Long-term outcome of patients with schizophrenia: a review

Characterizing Schizophrenia Spectrum Disorders: Results of the U.S. Mental and Substance Use Disorders Prevalence Study

OBJECTIVE

Current information on treatment and clinical characteristics of U.S. adults with schizophrenia spectrum disorders (i.e., schizophrenia, schizoaffective, and schizophreniform disorders) may help inform public health policy and service development for this population.

METHODS

Data were from the U.S. Mental and Substance Use Disorders Prevalence Study, conducted from October 2020 to October 2022. Clinicians administered the Structured Clinical Interview for the DSM-5 for past-year psychiatric and substance use disorder diagnoses among adults ages 18-65 years. Using sampling weights, the authors examined clinical and treatment characteristics among those with schizophrenia spectrum disorders and compared sociodemographic characteristics and comorbid behavioral health conditions of individuals with or without such disorders (N=4,764).

RESULTS

Among 114 adults with schizophrenia spectrum disorders, the most common comorbid conditions were major depressive episode (52%, 95% CI=34%-69%) and alcohol use (23%, CI=3%-43%), cannabis use (20%, 95% CI=1%-39%), and posttraumatic stress (17%, 95% CI=5%-30%) disorders. Global Assessment of Functioning scores were lower among people with than among those without schizophrenia spectrum disorders (mean±SE=44.8±2.0 vs. 77.2±0.5, p<0.01, respectively), indicating worse functioning. In the past year, 71% (95% CI=55%-87%) of adults with schizophrenia spectrum disorders received at least some mental health treatment, and 26% (95% CI=13%-38%) received minimally adequate treatment.

CONCLUSIONS

Individuals with schizophrenia spectrum disorders face substantial challenges in the United States, including high rates of comorbid mental health conditions and substance use; few received adequate treatment. A strong social safety net and active clinical interventions are required to address the socioeconomic challenges and unmet mental health service needs of this population.

Modelling the longitudinal dynamics of paranoia in psychosis: A temporal network analysis over 20 years

BACKGROUND

Paranoia is a key feature of psychosis that can be highly debilitating. Theories of paranoia mostly interface with short-scale or cross-sectional data models, leaving the longitudinal course of paranoia underspecified.

METHODS

We develop an empirical characterisation of two aspects of paranoia - persecutory and referential delusions - in individuals with psychosis over 20 years. We examine delusional dynamics by applying a Graphical Vector Autoregression Model to data collected from the Chicago Follow-up Study (n = 135 with a range of psychosis-spectrum diagnoses). We adjusted for age, sex, IQ, and antipsychotic use.

RESULTS

We found that referential and persecutory delusions are central themes, supported by other primary delusions, and are strongly autoregressive - the presence of referential and persecutory delusions is predictive of their future occurrence. In a second analysis we demonstrate that social factors influence the severity of referential, but not persecutory, delusions.

IMPLICATIONS

We suggest that persecutory delusions represent central, resistant states in the cognitive landscape, whereas referential beliefs are more flexible, offering an important window of opportunity for intervention. Our data models can be collated with prior biological, computational, and social work to contribute toward a more complete theory of paranoia and provide more time-dependent evidence for optimal treatment targets.

Factors associated with recovery during schizophrenia and related disorders: A review of meta-analysis

BACKGROUND

The spectrum of schizophrenia disorders (SSD) is a severe mental disorder. It is one of the main medical causes of disability that generates high health and social costs.

OBJECTIVE

To analyze the factors associated with clinical recovery (CR) (symptomatic remission-SR and functional recovery-FR) and personal recovery (PR) in people diagnosed with SSD.

METHODS

14 meta-analyses focused on recovery were reviewed following the PRISMA model statements. 95 % of CI was established.

RESULTS

Shorter Duration of Untreated Psychosis (Zr = 0.24, [0.17, 0.30]) and total Duration of Untreated Illness (Zr = 0.34, [0.20, 0.48]) were related to greater SR and general functioning, respectively. Resilience was the variable with the greatest effect on FR (Zr = 0.67, [0.63, 0.71]). Premorbid adjustment (Zr = 0.34, [0.18, 0.49]) and physical intervention (Zr = 0.71, [0.55, 0.86]) had the greatest effect on occupational and social functioning, respectively. Less severe affective symptoms were related to greater PR (Zr = 0.46, [0.42, 0.50]). There are differences between affective SR and the other types of SR (Zr(SR-A - SR-) = 0.13, Qb = 6.51, p = 0.011), (Zr(SR-A - SR+) = 0.20, Qb = 8.52, p = 0.004), (Zr(SR-A - SR) = 0.18, Qb = 19.29, p = 0.0001). In all, resilience was associated with greater recovery (Zr = 0.67, [0.53, 0.80]), with the global effect being greater on PR than on CR (Zr(PR-CR) = 0.07, Qb = 3.45, p = 0.05).

CONCLUSIONS

Resilience was the variable most strongly associated with recovery. Symptomatic or functional improvement obtained less statistical weight.

Family Fellowship Society for Psychosocial Rehabilitation Services (1993-2019): A Self-help Movement

Family Fellowship Society for Psychosocial Rehabilitation Services is an initiative of families of persons with mental illness and with psychiatric disabilities. It has been advocating self-help movement on the part of the families who have been on the lookout for alternative care services. This venture has been technically supported by the mental health professionals at National Institute of Mental Health and Neurosciences, Bangalore. It is a collaborative effort of families and professionals to address the needs that have been felt by the consumers and the professionals. It is the first of its kind in India. Over a period of 26 years, 150 + families have availed the alternative care for psychosocial rehabilitation services for their wards. In this context, an attempt was made to enlighten the psychosocial rehabilitation services at family fellowship society.

Conceptualizing a less paranoid schizophrenia

Schizophrenia stands as one of the most studied and storied disorders in the history of clinical psychology; however, it remains a nexus of conflicting and competing conceptualizations. Patients endure great stigma, poor treatment outcomes, and condemnatory prognosis. Current conceptualizations suffer from unstable categorical borders, heterogeneity in presentation, outcome and etiology, and holes in etiological models. Taken in aggregate, research and clinical experience indicate that the class of psychopathologies oriented toward schizophrenia are best understood as spectra of phenomenological, cognitive, and behavioral modalities. These apparently taxonomic expressions are rooted in normal human personality traits as described in both psychodynamic and Five Factor personality models, and more accurately represent explicable distress reactions to biopsychosocial stress and trauma. Current categorical approaches are internally hampered by axiomatic bias and systemic inertia rooted in the foundational history of psychological inquiry; however, when such axioms are schematically decentralized, convergent cross-disciplinary evidence outlines a more robust explanatory construct. By reconceptualizing these disorders under a dimensional and cybernetic model, the aforementioned issues of instability and inaccuracy may be resolved, while simultaneously opening avenues for both early detection and intervention, as well as for more targeted and effective treatment approaches.

