. BJPSYCH ADVANCES 2018. [DOI: 10.1192/apt.bp.115.014738] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
SummaryHallucinations (erroneous percepts in the absence of identifiable stimuli) are a key feature of psychotic states, but they have long been known to present in children with non-psychotic psychiatric disorders. Recent epidemiological studies of child populations found surprisingly high rates (about 10%) of hallucinatory experiences. These hallucinatory phenomena are most likely to occur in the absence of psychiatric disorder and are usually simpler, less elaborate and less distressing than those observed in children with psychiatric disorders. This article details the clinical assessment of hallucinations in children and adolescents, taking into account developmental considerations and paediatric organic associations. It describes hallucinations in young people with psychoses (schizophrenia spectrum and mood disorders) and non-psychotic psychiatric disorders (emotional and behavioural disorders), and it addresses therapeutic aspects.
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22
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Pientka LJ, Schulz SC, Lim KO, Jasberg SG. The Clinical Impact of Neuroimaging in First-Episode Psychosis. CLINICAL SCHIZOPHRENIA & RELATED PSYCHOSES 2017:CSRP.LPSS.111717. [PMID: 29164931 DOI: 10.3371/csrp.lpss.111717] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Laura J Pientka
- Department of Psychiatry, University of Minnesota, Minneapolis, MN, USA
| | - S Charles Schulz
- Department of Psychiatry, University of Minnesota, Minneapolis, MN, USA
| | - Kelvin O Lim
- Department of Psychiatry, University of Minnesota, Minneapolis, MN, USA
| | - Suzanne G Jasberg
- Department of Psychiatry, University of Minnesota, Minneapolis, MN, USA
- PrairieCare, A University of Minnesota Medical School Affiliate, Minneapolis, MN, USA
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23
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Bobo WV. The Diagnosis and Management of Bipolar I and II Disorders: Clinical Practice Update. Mayo Clin Proc 2017; 92:1532-1551. [PMID: 28888714 DOI: 10.1016/j.mayocp.2017.06.022] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2017] [Revised: 06/21/2017] [Accepted: 06/26/2017] [Indexed: 12/21/2022]
Abstract
Bipolar disorders, including bipolar I disorder (BP-I) and bipolar II disorder (BP-II), are common, potentially disabling, and, in some cases, life-threatening conditions. Bipolar disorders are characterized by alternating episodes of mania or hypomania and depression, or mixtures of manic and depressive features. Bipolar disorders present many diagnostic and therapeutic challenges for busy clinicians. Adequate management of bipolar disorders requires pharmacotherapy and psychosocial interventions targeted to the specific phases of illness. Effective treatments are available for each illness phase, but mood episode relapses and incomplete responses to treatment are common, especially for the depressive phase. Mood symptoms, psychosocial functioning, and suicide risk must, therefore, be continually reevaluated, and, when necessary, the plan of care must be adjusted during long-term treatment. Many patients will require additional treatment of comorbid psychiatric and substance use disorders and management of a variety of commonly co-occurring chronic general medical conditions.
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Affiliation(s)
- William V Bobo
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN
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24
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Tucci VT, Moukaddam N, Alam A, Rachal J. Emergency Department Medical Clearance of Patients with Psychiatric or Behavioral Emergencies, Part 1. Psychiatr Clin North Am 2017; 40:411-423. [PMID: 28800798 DOI: 10.1016/j.psc.2017.04.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patients presenting to the emergency department with mental illness or behavioral complaints merit workup for underlying physical conditions that can trigger, mimic, or worsen psychiatric symptoms. However, interdisciplinary consensus on medical clearance is lacking, leading to wide variations in quality of care and, quite often, poor medical care. Psychiatry and emergency medicine specialty guidelines support a tailored, customized approach. This article summarizes best-practice approaches to the medical clearance of patients with psychiatric illness, tips on history taking, system reviews, clinical or physical examination, and common pitfalls in the medical clearance process.
