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

Childhood trauma and treatment resistance in first-episode psychosis: Investigating the role of premorbid adjustment and duration of untreated psychosis

BACKGROUND

Early identification of treatment non-response in first-episode psychosis (FEP) is essential to outcome. Despite indications that exposure to childhood trauma (CT) can have adverse effects on illness severity, its impact on treatment non-response and the interplay with other pre-treatment characteristics is sparsely investigated. We use a lack of clinical recovery as an early indicator of treatment resistance to investigate the relationship between CT and treatment resistance status at one-year follow-up and the potential mediation of this effect by other pre-treatment characteristics.

METHODS

This prospective one-year follow-up study involved 141 participants recruited in their first year of treatment for a schizophrenia-spectrum disorder. We investigated clinical status, childhood trauma (CT), premorbid adjustment (PA), and duration of untreated psychosis (DUP) at baseline and clinical status at one-year follow-up. Ordinal regression analyses were conducted to investigate how PA and DUP affected the relationship between CT and one-year outcome in FEP.

RESULTS

45 % of the FEP sample reported moderate to severe CT, with significantly higher levels of CT in the early treatment resistant group compared to participants with full or partial early recovery. Ordinal regression analysis showed that CT was a significant predictor of being in a more severe outcome group (OR = 4.59). There was a partial mediation effect of PA and a full mediation effect of DUP on the effect of CT on outcome group membership.

DISCUSSION

Our findings indicate that reducing treatment delays may mitigate the adverse effects of CT on clinical outcomes and support the inclusion of broad trauma assessment in FEP services.

Symptom remission and functional outcome in an Egyptian sample of patients with schizophrenia

Background

The ultimate treatment goal of schizophrenia is regaining patients’ pre-morbid function.

Results

Ninety-three outpatients with schizophrenia, diagnosed according to the criteria of Diagnostic and Statistical Manual of Mental Disorders—fourth edition (DSM-IV), were recruited, of whom 35 patients (37.6%) had achieved the remission severity criteria, whereas 58 patients (62.4%) failed to fulfill the criteria for remission. The functional aspects were examined by the Global Assessment of Functioning scale (GAF) and the Social Functioning Questionnaire (SFQ). Predictors of outcome were examined by applying binary logistic regression analysis. Patients who fulfilled those specific criteria for remission showed a favorable outcome in the assessed areas, regarding GAF and social functioning in society. Lack of judgment or insight item of PANSS showed significantly good functional outcomes.

Conclusion

The results suggest that the remission concept has important implications for the treatment of schizophrenia. Remission seems to be associated with better functional capabilities. However, this does not necessarily mean that remitted patients have “adequate” functioning, especially regarding the social skills domain.

Schizophrenia outcomes in the 21st century: A systematic review

OBJECTIVE

We report a review of outcomes in schizophrenia in the twenty-first century, replicating and extending work undertaken by the late Richard Warner in his seminal book, "Recovery from Schizophrenia: Psychiatry and Political Economy" (1985;2004).

METHOD

Warner's methods were followed as closely as possible. Only observational/naturalistic studies were included. Six scientific databases were searched from 2000 to 2020. 6,640 records were retrieved. 47 met inclusion criteria.

RESULTS

Overall, complete recovery is higher in this study than in Warner's (37.75% cf 20.4%), especially for first episode psychosis (FEP) (57.1% cf 20.7%). Clinical recovery, annualized remission rate (ARR), and employment outcomes were significantly superior for first episode psychosis compared with multiple episode psychosis (MEP). ARR shows a trend toward reduction over time, from 2.2 before the financial crash of 2008 to 1.6 after (t = 1.85 df 40 p = .07). The decline is statistically significant for the MEP group (t = 2.32 df18 p = .03). There were no differences in outcome by region, sample characteristics, outcome measures used, or quality of studies. Heterogeneity of clinical outcome measures across the literature makes evidence synthesis difficult. Weak and inconsistent reporting of functional and employment outcomes mean that findings lack meaning with respect to lived experience.

CONCLUSION

Future research strategies should aim to reduce heterogeneity in clinical outcome measures and to increase the emphasis on capture and reporting of more sophisticated measures of social and functional outcome. Outcome domains should be disaggregated rather than conflated into unitary recovery constructs.