20-year trajectories of positive and negative symptoms after the first psychotic episode in patients with schizophrenia spectrum disorder: results from the OPUS study

This study aimed to identify the 20-year trajectories of positive and negative symptoms after the first psychotic episode in a sample of patients with an ICD-10 diagnosis of schizophrenia spectrum disorder, and to investigate the baseline characteristics and long-term outcomes associated with these trajectories. A total of 373 participants in the OPUS trial were included in the study. Symptoms were assessed at baseline and after 1, 2, 5, 10 and 20 years using the Scales for the Assessment of Positive and Negative Symptoms. We used latent class growth mixture modelling to identify trajectories, and multinominal regression analyses to investigate predictors of membership to identified trajectories. Five trajectories of positive symptoms were identified: early continuous remission (50.9% of the sample), stable improvement (18.0%), intermittent symptoms (10.2%), relapse with moderate symptoms (11.9%), and continuous severe symptoms (9.1%). Substance use disorder (odds ratio, OR: 2.83, 95% CI: 1.09-7.38, p=0.033), longer duration of untreated psychosis (OR: 1.02, 95% CI: 1.00-1.03, p=0.007) and higher level of negative symptoms (OR: 1.60, 95% CI: 1.07-2.39, p=0.021) were predictors of the relapse with moderate symptoms trajectory, while only longer duration of untreated psychosis (OR: 1.01, 95% CI: 1.00-1.02, p=0.030) predicted membership to the continuous severe symptoms trajectory. Two trajectories of negative symptoms were identified: symptom remission (51.0%) and continuous symptoms (49.0%). Predictors of the continuous symptoms trajectory were male sex (OR: 3.03, 95% CI: 1.48-6.02, p=0.002) and longer duration of untreated psychosis (OR: 1.01, 95% CI: 1.00-1.02, p=0.034). Trajectories displaying continuous positive and negative symptoms were linked to lower neurocognition, as measured by the Brief Assessment of Cognition in Schizophrenia (BACS) (z-score: -0.78, CI: -1.39 to -0.17, for continuous positive symptoms; z-score: -0.33, CI: -0.53 to -0.13, for continuous negative symptoms). The same trajectories were also linked to higher use of antipsychotic medication at 20-year follow-up (continuous positive symptoms: 78%; continuous negative symptoms: 67%). These findings suggest that the majority of patients with first-episode schizophrenia spectrum disorder have a trajectory with early stable remission of positive symptoms. Long duration of untreated psychosis and comorbid substance abuse are modifiable predictors of poor trajectories for positive symptoms in these patients. In about half of patients, negative symptoms do not improve over time. These symptoms, in addition to being associated with poor social and neurocognitive functioning, may prevent patients from seeking help.

Is a Holistic Health Practice Program Effective to Promote Personal Growth in Persons with Serious Mental Illness – A Pilot Study

Background:

Self-help groups (SHG) have been found to be effective in enhancing psychiatric rehabilitation. A Holistic Health Practice Program (HHPP) was developed in which all recovery components are covered. It has been conducted on a group of student nurses and was found to be effective in promoting holistic health, self-esteem, and self-efficacy. But the question arises if it is also effective when conducted on the members of the SHG comprising persons with serious mental illness.

Aim:

This study aimed to explore the holistic health status of the members of the SHG and investigate whether the HHPP is effective for the personal growth of members of the SHG, including persons with serious mental illness and trained lay persons as volunteers in the group.

Methods:

A pre- and post-test group approach was adopted in this study. Group members were invited to join an HHPP, which consisted of 6 sessions held within 6 weeks, with one session weekly comprising 3 hours per session. Participants were asked to fill in a pre-test questionnaire before the program and a post-test questionnaire when they completed the program.

Results:

Results showed that among the 6 domains of the healthy lifestyle profile, participants scored the lowest in the physical activity of the physical domain, followed by the health responsibility of the psychological domain. Whereas, they scored the highest in the interpersonal relations of the social domain. The study also found no significant differences between the mean scores of the persons with serious mental illness and the volunteers. Besides, there were significantly positive increases in mean scores in the domains of physical activity, nutritional habits, spiritual growth, and the total scores of HPLP-II (P<0.05), as well as self-esteem (P<0.05) and self-efficacy (P<0.05) when comparing the pre-test and post-test results.

Conclusion:

This study showed that the holistic health status of persons with serious mental illness is the same as that of the general population. It also demonstrated that the Holistic Health Practice Program is effective in promoting holistic health, self-esteem, and self-efficacy among the persons with serious mental illness and the volunteers.

Machine learning methods to predict outcomes of pharmacological treatment in psychosis

In recent years, machine learning (ML) has been a promising approach in the research of treatment outcome prediction in psychosis. In this study, we reviewed ML studies using different neuroimaging, neurophysiological, genetic, and clinical features to predict antipsychotic treatment outcomes in patients at different stages of schizophrenia. Literature available on PubMed until March 2022 was reviewed. Overall, 28 studies were included, among them 23 using a single-modality approach and 5 combining data from multiple modalities. The majority of included studies considered structural and functional neuroimaging biomarkers as predictive features used in ML models. Specifically, functional magnetic resonance imaging (fMRI) features contributed to antipsychotic treatment response prediction of psychosis with good accuracies. Additionally, several studies found that ML models based on clinical features might present adequate predictive ability. Importantly, by examining the additive effects of combining features, the predictive value might be improved by applying multimodal ML approaches. However, most of the included studies presented several limitations, such as small sample sizes and a lack of replication tests. Moreover, considerable clinical and analytical heterogeneity among included studies posed a challenge in synthesizing findings and generating robust overall conclusions. Despite the complexity and heterogeneity of methodology, prognostic features, clinical presentation, and treatment approaches, studies included in this review suggest that ML tools may have the potential to predict treatment outcomes of psychosis accurately. Future studies need to focus on refining feature characterization, validating prediction models, and evaluate their translation in real-world clinical practice.