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Affiliation(s)
- Veronica Theresa Tucci
- Merit Health Wesley, Department of Emergency Medicine, 5001 Hardy Street, Hattiesburg, MS 39402, USA.
| | - Nidal Moukaddam
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, 1502 Taub Loop, NPC Building 2nd Floor, Houston, TX 77030, USA
| | - Al Alam
- Weill Cornell Medical College, NewYork-Presbyterian/Westchester, 21 Bloomingdale Road, White Plains, NY 10605, USA; Stony Brook University, Stony Brook, NY, USA
| | - James Rachal
- Carolinas Health Care System, Behavioral Health, 501 Billingsley Road, Charlotte, NC 28211, USA
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Abstract
OBJECTIVE There is evidence that over time health outcomes of people with schizophrenia are deteriorating rather than improving both in terms of mortality rate and levels of morbidity, even in Australia where service resourcing is substantial. Our objective was to examine the evidence of whether poor outcomes reflect decreases in treatment effectiveness and, if so, what are the barriers to improving standards of care. This review will argue that the confidence of clinicians to diagnose schizophrenia early, and provide assertive and long-term care, may be being undermined by a series of controversies in the published literature and discrepancies in clinical practice guidelines. METHOD A critical review was conducted of the evidence regarding six issues of high clinical relevance to the treatment of schizophrenia formulated as questions: (1) Is schizophrenia a progressive disease? (2) Does relapse contribute to disease progression and treatment resistance? (3) When should the diagnosis of schizophrenia be made? (4) Should maintenance antipsychotic medication be discontinued in fully remitted first-episode patients? (5) Do antipsychotic medications cause deleterious reductions in cortical grey matter volumes? and (6) Are long-acting injectable antipsychotics more effective in reducing relapse rate compared to oral formulations? RESULTS There is reliable evidence for schizophrenia being a progressive disease with emergent treatment resistance in most cases, that relapse contributes to this treatment resistance, that maintenance antipsychotic medication should not be discontinued in remitted first-episode patients, that antipsychotic medication does not appear to cause deleterious grey matter volume changes, that maintenance antipsychotic medication reduces the mortality rate in schizophrenia and that long-acting injectable antipsychotics are more effective in preventing relapse than oral formulations. CONCLUSION There is an urgent need to re-engineer the early management of schizophrenia and to routinely evaluate this type of innovation within practice-based research networks. A proposal for an assertive treatment algorithm is included.
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Affiliation(s)
- Stanley Victor Catts
- Discipline of Psychiatry, Royal Brisbane Clinical School, School of Medicine, The University of Queensland, Herston, QLD, Australia .,Brain and Mind Centre, The University of Sydney, Camperdown, NSW, Australia.,Neuroscience Research Australia, Randwick, NSW, Australia
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26
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Coentre R, Silva-dos-Santos A, Talina MC. Retrospective study on structural neuroimaging in first-episode psychosis. PeerJ 2016; 4:e2069. [PMID: 27257547 PMCID: PMC4888294 DOI: 10.7717/peerj.2069] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Accepted: 05/02/2016] [Indexed: 11/20/2022] Open
Abstract
Background. No consensus between guidelines exists regarding neuroimaging in first-episode psychosis. The purpose of this study is to assess anomalies found in structural neuroimaging exams (brain computed tomography (CT) and magnetic resonance imaging (MRI)) in the initial medical work-up of patients presenting first-episode psychosis. Methods. The study subjects were 32 patients aged 18-48 years (mean age: 29.6 years), consecutively admitted with first-episode psychosis diagnosis. Socio-demographic and clinical data and neuroimaging exams (CT and MRI) were retrospectively studied. Diagnostic assessments were made using the Operational Criteria Checklist +. Neuroimaging images (CT and MRI) and respective reports were analysed by an experienced consultant psychiatrist. Results. None of the patients had abnormalities in neuroimaging exams responsible for psychotic symptoms. Thirty-seven percent of patients had incidental brain findings not causally related to the psychosis (brain atrophy, arachnoid cyst, asymmetric lateral ventricles, dilated lateral ventricles, plagiocephaly and falx cerebri calcification). No further medical referral was needed for any of these patients. No significant differences regarding gender, age, diagnosis, duration of untreated psychosis, in-stay and cannabis use were found between patients who had neuroimaging abnormalities versus those without. Discussion. This study suggests that structural neuroimaging exams reveal scarce abnormalities in young patients with first-episode psychosis. Structural neuroimaging is especially useful in first-episode psychosis patients with neurological symptoms, atypical clinical picture and old age.