What happens with schizophrenia patients after their discharge from hospital? Results on outcome and treatment from a "real-world" 2-year follow-up trial

Aim of the study was to examine the course of schizophrenia patients within 2 years after discharge. Within a multicenter study of the German Competence Network on Schizophrenia, patients suffering from a schizophrenia spectrum disorder were examined regarding their psychopathological improvement, tolerability, and the treatment regime applied during hospitalization and a 2-year follow-up period. Response, remission, the level of everyday functioning, and relapse were furthermore evaluated during the follow-up period using established definitions for these outcome domains. The psychopharmacological treatment was specifically evaluated in terms of a potential association with relapse. 149 patients were available for analysis, with 65% of the patients being in response, 52% in symptomatic remission, and 64% having a satisfiable everyday functioning 2 years after their discharge from hospital. Despite these favorable outcome rates, 63% of the patients suffered from a relapse within the 2-year follow-up period with 86% of these patients being rehospitalized. Discharge non-responder and non-remitter were twice as likely to relapse during follow-up. A significant decrease of side-effects was observed with negligible rates of extrapyramidal side-effects, sedation, and weight gain during follow-up. Patients receiving treatment with atypical antipsychotics were found to have the lowest risk to relapse (p < 0.0001). The results highlight the natural and unsteady course of schizophrenia in most patients underlining the need to develop more specific treatment strategies ensuring ongoing stability and preventing relapse.

Transition of Substance-Induced, Brief, and Atypical Psychoses to Schizophrenia: A Systematic Review and Meta-analysis

Some people who experience substance-induced psychosis later develop an enduring psychotic disorder such as schizophrenia. This study examines the proportion of people with substance-induced psychoses who transition to schizophrenia, compares this to other brief and atypical psychoses, and examines moderators of this risk. A search of MEDLINE, PsychINFO, and Embase identified 50 eligible studies, providing 79 estimates of transition to schizophrenia among 40 783 people, including 25 studies providing 43 substance-specific estimates in 34 244 people. The pooled proportion of transition from substance-induced psychosis to schizophrenia was 25% (95% CI 18%-35%), compared with 36% (95% CI 30%-43%) for brief, atypical and not otherwise specified psychoses. Type of substance was the primary predictor of transition from drug-induced psychosis to schizophrenia, with highest rates associated with cannabis (6 studies, 34%, CI 25%-46%), hallucinogens (3 studies, 26%, CI 14%-43%) and amphetamines (5 studies, 22%, CI 14%-34%). Lower rates were reported for opioid (12%), alcohol (10%) and sedative (9%) induced psychoses. Transition rates were slightly lower in older cohorts but were not affected by sex, country of the study, hospital or community location, urban or rural setting, diagnostic methods, or duration of follow-up. Substance-induced psychoses associated with cannabis, hallucinogens, and amphetamines have a substantial risk of transition to schizophrenia and should be a focus for assertive psychiatric intervention.

Early recovery in the first 24 months of treatment in first-episode schizophrenia-spectrum disorders

Studies assessing the treatment outcomes in first-episode schizophrenia have reported mixed results. While symptom improvement is frequently robust, when other domains are considered outcomes are generally poorer. We explored response trajectories, rates and predictors of recovery in the domains of core psychopathology, clinician-rated social and occupational functioning and patient-rated quality of life over 24 months of treatment in 98 patients with first-episode schizophrenia spectrum disorders who were treated with a long-acting antipsychotic medication. There was robust improvement in core psychopathology (effect size d = 3.36) and functionality (d = 1.78), with most improvement occurring within the first six months of treatment. In contrast, improvement in subjective quality of life was less marked (d = 0.37) and slower, only reaching significance after 12 months of treatment. Symptom remission was achieved by 70% of patients and over half met our criteria for functional remission and good quality of life. However, only 29% met the full criteria for recovery. Patients who met the recovery criteria had better premorbid adjustment, were less likely to be of mixed ethnicity and substance use emerged as the only modifiable predictor of recovery. Only 9% of our sample achieved both functional remission and good quality of life despite not being in symptom remission. We found high rates of symptom remission, functional remission and good quality of life in patients, although relatively few achieved recovery by meeting all three of the outcome criteria. Symptom remission is not a necessary prerequisite for functional remission and good quality of life, although few non-remitters achieve other recovery criteria.

Association of Pre-onset Subthreshold Psychotic Symptoms With Longitudinal Outcomes During Treatment of a First Episode of Psychosis

IMPORTANCE

The clinical high-risk state in psychosis is most often characterized by subthreshold psychotic symptoms (STPS) and represents a target for psychosis prevention. However, evidence suggests that between 30% and 50% of patients with a first episode of psychosis (FEP) report no prior history of STPS, indicating that not all patients with FEP experience a previous clinical high-risk phase. As with other early characteristics of illness onset, this diversity in the early course of symptoms may offer prognostic value for subsequent clinical trajectories.

OBJECTIVE

To determine whether a history of pre-onset STPS is associated with differential 1-year treatment outcomes in an early intervention service for FEP.