A One-Year Follow Up Study on Disability in Mental Health Nursing Practice

Disability is common in patients with mental disorders, and therapeutic approaches should promote functional recovery to achieve the highest quality of life. This study reports changes in WHODAS 2.0 scores at 1 year of follow-up among patients receiving care from a single mental-health nurse in a community setting in Spain and compare these changes by diagnosis (SMI vs. CMI). Baseline and 1-year follow-up scores were compared. For all participants, we collected sociodemographic information, clinical diagnosis, and disability scores according to WHODAS 2.0. Participating patients received the usual, non-manualized nursing intervention. Our sample comprised 133 patients, 75 of whom were assessed after 1 year. All patients had improved WHODAS 2.0 scores (difference of 9.20 ± 2.42; p < .001) in all domains except those domains related to work ("Life activities") and relationships ("Getting along"). Furthermore, almost half of the patients studied were no longer undergoing treatment with the nurse at 1-year follow-up.

Metabolic Syndrome in Adults Receiving Clozapine; The Need for Pharmacist Support

People who are diagnosed with treatment resistant schizophrenia (TRS) are likely to have clozapine as a therapeutic management option. There is a high prevalence of metabolic syndrome in patients receiving clozapine. To mitigate against this, monitoring of weight, waist circumference, lipid profile, glycated haemoglobin (HbA1c), fasting blood glucose (FBG) and blood pressure (BP) is recommended. The aims of this study were to examine the prevalence of metabolic syndrome and whether any variables were correlated with its development, and to highlight any opportunities for the pharmacist to offer support. This study was conducted in an urban hospital and its associated Clozapine Clinic in Cork, Ireland. A retrospective audit assessed the prevalence of metabolic syndrome using the International Diabetes Federation (IDF) criteria. Patients were eligible for inclusion if they were aged 18 years or more, registered with the Clozapine Clinic, and had the capacity to provide informed consent. All data were entered into Microsoft^® Excel ^® (Microsoft Corporation) and further statistical analysis was undertaken using R, t-tests, Fisher's Exact Test and Mann-Whitney U tests as appropriate, and p ≤ 0.05 was considered statistically significant. Of 145 patients (32% female; mean age (SD) 45.3 (±11.7) years; 86.2% living independently/in family home), nearly two thirds (n = 86, 59.3%) were diagnosed with metabolic syndrome. The mean age of participants with metabolic syndrome was 44.4 years (SD = 10.8), similar to the 46.6 years (SD = 12.8) for those without. Variables that were identified to be statistically significantly associated with metabolic syndrome included waist circumference, weight, triglycerides, high density lipoprotein-cholesterol (HDL-C), BP, FBG and HbA1c. The high incidence of metabolic syndrome in this patient population highlights the need for continued physical health monitoring of these patients to ameliorate the risk of developing metabolic syndrome.

Employment trajectories until midlife in schizophrenia and other psychoses: the Northern Finland Birth Cohort 1966

PURPOSE

Psychoses are associated with poor labour market attachment, but few studies have compared schizophrenia (SZ) and other psychoses (OP). Moreover, studies on long-term employment trajectories over individuals' working life courses are lacking. We compared 30 year employment trajectory patterns in a general population sample among individuals with SZ, OP, and those with no psychosis (NP).

METHODS

Utilising the Northern Finland Birth Cohort 1966, we collected survey data on employment from ages 16 to 45 and detected individuals with register-based history of SZ (n = 62), OP (n = 87), or NP (n = 6464) until age 46. Through gender-specific latent class analyses on annual employment roles, we identified traditional, highly educated, self-employed, delayed and floundering employment trajectories with distinct socioeconomic characteristics. We addressed attrition by conducting weighted analyses.

RESULTS

Floundering trajectories were common among individuals with SZ (79% of men, 73% of women) and OP (52% of men, 51% of women). In NP, a traditional employee trajectory was most common in men (31%), and a highly educated trajectory in women (28%). A history of psychosis was associated with heightened odds ratios (ORs; 95% confidence intervals (CIs)) for floundering trajectories in both men (SZ: 32.9 (13.3-81.4); OP: 7.4 (4.0-13.9)) and women (SZ: 9.9 (4.6-21.5); OP: 3.9 (2.1-7.1)) compared to NP. Weighted analyses produced similar results.

CONCLUSION

Most individuals with SZ or OP have floundering employee trajectories reflecting an elevated risk of unemployment and part-time work until midlife. These results indicate the importance of improving labour market attachment during the early phases of psychoses.

Real-life functioning in women with schizophrenia living in residential facilities: Gender-based comparison

Introduction

Despite many patients with schizophrenia being able to achieve good functional outcomes, the number of patients with poor functional outcome estimates at over 25 percent. One of the wider constructs, reflecting functional outcomes in schizophrenia, is real-life functioning, whose key domains include ability to live relatively autonomously, productive activity and social interaction. Negative symptoms are seen among independent predictors of real-life functioning. As most researchers agree that schizophrenia is a disease with gender differences in terms of both clinical and functional outcomes, the goal of our observational study was to examine real-life functioning of women with schizophrenia, living in residential care facilities, and study the relationship between daily functioning and negative symptoms.

Methods

Using the Standardized Protocol of Clinical Interview and observation for 1 or more weeks, we examined 46 females with schizophrenia, living in psychiatric residential facilities and compared them with 54 males with schizophrenia, living in the same facilities. In a pilot study 21 subjects with schizophrenia (13 females and 8 males), were evaluated by the Russian version of the Brief Negative Symptom Scale (BNSS).

Results

To the results, more females with schizophrenia, compared to males with schizophrenia, remained active and took initiative in their physical care, vocational activities, involvement in cultural events, and maintained friendly relationships with other inmates. We have identified a group of inmates, in which females prevailed, with less pronounced negative symptoms and a higher level of social functioning, who did not need residential social care in the institutions.

Discussion

Limitations of residential social care in the institutions for psychiatric patients are discussed.

The prognosis of schizophrenia: A systematic review and meta-analysis with meta-regression of 20-year follow-up studies

OBJECTIVE

The aim was to examine the general outcome of schizophrenia after 20 years or more.