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Affiliation(s)
- Ricardo Coentre
- First-Episode Psychosis Program, Department of Psychiatry, Hospital Vila Franca de Xira, Vila Franca de Xira, Portugal
- Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| | | | - Miguel Cotrim Talina
- Department of Psychiatry, Hospital Vila Franca de Xira, Vila Franca de Xira, Portugal
- CEDOC, Chronic Diseases Research Centre, Nova Medical School, Lisbon, Portugal
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Galletly C, Castle D, Dark F, Humberstone V, Jablensky A, Killackey E, Kulkarni J, McGorry P, Nielssen O, Tran N. Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the management of schizophrenia and related disorders. Aust N Z J Psychiatry 2016; 50:410-72. [PMID: 27106681 DOI: 10.1177/0004867416641195] [Citation(s) in RCA: 502] [Impact Index Per Article: 62.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES This guideline provides recommendations for the clinical management of schizophrenia and related disorders for health professionals working in Australia and New Zealand. It aims to encourage all clinicians to adopt best practice principles. The recommendations represent the consensus of a group of Australian and New Zealand experts in the management of schizophrenia and related disorders. This guideline includes the management of ultra-high risk syndromes, first-episode psychoses and prolonged psychoses, including psychoses associated with substance use. It takes a holistic approach, addressing all aspects of the care of people with schizophrenia and related disorders, not only correct diagnosis and symptom relief but also optimal recovery of social function. METHODS The writing group planned the scope and individual members drafted sections according to their area of interest and expertise, with reference to existing systematic reviews and informal literature reviews undertaken for this guideline. In addition, experts in specific areas contributed to the relevant sections. All members of the writing group reviewed the entire document. The writing group also considered relevant international clinical practice guidelines. Evidence-based recommendations were formulated when the writing group judged that there was sufficient evidence on a topic. Where evidence was weak or lacking, consensus-based recommendations were formulated. Consensus-based recommendations are based on the consensus of a group of experts in the field and are informed by their agreement as a group, according to their collective clinical and research knowledge and experience. Key considerations were selected and reviewed by the writing group. To encourage wide community participation, the Royal Australian and New Zealand College of Psychiatrists invited review by its committees and members, an expert advisory committee and key stakeholders including professional bodies and special interest groups. RESULTS The clinical practice guideline for the management of schizophrenia and related disorders reflects an increasing emphasis on early intervention, physical health, psychosocial treatments, cultural considerations and improving vocational outcomes. The guideline uses a clinical staging model as a framework for recommendations regarding assessment, treatment and ongoing care. This guideline also refers its readers to selected published guidelines or statements directly relevant to Australian and New Zealand practice. CONCLUSIONS This clinical practice guideline for the management of schizophrenia and related disorders aims to improve care for people with these disorders living in Australia and New Zealand. It advocates a respectful, collaborative approach; optimal evidence-based treatment; and consideration of the specific needs of those in adverse circumstances or facing additional challenges.