DESIGN, SETTING, AND PARTICIPANTS

Data on 195 patients 15 to 35 years of age who were recruited between January 17, 2003, and October 17, 2013, were collected from a catchment-based specialized early intervention service for FEP. Patients who reported experiencing at least 1 STPS prior to the onset of FEP were identified as STPS present (STPSp; n = 135); those who reported no such history were identified as STPS absent (STPSa; n = 60). Statistical analysis was conducted from December 15, 2016, to February 15, 2018.

MAIN OUTCOMES AND MEASURES

Summary scores on the Scale for the Assessment of Positive Symptoms and the Scale for the Assessment of Negative Symptoms, Calgary Depression Scale for Schizophrenia, Hamilton Anxiety Rating Scale, Global Assessment of Functioning scores, and Social and Occupational Functioning Assessment Scale scores at baseline and after 1 year of treatment were analyzed to evaluate 1-year outcomes.

RESULTS

Individuals in the STPSp group (39 female and 96 male participants; mean [SD] age, 23.4 [4.2] years) and the STPSa group (20 female and 40 male participants; mean [SD] age, 23.9 [5.1] years) did not differ in symptom severity or functioning at baseline. Although both groups improved by 1 year of treatment, mixed analyses of covariance (controlling for duration of untreated psychosis) revealed group-by-time interactions for scores on the Scale for the Assessment of Negative Symptoms (F1,192 = 6.17; P = .01), the Global Assessment of Functioning (F1,188 = 7.54; P = .006), and the Social and Occupational Functioning Assessment Scale (F1,192 = 3.79; P = .05). Mixed analyses of covariance also revealed a group effect for scores on the Scale for the Assessment of Positive Symptoms (F1,192 = 5.31; P = .02). After controlling for multiple comparisons, all significant results indicate poorer 1-year outcomes for patients with STPSp compared with patients with STPSa.

CONCLUSIONS AND RELEVANCE

A history of pre-onset STPS consistent with a prior clinical high-risk state is associated with poorer outcomes in psychotic symptoms and global functioning for patients after 1 year of treatment for FEP. The presence or absence of pre-onset STPS therefore has prognostic value for treatment outcomes, even during a later stage of psychotic illness.

Recommendations for the optimal care of patients with recent-onset psychosis in the Asia-Pacific region

Providing optimal care to patients with recent-onset psychosis can improve outcomes and reduce relapse. However, there is a lack of consistency of the implementation of guidelines for such patients across the Asia-Pacific region. We determined a pragmatic set of recommendations for use on a day-to-day basis to help provide optimal care at this crucial stage of illness. The recommendations were developed over a series of meetings by an international faculty of 15 experts from the Asia-Pacific region, Europe, and South Africa. A structured search of the PubMed database was conducted. This was further developed based on the faculty's clinical experience and knowledge of the literature into 10 key aspects of optimal care for patients during the first five years of a diagnosis of a psychotic disorder, with particular relevance to the Asia-Pacific region. Several common principles emerged: adherence to antipsychotic medications is crucial; substance abuse, psychiatric and medical comorbidities should be addressed; psychosocial interventions play a pivotal role; and family members can play a vital role in overall patient care. By following these recommendations, clinicians may improve outcomes for patients with recent-onset psychosis.

Predictors of functional outcome in individuals at high clinical risk for psychosis at six years follow-up

BACKGROUND

The long-term functional status of subjects at ultra high risk for psychosis (HR) is relatively under investigated. This study explores baseline predictors of long-term functional outcome in HR subjects who did not convert to psychosis during a 6 years follow-up period.

METHODS

A total of 154 HR were followed up for an average of 6 years. The primary outcome variable was global assessment of functioning at the last follow-up visit as assessed with the Global Assessment of Functioning tool. A multinomial logistic regression was performed to identify potential predictors of functional outcome.

RESULTS

Baseline and follow-up data on functioning was available for 92 HR. Twenty-four (43%) individuals who did not convert to psychosis reported poor functioning at follow-up. Baseline scores in the GAF (Exp(b) = 0.857; 95% CIs: 0.75/0.97), employment status (Exp(b) = 0.029; 95% CIs: 0.00/0.268), and CAARMS total scores (Exp(b) = 1.976; 95% CIs: 1.00/1.14) predicted functional outcome in HR subjects at 6 years.

CONCLUSIONS

Despite the preventive treatments received, many individuals who did not convert to full-blown psychosis in the longer term do not functionally remit. These individuals are lower functioning, unemployed and have higher symptom loading at the time of their presentation to the prodromal clinic. Our study suggests the need for innovative treatments targeting long term functional status beyond the prevention of psychosis onset in the HR population.

MRI predicts remission at 1 year in first-episode schizophrenia in females with larger striato-thalamic volumes

BACKGROUND/AIMS

The Remission in Schizophrenia Working Group has defined remission as 'a low-mild symptom intensity level, maintained for a minimum of 6 months, where such symptoms do not affect an individual's behaviour' [Andreasen et al.: Am J Psychiatry 2005;162:441-449]. Since brain morphology relates to symptomatology, treatment and illness progression, MRI may assist in predicting remission.