METHODS

Using the PRISMA guidelines, we conducted a systematic review and meta-analysis with meta-regression on long-term follow-up studies of schizophrenia up until April 21, 2021. We included prospective studies with at least 20 years of follow-up on patients with a diagnosis of schizophrenia, and the studies had to include face-to-face clinical evaluation. We examined outcome in three nested groups: 'recovery', 'good or better' (including also 'recovery'), and 'moderate or better' (including also 'recovery' and 'good or better'). We used random-effects meta-analysis and meta-regression to examine mean estimates and possible moderators.

RESULTS

We identified 1089 records, which were screened by two independent researchers. 14 prospective studies (1991 patients) published between 1978 and 2020 were found eligible. The studies used a range of different scales and definitions for outcome, and some used the same definitions for different outcomes. To compare outcome across studies, we designed and applied a unified template for outcome definitions and cutoffs, based on earlier studies' recommendations. Our meta-analysis found that 24.2 % had 'recovered' (n = 246, CI: 20.3-28.0 %), 35.5 % had a 'good or better' outcome (n = 766, CI: 26.0-45.0%), and 59.7% had 'moderate or better' outcome (n = 1139, CI: 49.3-70.1 %).

CONCLUSIONS

The results contribute to debunk the myth that schizophrenia inevitably has a deteriorating course. Recovery is certainly possible. Schizophrenia remains, however, a severe and complex mental disorder, exhibiting a limited change in prognosis despite >100 years of research and efforts to improve treatment.

Bayesian reasoning with emotional material in patients with schizophrenia

Delusions are one of the most classical symptoms described in schizophrenia. However, despite delusions are often emotionally charged, they have been investigated using tasks involving non-affective material, such as the Beads task. In this study we compared 30 patients with schizophrenia experiencing delusions with 32 matched controls in their pattern of responses to two versions of the Beads task within a Bayesian framework. The two versions of the Beads task consisted of one emotional and one neutral, both with ratios of beads of 60:40 and 80:20, considered, respectively, as the “difficult” and “easy” variants of the task. Results indicate that patients showed a greater deviation from the normative model, especially in the 60:40 ratio, suggesting that more inaccurate probability estimations are more likely to occur under uncertainty conditions. Additionally, both patients and controls showed a greater deviation in the emotional version of the task, providing evidence of a reasoning bias modulated by the content of the stimuli. Finally, a positive correlation between patients’ deviation and delusional symptomatology was found. Impairments in the 60:40 ratio with emotional content was related to the amount of disruption in life caused by delusions. These results contribute to the understanding of how cognitive mechanisms interact with characteristics of the task (i.e., ambiguity and content) in the context of delusional thinking. These findings might be used to inform improved intervention programs in the domain of inferential reasoning.

Cerebral, Psychosocial, Family Functioning and Disability of Persons with Schizophrenia

The human brain is the most cognitively capable of mammalian brains, endowed as it is with an overdeveloped cerebral cortex that, in parallel, renders it vulnerable to mental disorders. Schizophrenia is the expression of the dysregulation of the neuronal activity of cortical and subcortical regions due to modifications in the levels of the various neurotransmitters, especially of dopamine, with a reciprocal, intimate relationship among genes with environmental and psychosocial factors. If the dopaminergic system increases the function prefrontal cortex will be reduced: this is the main reason of social, occupational and familiar disruption. The present article describes the function of the brain in schizophrenia and its relation with anatomical, physiological, and genetic changes, in addition to identifying, psychosocial and family factors that can be determinant in the functionality of the patient. A review of national and international bibliography was conducted bearing in mind the following variables: functioning at the cerebral level; psychosocial functioning, familial functioning, disability, and functionality in persons with schizophrenia. Due to the variety of the issues included in this review, it can be concluded that schizophrenia is the product of a complex array of symptoms, deficits and disabilities. It was identified that there is a reciprocal confluence of diverse genetic, psychosocial, familial, environmental, educative, and social factors which affect the functionality of persons with this disorder. The latter makes it necessary to study the patient taking into consideration all of these components in an integral manner.

'An experience of meaning': A 20-year prospective analysis of delusional realities in schizophrenia and affective psychoses

Delusions are transdiagnostic and heterogeneous phenomena with varying degrees of intensity, stability, and dimensional attributes where the boundaries between everyday beliefs and delusional beliefs can be experienced as clearly demarcated, fuzzy, or indistinguishable. This highlights the difficulty in defining delusional realities. All individuals in the current study were evaluated at index and at least one of six subsequential follow-ups over 20 years in the Chicago Longitudinal Study. We assessed 16 distinct delusions categorized as thought or thematic delusions. We also examined the probability of recurrence and the relationships between delusions and hallucinations, depression, anxiety, and negative symptoms. The sample consisted of 262 individuals with schizophrenia vs. affective psychosis. Thought delusions were significantly different between groups at all follow-up evaluations except the 20-year timepoint. Thematic delusions were more common than thought delusions and show a significant decreasing pattern. In general, delusional content varied over time. Referential, persecutory, and thought dissemination delusions show the highest probability of recurrence. Hallucinations were the strongest indicator for thought, thematic, and overall delusions. The formation and maintenance of delusions were conceptualized as a multimodal construct consisting of sensory, perceptual, emotional, social, and somatic embodiment of an "experience of meanings". Given the significant associations between delusions and hallucinations, future work incorporating participatory research is needed to better define and align subjective and objective perspectives. Our research also points to the need for future clinical interventions that specifically evaluate and target the coexistence and entanglement of delusions and hallucinations.

Health Care Costs of Individuals With Chronic Psychotic Disorders Who Experience Incarceration in Ontario

OBJECTIVE

Little is known about the health care costs of individuals with chronic psychotic disorders who experience incarceration. This study sought to address this knowledge gap.

METHODS

The authors analyzed linked 2007-2010 correctional and administrative health care data on sex- and age-matched individuals with chronic psychotic disorders with and without known incarceration in prison for up to 2 years in the Ontario correctional system. Mean 1-year health care costs (overall and by sex) in the year before incarceration (when release occurred in 2010) were estimated from third-party payer data and compared between the two groups. Costs were calculated in 2018 Canadian dollars.

RESULTS

Individuals who experienced incarceration (N=3,197) had mean 1-year costs of $15,728 in the year before incarceration, whereas those who did not (N=6,393) had 1-year costs of $11,588. This difference was mostly due to costs arising from psychiatric hospitalizations, emergency department visits, and physician services. The main factors associated with the difference were incarceration in the following year (increase of $4,827, p<0.001), being age 18-29 years compared with ages 30-39 or 40-49 (increase of $4,448 and $4,218, respectively, p<0.001), and chronic psychotic disorder duration of 1-2 years compared with ≤1 year duration (increase of $6,812, p=0.004). Women who experienced incarceration had higher costs than incarcerated men ($20,648 vs. $14,763).