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Affiliation(s)
- Cherrie Galletly
- Discipline of Psychiatry, School of Medicine, The University of Adelaide, SA, Australia Ramsay Health Care (SA) Mental Health, Adelaide, SA, Australia Northern Adelaide Local Health Network, Adelaide, SA, Australia
| | - David Castle
- Department of Psychiatry, St Vincent's Health and The University of Melbourne, Melbourne, VIC, Australia
| | - Frances Dark
- Rehabilitation Services, Metro South Mental Health Service, Brisbane, QLD, Australia
| | - Verity Humberstone
- Mental Health and Addiction Services, Northland District Health Board, Whangarei, New Zealand
| | - Assen Jablensky
- Centre for Clinical Research in Neuropsychiatry, School of Psychiatry and Clinical Neurosciences, The University of Western Australia (UWA), Crawley, WA, Australia
| | - Eóin Killackey
- Orygen - The National Centre of Excellence in Youth Mental Health, Parkville, VIC, Australia The University of Melbourne, Melbourne, VIC, Australia
| | - Jayashri Kulkarni
- The Alfred Hospital and Monash University, Clayton, VIC, Australia Monash Alfred Psychiatry Research Centre, Melbourne, VIC, Australia
| | - Patrick McGorry
- Orygen - The National Centre of Excellence in Youth Mental Health, Parkville, VIC, Australia The University of Melbourne, Melbourne, VIC, Australia Board of the National Youth Mental Health Foundation (headspace), Parkville, VIC, Australia
| | - Olav Nielssen
- Psychiatry, Northern Clinical School, The University of Sydney, Sydney, NSW, Australia
| | - Nga Tran
- St Vincent's Mental Health, Melbourne, VIC, Australia Department of Psychiatry, The University of Melbourne, Melbourne, VIC, Australia
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Quintana DS, Westlye LT, Kaufmann T, Rustan ØG, Brandt CL, Haatveit B, Steen NE, Andreassen OA. Reduced heart rate variability in schizophrenia and bipolar disorder compared to healthy controls. Acta Psychiatr Scand 2016; 133:44-52. [PMID: 26371411 DOI: 10.1111/acps.12498] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/11/2015] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Despite current diagnostic systems distinguishing schizophrenia (SZ) and bipolar disorder (BD) as separate diseases, emerging evidence suggests they share a number of clinical and epidemiological features, such as increased cardiovascular disease (CVD) risk. It is not well understood if poor cardiac autonomic nervous system regulation, which can be indexed non-invasively by the calculation of heart rate variability (HRV), contributes to these common CVD risk factors in both diseases. METHOD We calculated HRV in 47 patients with SZ, 33 patients with BD and 212 healthy controls. Measures of symptom severity were also collected from the patient groups. RESULTS Heart rate variability was significantly reduced in both these disorders in comparison with the healthy participants; however, there were no HRV differences between disorders. Importantly, these reductions were independent of the medication, age or body mass index effects. There was also preliminary evidence that patients with reduced HRV had increased overall and negative psychosis symptom severity regardless of SZ or BD diagnosis. CONCLUSION We suggest that HRV may provide a possible biomarker of CVD risk and symptom severity in severe mental illness. Thus, our results highlight the importance of cardiometabolic screening across SZ and bipolar spectrum disorders.
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Affiliation(s)
- D S Quintana
- NORMENT, KG Jebsen Centre for Psychosis Research, Division of Mental Health and Addiction, Oslo University Hospital, University of Oslo, Oslo, Norway
| | - L T Westlye
- NORMENT, KG Jebsen Centre for Psychosis Research, Division of Mental Health and Addiction, Oslo University Hospital, University of Oslo, Oslo, Norway.,Department of Psychology, University of Oslo, Oslo, Norway
| | - T Kaufmann
- NORMENT, KG Jebsen Centre for Psychosis Research, Division of Mental Health and Addiction, Oslo University Hospital, University of Oslo, Oslo, Norway
| | - Ø G Rustan
- NORMENT, KG Jebsen Centre for Psychosis Research, Division of Mental Health and Addiction, Oslo University Hospital, University of Oslo, Oslo, Norway
| | - C L Brandt
- NORMENT, KG Jebsen Centre for Psychosis Research, Division of Mental Health and Addiction, Oslo University Hospital, University of Oslo, Oslo, Norway
| | - B Haatveit