METHODS

Thirty-nine patients newly diagnosed with DSM-IV schizophrenia underwent MRI brain scan prior to antipsychotic exposure. The Global Assessment of Functioning (GAF) score was entered into a voxel-based analysis to evaluate its relationship with cerebral grey matter volume from the baseline MRI. We entered age, total intracranial volume and intake GAF score as co-variates. Males and females were analysed separately because gender is a potent determinant of outcome.

RESULTS

Males had lower GAF scores than females, both at intake and at 1 year. Males comprised only 40% (12 out of 39) of the early remission group. For females only, early remission was strongly and positively correlated with bilateral lentiform and striatal volumes. For males, there was no such relationship.

CONCLUSION

Larger striato-thalamic volume correlated with early remission in females only. These baseline MRI findings were unlikely to be confounded by antipsychotic treatment and chronicity. These brain morphological markers show gender dimorphism and may assist in the prediction of early remission in newly diagnosed schizophrenia.

High relapse rate and poor medication adherence in the Chinese population with schizophrenia: results from an observational survey in the People's Republic of China

BACKGROUND

Relapse is common in schizophrenia, and seriously impacts patients' quality of life and social functioning. Many factors have been identified that may potentially increase the risk of relapse. This study was designed to investigate the relapse rate in the year following hospital discharge among Chinese patients with schizophrenia in the naturalistic condition, and to explore possible risk factors related to relapse.

METHODS

We conducted a large, multicenter, retrospective, observational study in ten psychiatric hospitals throughout the People's Republic of China. Nine hundred and ninety-two schizophrenic outpatients aged 18-65 years discharged from these hospitals between September 2011 and February 2012 with recovery/improvement of their condition were included in the study. Information about relapse and correlative factors during the year after discharge was collected by telephone interview using a questionnaire.

RESULTS

Eight hundred and seventy-six of 992 eligible patients completed the telephone survey. Of these patients, 293 (33.4%) had at least one relapse within 1 year after discharge, and 165 (18.8%) were rehospitalized. In respondents' view, the most important factor contributing to relapse was poor medication adherence (50.7%). Approximately 30% of the respondents had a negative attitude toward medication, with the impression that there was no need to take drugs at all or for a long time. Nonadherent patients (37.9%) had a relapse rate that was 2.5-fold higher than adherent patients (54.5% versus 20.7%, P<0.001). The top five risk factors associated with relapse were nonadherence to medication (odds ratio [OR] 4.602, 95% confidence interval [CI] 3.410-6.211), being without work (OR 3.275, 95% CI 2.291-4.681), poor self-care ability (OR 2.996, 95% CI 2.129-4.214), poor interpersonal skills (OR 2.635, 95% CI 1.951-3.558), and hospitalization on more than three occasions (OR 2.299, 95% CI 1.691-3.126).

CONCLUSION

The 1-year relapse rate after discharge in patients with schizophrenia was 33.5% in our study. The most important risk factor related to relapse was poor medication adherence, which was mainly due to patients having a negative attitude toward their medication. Lack of psychosocial support and a complicated disease history also increased the risk of relapse.

Which aspects of long-term outcome are predicted by positive and negative symptoms in early-onset psychosis? An exploratory eight-year follow-up study

BACKGROUND

Early-onset psychoses show substantial variability of diagnostic and functional outcome. Finding reliable prognostic factors may allow to allocate resources to those with the worst prognosis. The aim of the study was to gain new insights regarding the potential value of baseline negative and positive symptoms as predictors of outcome in psychoses of early onset.

METHOD

Sixty-three patients with early-onset schizophrenia spectrum psychosis hospitalized in an adolescent psychiatry unit were assessed with the Positive and Negative Syndrome Scale during the index admission. Associations with diagnosis, illness course and functional outcome were analysed in mean 8 years of follow-up (range 3.4-13.5 years).

RESULTS

The mean age at the index admission and the follow-up was 16.6 ± 1.2 and 24.5 ± 3.0 years, respectively. A significant majority of subjects continued psychiatric treatment (95%) and had been readmitted (71%). The mortality rate was 3% (suicide and accident). Negative symptoms were related to mental health service utilization during the follow-up. General severity of symptoms, specifically positive and cognitive factors were associated with the diagnosis of schizophrenia and inversely with diagnostic shift outside the schizophrenia spectrum at the catamnesis. Poor impulse control at baseline was associated with worse functional outcome. The drug-free subgroup with no occupational/educational activity compared with the drug-treated subjects showed lower levels of baseline negative symptomatology.