CONCLUSIONS

Individuals with chronic psychotic disorders who experienced incarceration had higher health care costs than comparable individuals who did not. These higher health care costs may signal the need for interventions and policies that help individuals with psychotic disorders avoid criminal justice system involvement.

Long-Term Outcomes of First-Admission Psychosis: A Naturalistic 21-Year Follow-Up Study of Symptomatic, Functional and Personal Recovery and Their Baseline Predictors

This study was aimed at characterizing long-term outcomes of first-admission psychosis and examining their baseline predictors. Participants were assessed at baseline for 38 candidate predictors and re-assessed after a median follow-up of 21 years for symptomatic, functional, and personal recovery. Associations between the predictors and the outcomes were examined using univariate and multivariate Cox regression models. At baseline, 623 subjects were assessed for eligibility, 510 met the inclusion/exclusion criteria and 243 were successfully followed-up (57.3% of the survivors). At follow-up, the percentages of subjects achieving symptomatic, functional, and personal recovery were 51.9%, 52.7%, and 51.9%, respectively; 74.2% met at least one recovery criterion and 32.5% met all three recovery criteria. Univariate analysis showed that outcomes were predicted by a broad range of variables, including sociodemographics, familial risk, early risk factors, premorbid functioning, triggering factors, illness-onset features, neurological abnormalities, deficit symptoms and early response to treatment. Many of the univariate predictors became nonsignificant when entered into a hierarchical multivariate model, indicating a substantial degree of interdependence. Each single outcome component was independently predicted by parental socioeconomic status, family history of schizophrenia spectrum disorders, early developmental delay, childhood adversity, and mild drug use. Spontaneous dyskinesia/parkinsonism, neurological soft signs and completion of high school remained specific predictors of symptomatic, functional, and personal outcomes, respectively. Predictors explained between 27.5% and 34.3% of the variance in the outcomes. In conclusion, our results indicate a strong potential for background and first-episode characteristics in predicting long-term outcomes of psychotic disorders, which may inform future intervention research.

Psychological Resilience to Suicidal Experiences in People with Non-Affective Psychosis: A Position Paper

It is important to understand the psychological factors which underpin pathways to suicidal experiences. It is equally as important to understand how people develop and maintain resilience to such psychological factors implicated in suicidal experiences. Exploring optimal routes to gaining this understanding of resilience to suicidal thoughts and acts in people with severe mental health problems, specifically non-affective psychosis, was the overarching aim of this position paper. There are five central suggestions: 1. investigating resilience to suicidal experiences has been somewhat over-looked, especially in those with severe mental health problems such as schizophrenia; 2. it appears maximally enlightening to use convergent qualitative, quantitative and mixed research methods to develop a comprehensive understanding of resilience to suicide; 3. relatedly, involving experts-by-experience (consumers) in suicide research in general is vital, and this includes research endeavours with a focus on resilience to suicide; 4. evidence-based models of resilience which hold the most promise appear to be buffering, recovery and maintenance approaches; and 5. there is vast potential for contemporary psychological therapies to develop and scaffold work with clients centred on building and maintaining resilience to suicidal thoughts and acts based on different methodological and analytical approaches which involve both talking and non-talking approaches.

Whole Life: a feasibility study of a recovery-focussed intervention in patients with stabilised schizophrenia

Background

The Recovery Approach is about supporting people to live the best life they possibly can. This paper reports on a 2008-11 study of a recovery-focussed, one-to-one coaching programme called Whole Life (WL) in a group of people with stabilised schizophrenia. WL comprises 15 modules, each addressing an aspect of life that may pose challenges for someone with mental illness. It involves regular meetings with a coach, additional homework activities and lasts approximately one-year. This level of commitment requires participants to be motivated and enthusiastic.

Methods

This was a non-randomised feasibility study, designed to assess acceptability and potential benefits of WL. The WL group was compared to another group of people with the same diagnosis, who received their usual treatment. This was not a strict control group. The primary outcome measure was the Social Adaptation Self-Assessment Scale.

Results

Of those recruited to the WL group, 33/44 (75%) completed the full programme. WL participants showed an 11-point increase in mean SASS between baseline and Week 60. Subjective ratings showed benefits of WL at 3 and 6 months after the intervention had ceased, with most saying they felt better and none saying that they felt worse. The comparison group was more ill than the WL group at baseline and showed some improvement over the course of the study, albeit at a lower level than the WL group. However, controlling for baseline group differences meant that none of the outcome measures could reliably distinguish between WL and comparison groups.

Conclusions

The study showed that WL is an acceptable and helpful intervention for motivated and enthusiastic individuals. It may have wider applicability for people with a less serious and chronic mental illness, although we do not know how it compares to other interventions. We discuss some methodological limitations of the study.

Association of cardiovascular metabolic risk factor measurements with psychiatric readmission among in-hospital patients with severe mental illness: a retrospective study

BACKGROUND

Patients with severe mental illness (SMI) and comorbid physical conditions were often associated with higher risks of mortality and hospital readmission. In this study, we aim to examine the association of cardiovascular metabolic risk factor measurements with risks of psychiatric readmissions among in-hospital patients with severe mental illness (SMI).

METHODS

We collected the longitudinal information of laboratory investigations, blood pressure and body mass index (BMI) among in-hospital patients who had been diagnosed with schizophrenia, major depression disorder or bipolar disorder and with comorbid diagnosis of hypertension, hyperlipidemia or diabetes from Jan 2014 to Jan 2019. The primary outcome was time to first psychiatric readmission. Cox proportional hazard model was utilized to calculate the hazard risks (HR) of cardiovascular metabolic risk factors with psychiatric readmission.

RESULTS

A total of 5,256 patients were included in the analysis. Compared to patients with normal blood parameters, patients with aberrant tests of high-density dyslipidemia (HDL) and diastolic blood pressure (DBP) during in-hospitalization period were associated with higher risks to first psychiatric readmission [ HR (Hazard Ratio), 1.37 95% Confidence interval (CI), 1.03-1.83 for HDL and HR, 1.32 (95% CI, 1.04-1.67])for DBP]. Compared to patients with optimal monitoring, patients with suboptimal monitoring of blood lipids and blood pressure during in-hospitalization period or recommended window period of cardiovascular disease (CVD) risk management were associated with higher risks to first psychiatric readmission.