- NORMENT, KG Jebsen Centre for Psychosis Research, Division of Mental Health and Addiction, Oslo University Hospital, University of Oslo, Oslo, Norway
| | - N E Steen
- NORMENT, KG Jebsen Centre for Psychosis Research, Division of Mental Health and Addiction, Oslo University Hospital, University of Oslo, Oslo, Norway.,Drammen Outpatient Clinic, Clinic of Mental Health and Addiction, Vestre Viken Hospital Trust, Drammen, Norway
| | - O A Andreassen
- NORMENT, KG Jebsen Centre for Psychosis Research, Division of Mental Health and Addiction, Oslo University Hospital, University of Oslo, Oslo, Norway
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Shtasel DL, Freudenreich O, Baggett TP. CASE RECORDS of the MASSACHUSETTS GENERAL HOSPITAL. Case 40-2015. A 40-Year-Old Homeless Woman with Headache, Hypertension, and Psychosis. N Engl J Med 2015; 373:2563-70. [PMID: 26699172 DOI: 10.1056/nejmcpc1405204] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Schulz SC, Murray A, Silberschmidt A, Bond DJ. A Multidisciplinary First-Episode Psychosis Program. Psychiatr Ann 2015. [DOI: 10.3928/00485713-20151103-07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Hazen EP, Sherry NA, Parangi S, Rabito CA, Sadow PM. Case records of the Massachusetts General Hospital. Case 10-2015. A 15-year-old girl with Graves’ disease and psychotic symptoms. N Engl J Med 2015; 372:1250-8. [PMID: 25806918 DOI: 10.1056/nejmcpc1314239] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Abstract
Psychosis is one of the most common conditions in later life with a lifetime risk of 23 %. Despite its high prevalence, late-onset psychosis remains a diagnostic and treatment dilemma. There are no reliable pathognomonic signs to distinguish primary or secondary psychosis. Primary psychosis is a diagnosis of exclusion and the clinician must rule out secondary causes. Approximately 60 % of older patients with newly incident psychosis have a secondary psychosis. In this article, we review current, evidence-based diagnostic and treatment approaches for this heterogeneous condition, emphasizing a thorough evaluation for the "six d's" of late-life psychosis (delirium, disease, drugs dementia, depression, delusions). Treatment is geared towards the specific cause of psychosis and tailored based on comorbid conditions. Frequently, environmental and psychosocial interventions are first-line treatments with the judicious use of pharmacotherapy as needed. There is an enormous gap between the prevalence of psychotic disorders in older adults and the availability of evidence-based treatment. The dramatic growth in the elderly population over the first half of this century creates a compelling need to address this gap.
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Stevens JR, Prince JB, Prager LM, Stern TA. Psychotic disorders in children and adolescents: a primer on contemporary evaluation and management. Prim Care Companion CNS Disord 2014; 16:13f01514. [PMID: 25133052 DOI: 10.4088/pcc.13f01514] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Accepted: 11/26/2013] [Indexed: 10/25/2022] Open
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Maloney AE, Yakutis LJ, Frazier JA. Empirical evidence for psychopharmacologic treatment in early-onset psychosis and schizophrenia. Child Adolesc Psychiatr Clin N Am 2012; 21:885-909. [PMID: 23040906 DOI: 10.1016/j.chc.2012.07.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Psychotic symptoms presenting in youth can be clinically complex and require that a child and adolescent psychiatrist use significant skill in making a diagnosis and initiating treatment. There are a number of illnesses to rule out before making a diagnosis of early-onset schizophrenia in particular. Psychosis in youth has significant associated morbidity and places high demands not only on families but also on the medical and educational systems. More effective pharmacologic and nonpharmacologic treatments for psychosis are needed. Nonpharmacologic therapies targeting relatively treatment-resistant domains of dysfunction such as neurocognition are also necessary as adjunctive treatments to our extant pharmacologic agents.
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Affiliation(s)
- Ann E Maloney
- Department of Psychiatry, Child and Adolescent NeuroDevelopment Initiative (CANDI), University of Massachusetts Memorial Health Care, University of Massachusetts Medical School, Worcester, MA, USA.