CONCLUSION

The study findings suggest that in patients with early-onset psychosis negative and positive symptoms show a differential prognostic value. Pharmacotherapy may attenuate the effect of symptoms on functional outcome. These hypotheses need to be tested in future studies using confirmatory approaches.

Self-reported attenuated psychotic-like experiences in help-seeking adolescents and their association with age, functioning and psychopathology

OBJECTIVE

Self-rated attenuated psychotic-like experiences (APLEs) are increasingly used to screen for ultra-high-risk (UHR) across all ages. However, self-rated psychotic-like experiences (PLEs), in particular perception-related ones, were more frequent in children and adolescents, in which they possessed less clinical significance. We therefore explored the prevalence of different factors of APLEs in help-seeking adolescents, and their relationship with age, functioning and psychopathology.

METHOD

As a part of the "Liberiamo il Futuro" project, help-seeking adolescents (N=171; 11-18 years, 53% male) were screened with the 92-item Prodromal Questionnaire (PQ-92). A factor analysis was performed on the PQ-92 positive items (i.e., APLEs) to identify different APLE-factors. These were assessed for their association with age, functioning and psychopathology using regression analyses.

RESULTS

APLEs were very common in help-seeking adolescents, and formed four factors: "Conceptual Disorganization and Suspiciousness", "Perceptual Abnormalities", "Bizarre Experiences", and "Magical Ideation". Associations with age and functioning but not psychopathology were found for "Perceptual Abnormalities" that was significantly more severe in 11-12-year-olds, while "Conceptual Disorganization and Suspiciousness" was significantly related to psychopathology.

CONCLUSION

In line with findings on PLEs, prevalence and clinical significance of APLEs, especially perception-related ones, might depend on age and thus neurodevelopmental stage, and may fall within the normal spectrum of experience during childhood. This should be considered when screening for UHR status in younger age groups.

Empowerment and its associations in schizophrenia: a cross-sectional study

Empowerment denotes a sense of personal competence which is considered an essential requisite of fair outcome in schizophrenia. The current study assessed empowerment along with other relevant variables in patients with schizophrenia and a comparison group. Hierarchical multiple linear regression analysis identified independent living skills survey score and perceived social support as predicting empowerment in patients with schizophrenia, suggesting a correlational relationship. Empowerment could be a treatment goal in schizophrenia and independent living skills as well as perceived social support could be the mediating factors.

Predictors of clinical remission following a first episode of non-affective psychosis: sociodemographics, premorbid and clinical variables

The aim of the study was to identify predictors associated with a lower likelihood of achieving a clinical remission 1 year after the first break of the illness. Participants were 174 consecutive subjects included in a first episode programme with no prior treatment with antipsychotic medication. Patients were assigned to haloperidol, olanzapine or risperidone in a randomized, open-label, prospective clinical trial. The main outcome variable was the remission criteria developed by the Remission in Schizophrenia Working Group. Clinical variables were included in a logistic regression analysis in order to predict the remission state at 1 year. At 1 year, 31% of patients met criteria for remission. The logistic regression analysis revealed that the strongest predictors of achieving clinical remission 1 year away from a first episode of non-affective psychosis were the length of duration of untreated psychosis (DUP), the severity of negative symptomatology and the educational level attained at baseline. The results suggest that: (1) patients with a lengthy DUP, a greater severity of negative symptomatology at baseline and with a lower education level are in a higher risk of not achieving a clinical remission during the first year of treatment; and (2) early intervention clinical programs should aim to reduce the length of DUP in order to provide a better outcome for patients.

One-year functional outcomes of naturalistically treated patients with schizophrenia

Against the background of the growing evidence that the patient's functioning significantly influences the course and outcome of schizophrenia, the aims of this analysis were to examine what proportion of patients achieve functional outcome criteria after 1 year, and to identify clinical and sociodemographic predictive factors for functional remission. Patients with the diagnosis of schizophrenia who were treated as inpatients at the beginning of the study were examined within a naturalistic follow-up trial. The present study reports on the time frame from admission to discharge of an inpatient treatment period and the 1-year follow-up assessment. The Global Assessment of Functioning (GAF) Scale and Social and Occupational Functioning Assessment Scale (SOFAS) were evaluated with respect to functional outcome, whereas Positive and Negative Syndrome Scale (PANSS) scores were rated as psychopathological outcome measures. Functional remission thresholds were defined according to a GAF score of ≥61 points and a SOFAS score ≥61 points. Symptomatic remission criteria were applied according to the remission criteria of the Schizophrenia Working Group. The Strauss-Carpenter Prognostic Scale (SCPS), the Phillips Premorbid Adjustment Scale, medical history, sociodemographic and psychopathologic parameters were evaluated in order to find valuable predictors for functional remission. One year after discharge from inpatient treatment, 211 out of 474 patients were available for analysis according to both rating scales used to assess functional remission (GAF and SOFAS). Forty-seven percent of patients fulfilled criteria for functional remission (GAF and SOFAS) at discharge and 51% of patients at the 1-year follow-up visit. With regard to symptomatic remission criteria, the corresponding remitter rates were 61% of patients at discharge and 54% at the 1-year follow-up visit. Forty-two percent of patients fulfilled both remission criteria at discharge and 37% at the 1-year follow-up visit. A significant association was found between functional and symptomatic remission at discharge and at the 1-year follow-up visit. The strongest predictors for functional remission at the 1-year follow-up visit were: a higher SCPS total score at admission, a lower number of previous hospitalizations, a status of employment, lower scores in all PANSS subscales at discharge, a better premorbid social adjustment, the occurrence of a first psychotic episode, a younger age, a lower PANSS negative subscore at admission, a status of being an early responder, a shorter duration of inpatient treatment, a later age of onset, and female gender.