CONCLUSIONS

Aberrant cardiovascular metabolic blood test and blood pressure and missing measurements among in-hospital patients with SMI were associated with increased risks of psychiatric readmissions. This calls for more active screening and monitoring of CVD risk factors for those in-hospital patients in need.

Antipsychotic Maintenance Treatment for Patients With Schizophrenia: The Need for Placebo-Controlled Trials and The Risk of Paradigm Shifts

Background and Hypothesis

There is limited evidence guiding clinicians and patients on how long to continue antipsychotic medication beyond the first 1-2 years of treatment. Data from long-term (beyond 2 years) placebo-controlled trials would be informative but would be resource-intensive and technically difficult to obtain. Philosophy and history offer perspective on whether schizophrenia researchers should invest in such trials.

Study Design

Essay.

Results

In Descartes' model of science, knowledge grows by accumulation and evolves from simpler toward more complex areas. From this perspective, the most important questions are when and how to build this evidence base. In Kuhn's model of science, paradigm shifts can occur that reframe which questions and answers are meaningful. From this perspective, the question of whether to invest in long-term placebo-controlled trials is especially important. An historical review of schizophrenia over the past century indicates that major paradigm shifts have occurred regarding schizophrenia treatments, what counts as evidence, and the definition of schizophrenia.

Conclusions

While long-term placebo-controlled trials would add value within the current paradigm, if a paradigm shift occurs there is a risk that this value would not be maintained in the new paradigm.

Short-term functional outcome in psychotic patients: results of the Turku early psychosis study (TEPS)

BACKGROUND

Functional recovery of patients with clinical and subclinical psychosis is associated with clinical, neuropsychological and developmental factors. Less is known about how these factors predict functional outcomes in the same models. We investigated functional outcomes and their predictors in patients with first-episode psychosis (FEP) or a confirmed or nonconfirmed clinical high risk of psychosis (CHR-P vs. CHR-N).

METHODS

Altogether, 130 patients with FEP, 60 patients with CHR-P and 47 patients with CHR-N were recruited and extensively examined at baseline (T0) and 9 (T1) and 18 (T2) months later. Global Assessment of Functioning (GAF) at T0, T1 and T2 and psychotic, depression, and anxiety symptoms at T1 and T2 were assessed. Functional outcomes were predicted using multivariate repeated ANOVA.

RESULTS

During follow-up, the GAF score improved significantly in patients with FEP and CHR-P but not in patients with CHR-N. A single marital status, low basic education level, poor work situation, disorganization symptoms, perceptual deficits, and poor premorbid adjustment in patients with FEP, disorganization symptoms and poor premorbid adjustment in patients with CHR-P, and a low basic education level, poor work situation and general symptoms in patients with CHR-N predicted poor functional outcomes. Psychotic symptoms at T1 in patients with FEP and psychotic and depression symptoms at T1 and anxiety symptoms at T2 in patients with CHR-P were associated with poor functioning.

CONCLUSIONS

In patients with FEP and CHR-P, poor premorbid adjustment and disorganization symptomatology are common predictors of the functional outcome, while a low education level and poor work situation predict worse functional outcomes in patients with FEP and CHR-N. Interventions aimed at improving the ability to work and study are most important in improving the functioning of patients with clinical or subclinical psychosis.

A meta-analysis of effectiveness of real-world studies of antipsychotics in schizophrenia: Are the results consistent with the findings of randomized controlled trials?

Randomized controlled trials (RCTs) have been considered as gold standard for establishing the efficacy and safety of investigational new drugs; nonetheless, the generalizability of their findings has been questioned. To address this issue, an increasing number of naturalistic studies and real-world database analyses have been conducted. The question of how much information from these two approaches is congruent or discrepant with each other is of great importance for the clinical practice. To answer this question, we focused on data from the antipsychotic (AP) treatment of schizophrenia. Our aim was two-fold: to conduct a meta-analysis of real-world studies (RWS), and to compare the results of RWS meta-analysis with previously published meta-analyses of RCTs. The principal measure of effectiveness was all-cause treatment discontinuation for both RWS and RCTs (when not available, then drop out for RCTs). We included publications for 8 selected APs (oral formulations of amisulpride, aripiprazole, clozapine, haloperidol, olanzapine, quetiapine, risperidone, and long-acting injectable (LAI) risperidone). We identified 11 RWS and 7 RCT meta-analyses for inclusion. Our results indicated that the RWS yielded statistically conclusive and consistent findings across individual investigations. For the overwhelming majority of the comparisons where both RWS and RCT meta-analyses were available, there was good congruency between the RWS and the RCT results. Our results support that RCTs, despite their limitations, provide evidence which is generalizable to real-world settings. This is an important finding for both regulators and clinicians. RWS can provide guidance for situations where no evidence is available from double-blind clinical trials.

Comparison of mental-physical comorbidity, risk of death and mortality among patients with mental disorders - A retrospective cohort study

AIM

To compare the risk of death, the prevalence of comorbid chronic physical illness and mortality among an Asian population of patients with mental disorders.

METHODS

This was a retrospective data analysing of medical records of patients with schizophrenia, depression, anxiety, bipolar disorder, alcohol use disorder (AUD) or substance use disorder and the comorbid chronic physical illnesses. The hazard risk of death was calculated with Cox regression and compared between patients with and without comorbid chronic physical illness(es). Odds ratios of specific comorbid chronic physical illness were calculated with logistic regression and mean crude death rate was calculated for patients with different mental disorders.

RESULTS

A total of 56,447 patients with mental disorders were included in the analysis. Compared to patients without comorbid physical illness, patients with mental-physical comorbidity were associated with a higher risk of death [2.36 (2.22-2.52); hazard ratio (95% CI)] and less estimated survival days [2157 (2142-2172) vs 2508 (2504-2513)]. Compared to other mental disorders, those with AUD had the highest prevalence of two or more comorbid chronic physical illnesses and associated with the highest odds of comorbid hypertension, diabetes mellitus, stroke, nephritis, chronic kidney disease, and cancer. The highest one-year crude death rate was similarly observed in patients with AUD.

CONCLUSIONS

Mental-physical comorbidity was associated with a higher risk of death compared to patients with mental disorders only. The highest prevalence of mental-physical comorbidity and mortality were observed in patients with AUD. More attention and resources may be needed to tackle the burden of AUD.