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Viron M, Baggett T, Hill M, Freudenreich O. Schizophrenia for primary care providers: how to contribute to the care of a vulnerable patient population. Am J Med 2012; 125:223-30. [PMID: 22340915 DOI: 10.1016/j.amjmed.2011.05.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2011] [Accepted: 05/02/2011] [Indexed: 10/14/2022]
Abstract
Patients with schizophrenia represent a vulnerable population with high medical needs that are often missed or undertreated. Primary care providers have the potential to reduce health disparities experienced by this population and make a substantial difference in the overall health of these patients. This review provides primary care providers with a general understanding of the psychiatric and medical issues specific to patients with schizophrenia and a clinically practical framework for engaging and assessing this vulnerable patient population and assisting them in achieving optimal health. Initial steps in this framework include conducting a focused medical evaluation of psychosis and connecting patients with untreated psychosis to psychiatric care as promptly as possible. Given the significant contribution of cardiovascular disease to morbidity and mortality in schizophrenia, a top priority of primary care for patients with schizophrenia should be cardiovascular disease prevention and treatment through regular risk factor screening, appropriate lifestyle interventions, and other indicated therapies.
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Affiliation(s)
- Mark Viron
- Massachusetts General Hospital Schizophrenia Program, Boston, USA.
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Freudenreich O, Basgoz N, Fernandez-Robles C, Larvie M, Misdraji J. Case records of the Massachusetts General Hospital. Case 5-2012. A 39-year-old man with a recent diagnosis of HIV infection and acute psychosis. N Engl J Med 2012; 366:648-57. [PMID: 22335743 DOI: 10.1056/nejmcpc1005311] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Popolo R, Vinci G, Balbi A. Cognitive function, social functioning and quality of life in first-episode psychosis: A 1-year longitudinal study. Int J Psychiatry Clin Pract 2010; 14:33-40. [PMID: 24917230 DOI: 10.3109/13651500903282881] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract Objective. The majority of patients with schizophrenia have cognitive deficits early in the disease. We evaluated the relationship between cognitive function, social functioning and quality of life in patients with first-episode psychosis. Methods. This was a longitudinal study in 15 patients aged 18-30 years who had recently experienced a first psychotic episode and were treated with the atypical antipsychotic aripiprazole, cognitive-behavioural therapy, psycho-educational sessions, family supportive sessions and social interventions. Patients were evaluated at baseline and after 1 year. Cognitive assessment included attention, memory, language skills and problem solving. Social functioning, quality of life, and psychopathological evaluation were performed with validated tools. Results. At baseline, patients had a severe impairment of social functioning and a low quality of life, while a specific pattern of cognitive functions was not identified. After 1-year, we observed a significant improvement in social functioning and quality of life, without a significant decrease in cognitive function. Conclusion. Contrary to previous findings, we found that social functioning and quality of life are related, but independent of cognitive impairment. The use of antipsychotic agents that do not interefere with cognitive function plus psychological assistance is a valuable treatment approach in patients with first-episode schizophrenia.
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Affiliation(s)
- Raffaele Popolo
- Terzo Centro di Psicoterapia Cognitiva, Associazione di Psicologia Cognitiva (APC), Rome, Italy
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Crabb J, McAllister M, Blair A. Who should swing the stethoscope? An audit of baseline physical examination and blood monitoring on new patients accepted by an early intervention in psychosis team. Early Interv Psychiatry 2009; 3:312-6. [PMID: 22642736 DOI: 10.1111/j.1751-7893.2009.00140.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIM It has been established that patients with severe mental illness are at increased risk of physical illness and that physical health screening should be performed when an individual experiences a first episode of psychosis. The aim of the audit was to examine how physical health screening was achieved in the real world of an early intervention in psychosis (EIP) service in Scotland. Of particular interest was considering if primary or secondary care were more effective in providing specific physical health assessment for those presenting to the service. METHODS A case note audit was performed. RESULTS The audit shows that physical examination and blood tests were being completed in the majority of service users under the care of the Esteem service. However, an unacceptably high number were not undergoing sufficient initial screening for metabolic syndrome or having baseline monitoring prior to commencing antipsychotic medication. CONCLUSIONS Our results suggest that relying on primary care to provide physical health screening was not an effective approach in a population experiencing first-episode psychosis. Having a psychiatrist motivated to perform physical health screening within the EIP team may help to improve the uptake of physical health screening. Strategies to improve physical health screening in EIP services are discussed.
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Affiliation(s)
- Jim Crabb
- Department of Liaison Psychiatry, Southern General Hospital, Glasgow, UK
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