Functional outcomes in schizophrenia: employment status as a metric of treatment outcome

The importance of an adequate and satisfying level of functioning for the course and outcome of schizophrenia has been increasingly emphasized by researchers in recent years. Employment status is a major component of the patient's functioning and is generally believed to be essential for well-being, satisfaction in life, and a better prognosis for schizophrenia illness. This article summarizes recent relevant publications concerning the employment status of schizophrenia patients and its influence on treatment outcome. Given the significant link between employment status and outcome in schizophrenia, different influencing factors of employment are discussed, as they mirror potential treatment targets. Finally, currently available treatment strategies for the improvement of employment status are outlined.

[Response and remission in schizophrenic subjects]

BACKGROUND

This naturalistic study investigates in detail symptom reduction during acute inpatient treatment (response), long-term symptom improvement in the post-acute phase (remission) and the rate of re-hospitalisations.

MATERIAL AND METHODS

A total of 183 patients were enrolled. Criteria for response were PANSS total score and syndrome reductions of 20, 30, 40 and 50%. Remission criteria employed were based on recommendations from Andreasen et al.

RESULTS

The average length of stay was 45.6 days (SD 42.7). PANSS total score response rates were found to be 63.9% for the 20% level and were reduced in the following consecutive levels by approximately 15%. Only 10.3% of the patients remitted during a 1-year follow-up period. At least one re-hospitalisation was reported for 43.9% of the subjects.

CONCLUSION

Compared to previous randomised and controlled trials, the rates of response and remission are significantly lower. In daily inpatient care, the chronic course of schizophrenia is far commoner than expected from previous reports.

Neurological soft signs and gray matter changes: a longitudinal analysis in first-episode schizophrenia

Neurological soft signs (NSS) - i.e. discrete deficits of sensory and motor function - are frequently found in schizophrenia and vary with psychopathological symptoms in the course of the disorder. Hence, persistence of NSS herald chronicity in first episode schizophrenia. To investigate the cerebral correlates of persisting NSS over time, 20 patients with first-episode schizophrenia underwent T1 magnetic resonance imaging (MRI) after remission of the acute symptoms and after 1 year of follow-up. NSS were rated on the Heidelberg Scale. Twenty age- and gender-matched control subjects were scanned once. Longitudinal gray matter (GM) changes were measured by using tensor based morphometry (TBM). At follow-up, patients demonstrated significantly decreased NSS scores. For further analysis, the patient sample was dichotomized into patients with decreasing NSS scores and patients with persistently increased scores, respectively. While patients with decreasing NSS exhibited only localized changes within the left frontal lobe, cerebellum, and cingulate gyrus, patients with persistently increased scores showed pronounced GM reductions of the sub-lobar claustrum, cingulate gyrus, cerebellum, frontal lobe, and middle frontal gyrus. Results were confirmed after correction for multiple comparisons. These findings support the hypothesis that persisting NSS refer to progressive cerebral changes in first-episode schizophrenia. Since NSS can be assessed in any clinical environment, this association facilitates the prospect that NSS can help to establish prognosis in first-episode patients with schizophrenia.

Remission and recovery during the first outpatient year of the early course of schizophrenia

BACKGROUND

Although in the early course of schizophrenia relapse prevention is of paramount importance, there is an increasing emphasis on establishing and maintaining sustained periods of symptom remission. Recovery in the early course of illness is also possible, although the rates of recovery are lower than for symptom remission. Symptom remission and recovery rates vary considerably across recent-onset schizophrenia studies because of a lack of consistency in treatment interventions and in applying operational outcome criteria.

METHOD

Patients who were within two years of their first psychotic episode (N=77) that were treated with continuous antipsychotic medication in conjunction with psychosocial interventions (without targeted work rehabilitation) were assessed during the first outpatient year after hospital discharge. Published operational criteria were used to classify symptom remission and recovery.