Functioning Problems in Persons with Schizophrenia in the Russian Context

Assessing functionality in schizophrenia from a biopsychosocial perspective is essential to generate treatments that respond to the needs of the individual in his/her context. This research aims to assess the prevalence of functioning problems and their association with socio-demographic and clinical variables in a sample of Russian individuals with schizophrenia, using the International Classification of Functioning, Disability, and Health as a framework. An empirical cross-sectional study assessed the functioning of 40 individuals with schizophrenia using the International Classification of Functioning, Disability, and Health Core Set for schizophrenia. For the Body functions component, the highest prevalence of problems was found in b144 Memory functions (75%) and b140 Attention functions (70%). In the Activities and participation component, the greatest limitations were in d770 Intimate relationships (79.3%) and d240 Handling stress and other psychological demands (82.5%). In the Environmental factors, the most frequent problems were in e110 Products or substances for personal consumption (25%) and e460 Societal attitudes (22.5%); when scored as facilitators, the highest rated categories were e125 Products and technology for communication (100%) and e165 Assets (100%). These results may guide the design of specific treatments for these individuals and serve as a starting point for further studies in similar contexts and in other regions in Russia.

Examining equity in the utilisation of psychiatric inpatient care among patients with severe mental illness (SMI) in Ontario, Canada

BACKGROUND

Severe mental illness (SMI) comprises a range of chronic and disabling conditions, such as schizophrenia, bipolar disorder and other psychoses. Despite affecting a small percentage of the population, these disorders are associated with poor outcomes, further compounded by disparities in access, utilisation, and quality of care. Previous research indicates there is pro-poor inequality in the utilisation of SMI-related psychiatric inpatient care in England (in other words, individuals in more deprived areas have higher utilisation of inpatient care than those in less deprived areas). Our objective was to determine whether there is pro-poor inequality in SMI-related psychiatric admissions in Ontario, and understand whether these inequalities have changed over time.

METHODS

We selected all adult psychiatric admissions from April 2006 to March 2011. We identified changes in socio-economic equity over time across deprivation groups and geographic units by modeling, through ordinary least squares, annual need-expected standardised utilisation as a function of material deprivation and other relevant variables. We also tested for changes in socio-economic equity of utilisation over years, where the number of SMI-related psychiatric admissions for each geographic unit was modeled using a negative binomial model.

RESULTS

We found pro-poor inequality in SMI-related psychiatric admissions in Ontario. For every one unit increase in deprivation, psychiatric admissions increased by about 8.1%. Pro-poor inequality was particularly present in very urban areas, where many patients with SMI reside, and very rural areas, where access to care is problematic. Our main findings did not change with our sensitivity analyses. Furthermore, this inequality did not change over time.

CONCLUSIONS

Individuals with SMI living in more deprived areas of Ontario had higher psychiatric admissions than those living in less deprived areas. Moreover, our findings suggest this inequality has remained unchanged over time. Despite the debate around whether to make more or less use of inpatient versus other care, policy makers should seek to address suboptimal supply of primary, community or social care for SMI patients. This may potentially be achieved through the elimination of barriers to access psychiatrist care and the implementation of universal coverage of psychotherapy.

Reversible Changes in BDNF Expression in MK-801-Induced Hippocampal Astrocytes Through NMDAR/PI3K/ERK Signaling

Dizocilpine (MK-801), a non-competitive N-methyl-D-aspartic acid receptor (NMDA-R) antagonist, can induce schizophrenia-like symptoms in healthy individuals, implicating NMDA-R hypofunction in disease pathogenesis. Brain-derived neurotrophic factor (BDNF) is also implicated in schizophrenia, and expression is regulated by NMDA-R activity, suggesting a functional link. We previously found that BDNF signaling was upregulated by MK-801 in cultured hippocampal astrocytes, but the underlying mechanism is not clear. To address this issue, the levels of BDNF expression and secretion were evaluated in hippocampal astrocytes incubated with MK-801 by ELISA and qPCR, with and without NMDA co-incubation or pretreatment of either the ERK1/2 inhibitor, PD98059 or the PI3K inhibitor, LY294002. The apoptosis, viability, and proliferation of the astrocytes were also examined. In the current study, we demonstrate that MK-801 treatment (20 μM for 5 days) enhances the proliferation of rat cultured hippocampal astrocytes. Expression of BDNF mRNA was enhanced after 24 h in MK-801, but returned to near baseline over the next 24 h in the continued presence of MK-801. However, two successive 24-h treatments enhanced BDNF expression. These application regimens had no effect on apoptosis or proliferation rate. Co-addition of NMDA significantly inhibited MK-801-induced upregulation of BDNF. Similarly, MK-801-induced BDNF upregulation was blocked by pretreatment with inhibitors of PI3K and ERK1/2, but not by inhibitors of p38 and JNK. These findings suggested that astrocytes may contribute to the acute neurological and behavioral response to MK-801 treatment via a transient increase in BDNF expression involving NMDA-R–PI3K–ERK signaling.

Demographic and clinical variables associated with response to clozapine in schizophrenia: a systematic review and meta-analysis

Clozapine is the only licensed pharmacotherapy for treatment-resistant schizophrenia. However, response to clozapine is variable. Understanding the demographic and clinical features associated with response to clozapine may be useful for patient stratification for clinical trials or for identifying patients for earlier initiation of clozapine. We systematically reviewed the literature to investigate clinical and demographic factors associated with variation in clozapine response in treatment-resistant patients with schizophrenia spectrum disorders. Subsequently, we performed a random-effects meta-analysis to evaluate differences in duration of illness, age at clozapine initiation, age of illness onset, body weight and years of education between clozapine responders and non-responders. Thirty-one articles were eligible for qualitative review and 17 of these were quantitatively reviewed. Shorter duration of illness, later illness onset, younger age at clozapine initiation, fewer hospitalisations and fewer antipsychotic trials prior to clozapine initiation showed a trend to be significantly associated with a better response to clozapine. Meta-analysis of seven studies, totalling 313 subjects, found that clozapine responders had a significantly shorter duration of illness compared to clozapine non-responders [g = 0.31; 95% confidence interval (CI) 0.06-0.56; p = 0.01]. The results imply that a delay in clozapine treatment may result in a poorer response and that a focus on prompt treatment with clozapine is warranted.