RESULTS

The rate of full symptom remission maintained for 6 months was 36%, while the rate of recovery for 6 months was 10%. When the same criteria were applied for a continuous period of one year, 22% of patients were found to achieve symptom remission but only 1% of patients met recovery criteria. Using multivariate prediction, the WAIS Comprehension score was a significant predictor of 6 months of good functional outcome.

CONCLUSIONS

Although some schizophrenia patients can achieve both symptom remission and recovery in the early course of illness, the overall rate of symptom remission during the first post-hospitalization year is much higher than the rate of recovery. This suggests that interventions targeting work and social functioning are likely necessary to raise the chances of recovery. Cognitive factors can be predictive of good functional outcome even in the early course of schizophrenia.

Second-generation antipsychotic discontinuation in first episode psychosis: an updated review

"All-causes discontinuation" refers to discontinuation of treatment for any reason, and medication adherence is an important component of this measure. Similar to our previous results, we found that almost 30% of patients with first-episode psychosis (FEP) discontinue medication in the first 9 months of treatment, a finding that has important implications for long-term outcomes. Many newer second-generation antipsychotics have not been studied in FEP. The self-reported Drug Attitude Inventory may help identify patients at heightened risk for medication discontinuation. In addition to vigilant monitoring for and adequate treatment of psychopathology and medication side effects, Relapse Prevention Therapy and the use of long-acting injectable agents may be effective interventions decrease discontinuation rates in FEP. There is currently no consensus on how long a patient should remain on an antipsychotic medication following remission of FEP. Studies are needed to identify predictors of which patients in remission from FEP are less likely to relapse when medication is discontinued. Taken together, our findings presented here underscore the importance of addressing medication discontinuation both as a means of preventing long-term morbidity and enhancing remission and functional recovery in FEP.

Remission after first-episode schizophrenia: results of a long-term follow-up

The aim of this study was to identify the rate and predictors of remission after first episode of schizophrenia (FES). Ninety-three FES patients were followed for at least 12 months and up to 12 years (mean=58.4 months) including monthly assessments with the Brief Psychiatric Rating Scale-Expanded (BPRS), the Scale for the Assessment of Positive Symptoms (SAPS), and Scale for the Assessment of Negative Symptoms (SANS). We also administered the Premorbid Adjustment Scale (PAS). We used the remission criteria recently defined by Andreasen et al. (2005). Fifty-six (59.5%) patients met the remission criteria in the first 24 months of the follow-up period, but 40 (71.5%) of these patients could not maintain their status. However, 23 (57%) of these patients later met the remission criteria again. The remission group patients achieved a higher rate of employment both in the first year and overall. In the logistic regression analysis, lower negative and higher positive symptoms at admission, lower positive symptoms at month 3 of the follow-up, medication compliance in the first 6 months, and occupational status during the last month before admission were found related to remission status. Our findings suggest that the remission group has advantages in terms of occupational status and symptom severity compared with their counterparts who did not achieve or maintain a state of remission.

Remission in schizophrenia: validity, frequency, predictors, and patients' perspective 5 years later

In March 2005, the Remission in Schizophrenia Working Group (RSWG) proposed a consensus definition of symptomatic remission in schizophrenia and developed specific operational criteria for its assessment. They pointed out, however, that the validity and the relationship to other outcome dimensions required further examination. This article reviews studies on the validity, frequency, and predictors of symptomatic remission in schizophrenia and studies on patients' perspectives. These studies have demonstrated that the RSWG remission criteria appear achievable and sustainable for a significant proportion of patients, and are related to a better overall symptomatic status and functional outcome and, to a less clear extent, to a better quality of life and cognitive performance. However, achieving symptomatic remission is not automatically concurrent with an adequate status in other outcome dimensions. The results of the present review suggest that the RSWG remission criteria are valid and useful. As such, they should be consistently applied in clinical trials. However, the lack of consensus definitions of functional remission and adequate quality of life hampers research on their predictive validity on these outcome dimensions. Future research should therefore search for criteria of these dimensions and test whether the RSWG remission criteria consistently predict a “good” outcome with respect to functioning and quality of life.

Remission, prediction and stability of symptoms in schizophrenia: A naturalistic 12-month follow-up study

Abstract Objective. Since its introduction in 2005, schizophrenia remission consensus criteria have been used in several prospective and cross-sectional studies. The aim of this prospective assessment of patients with schizophrenia was to employ the remission criteria in a naturalistic study design. Methods. One hundred and six patients with schizophrenia (ICD10 F 20.x) were enrolled into the study during inpatient treatment. Remission criteria with respect to changes in psychopathology ratings were obtained by trained interviewers at discharge and at 12-month follow-up using BPRS. Furthermore, information on social functioning and treatment-related quality of life were assessed using GAF (Global Assessment of Functioning) and SWN-K (Subjective Wellbeing under Neuroleptic Treatment Scale). Results. A total of 13.2% of the patients were found to meet remission criteria during follow-up. While there was no significant change in the mean BPRS scores, 14.2% of the subjects showed significant worsening and 29.2% significant improvement of their psychotic symptoms. Subsequent logistic regression analysis, explaining approximately 32% of symptomatic remission variance, indicated a significant influence of BPRS-Overall-Score and independent living at discharge. Conclusions. The results of this naturalistic study indicate that only a minority of former inpatients with schizophrenia achieve remission after 1 year and relevant subgroups of patients have significant bi-directional changes in symptoms during follow-up.

Defining and predicting functional outcome in schizophrenia and schizophrenia spectrum disorders

BACKGROUND

To assess criteria and to identify predictive factors for functional outcome. The criteria should cover all domains proposed by the Remission in Schizophrenia Working Group.

METHOD

PANSS ratings were used to evaluate the symptomatic treatment outcome of 262 inpatients with schizophrenia spectrum disorders within a naturalistic multicenter trial. Functional remission was defined as a GAF score >61 (Global Assessment of Functioning Scale), SOFAS score >61 (Social and Occupational Functioning Scale) and a SF-36 mental health subscore >40 (Medical Outcomes Study-Short Form Health Survey). Multivariate logistic regression and CART analyses were used to determine valid clinical and sociodemographic predictors.

RESULTS

In total, 52 patients (20%) fulfilled the criteria for functional remission, 125 patients (48%) achieved symptomatic resolution and when criteria for functional remission and symptomatic resolution were combined 33 patients (13%) achieved complete remission. Younger age, employment, a shorter duration of illness, a shorter length of current episode, less suicidality, and a lower PANSS negative and global subscore at admission were predictive of functional remission. The regression model showed a predictive value of more than 80%.

CONCLUSIONS

A significant association was found between functional remission and symptomatic resolution, indicating reasonable validity of the proposed definition for functional outcome. The revealed predictors for functional treatment outcome emphasize the need for psychosocial and vocational rehabilitation in schizophrenic patients.

Risperidone long-acting injection: a review of its long term safety and efficacy

A long-acting form of the second-generation antipsychotic drug risperidone is now broadly available for the treatment of schizophrenia and closely related psychiatric conditions. It combines the advantage of previously available depot formulations for first-generation drugs with the favorable characteristics of the modern "atypical" antipsychotics, namely higher efficacy in the treatment of the negative symptoms of schizophrenia and reduced motor disturbances. Published clinical studies show an objective clinical efficacy (as per psychiatric symptom scores and relapse data) that exceeds that of oral atypical antipsychotics when patients are switched to the long-acting injectable form, a low incidence of treatment-emergent extrapyramidal side effects, and very good acceptance by patients. Available data for maintenance treatment of bipolar disorder show equivalence with the oral form instead of superiority, but are still limited. As it seems likely that efficacy benefits are mostly due to the fact that the injectable form reduces the demand for patient compliance to one physician visit every 2 weeks instead of self-administration on a daily or twice-daily basis, additional potential could exist in other psychiatric disorders where atypical antipsychotic drugs are of benefit but where patient adherence to treatment schedules is typically low.

A review of second-generation antipsychotic discontinuation in first-episode psychosis

"All-causes discontinuation" refers to discontinuation of treatment for any reason, and adherence to medication is an important component of this measure. Two recent landmark studies suggest that adherence is a major issue in patients with first-episode psychosis (FEP) right from the onset of treatment. In this review, the incidence, reasons for, and clinical outcomes of medication discontinuation in FEP are considered. More than 40% of patients with FEP discontinue medication during the first 9 months of treatment, at which point the chances of relapse increase dramatically. Findings concerning predictors of medication discontinuation in this patient population that have been replicated in more than one study include severity of psychopathology, lack of insight into illness, negative attitudes towards medications, comorbid substance use, and medication side effects. Interventions that have the potential to decrease discontinuation rates in patients with psychotic disorders include orally disintegrating tablets, long-acting injectable drugs, cognitive-behavioral therapy, compliance therapy, family support/intervention, and peer support, although these strategies have largely been unexplored in FEP. In addition to the question of medication discontinuation in the acute treatment of FEP, another important issue is how long patients with FEP should be treated with antipsychotics once they have achieved remission; unfortunately, little evidence is available to guide the decision as to whether medication should be discontinued or maintenance treatment provided in this situation. Studies are therefore needed to identify predictors of patients with remitted FEP who are less likely to relapse when medication is discontinued. Taken together, the findings presented in this article underscore the importance of addressing issues related to medication discontinuation as a means of preventing long-term morbidity and enhancing remission and functional recovery in FEP.