Rationale and neurobiological effects of treatment with antipsychotics in patients with chronic schizophrenia considering dopamine supersensitivity

The long-term treatment of patients with schizophrenia often involves the management of relapses for most patients and the development of treatment resistance in some patients. To stabilize the clinical course and allow as many patients as possible to recover, clinicians need to recognize dopamine supersensitivity, which can be provoked by administration of high dosages of antipsychotics, and deal with it properly. However, no treatment guidelines have addressed this issue. The present review summarized the characteristics of long-acting injectable antipsychotics, dopamine partial agonists, and clozapine in relation to dopamine supersensitivity from the viewpoints of receptor profiles and pharmacokinetics. The potential merits and limitations of these medicines are discussed, as well as the risks of treating patients with established dopamine supersensitivity with these classes of drugs. Finally, the review discussed the biological influence of antipsychotic treatment on the human brain based on findings regarding the relationship between the hippocampus and antipsychotics.

Behind the opaque curtain: A 20-year longitudinal study of dissociative and first-rank symptoms in schizophrenia-spectrum psychoses, other psychoses and non-psychotic disorders

BACKGROUND

Depersonalization and derealization are currently considered diagnostically distinct from first-rank symptoms (FRS) seen in schizophrenia-spectrum psychoses. Nevertheless, the lived experiences of these symptoms can be very similar phenomenologically.

AIMS

To investigate the interrelationships between depersonalization, derealization and FRS in individuals with different types of psychotic and non-psychotic diagnoses.

METHODS

The Chicago Follow-up Study was a prospective longitudinal research program designed to study psychopathology and recovery in psychiatric disorders consisting of 555 participants, who were recruited at index hospitalization and studied over six follow-up timepoints at approximately 2, 4.5, 7.5, 10, 15, and 20 years later. The primary clinical indices were depersonalization, derealization and Schneiderian FRS that were measured at index hospitalization and at each subsequent follow-up.

RESULTS

62.8% of participants had at least four follow-ups. There were significant differences in the course and chronicity of depersonalization, derealization and first-rank symptoms across the three diagnostic groups. For the whole sample, derealization was significantly associated with FRS at 2-, 4.5- and 7.5-year follow-up timepoints whereas depersonalization was related to FRS from 10-year follow-up to 20-year follow-up. In participants with schizophrenia, overall depersonalization was more often associated with passivity phenomena whereas derealization was more often associated with overall delusions. There was also a significant effect of time on the associations between depersonalization, derealization and FRS across follow-ups.

CONCLUSIONS

Depersonalization and derealization should be viewed as transdiagnostic phenomena that are associated with FRS psychopathology along a continuum, although they are more closely associated with schizophrenia-spectrum psychoses.

Promoting stigma coping and empowerment in patients with schizophrenia and depression: results of a cluster-RCT

There is a need for interventions supporting patients with mental health conditions in coping with stigma and discrimination. A psycho-educational group therapy module to promote stigma coping and empowerment (STEM) was developed and tested for efficacy in patients with schizophrenia or depression. 30 clinical centers participated in a cluster-randomized clinical trial, representing a broad spectrum of mental health care settings: in-patient (acute treatment, rehabilitation), out-patient, and day-hospitals. As randomized, patients in the intervention group clusters/centers received an illness-specific eight sessions standard psychoeducational group therapy plus three specific sessions on stigma coping and empowerment ('STEM'). In the control group clusters the same standard psychoeducational group therapy was extended to 11 sessions followed by one booster session in both conditions. In total, N = 462 patients were included in the analysis (N = 117 with schizophrenia spectrum disorders, ICD-10 F2x; N = 345 with depression, ICD-10 F31.3-F31.5, F32-F34, and F43.2). Clinical and stigma-related measures were assessed before and directly after treatment, as well as after 6 weeks, 6 months, and 12 months (M12). Primary outcome was improvement in quality of life (QoL) assessed with the WHO-QOL-BREF between pre-assessment and M12 analyzed by mixed models and adjusted for pre-treatment differences. Overall, QoL and secondary outcome measures (symptoms, functioning, compliance, internalized stigma, self-esteem, empowerment) improved significantly, but there was no significant difference between intervention and control group. The short STEM module has proven its practicability as an add-on in different settings in routine mental health care. The overall increase in empowerment in both, schizophrenia and depression, indicates patients' treatment benefit. However, factors contributing to improvement need to be explored.The study has been registered in the following trial registers. ClinicalTrials.gov: https://register.clinicaltrials.gov/ Registration number: NCT01655368. DRKS: https://www.drks.de/drks_web/ Registration number: DRKS00004217.

The association between perceived racial discrimination and subclinical symptoms of psychosis

BACKGROUND

Schizophrenia is one of the most disabling disorders with the poorest outcomes. Cross-cultural research indicates an association between perceived racial discrimination and depression, anxiety, general psychological distress, and psychotic-spectrum disorders. Studies also find that coping moderates the relationship between discrimination and depression. Assessing subclinical symptoms may be useful in prevention efforts.

AIMS

The study aims to (1) assess if perceived racial discrimination is associated with psychosis subclinical symptoms among a non-clinical sample and (2) examine the role of maladaptive coping and depression, anxiety, and stress.

METHODS

The sample consisted of 261 ethnic minority undergraduate students. A structural equation model using a subclinical psychosis latent variable within a moderated mediation model assessed relationships between racial discrimination, maladaptive coping, depression, anxiety, and stress, and subclinical psychosis.

RESULTS

Perceived racial discrimination was associated with greater subclinical symptoms of psychosis through increased depression, anxiety, and stress at greater levels of maladaptive coping.

CONCLUSIONS

Knowing risk factors that can be targeted, such as perceived discrimination and maladaptive coping, may have implications for vulnerable populations.

The association between childhood trauma and treatment outcomes in schizophrenia spectrum disorders

Childhood trauma exposure has been associated with poorer treatment outcomes in schizophrenia. Most studies to date have been conducted in naturalistic settings in which the outcome may have been mediated by factors such as poor adherence and substance abuse. We compared the effects of high vs low childhood trauma exposure on the treatment response over 24 months in 78 patients with first-episode schizophrenia spectrum disorders who received standardised treatment with a long acting injectable antipsychotic. Compared to the low childhood trauma group (n = 37), the high childhood trauma group (n = 41) received higher doses of antipsychotic medication and were less likely to achieve remission. When age, sex and cannabis use were controlled for, patients with high levels of childhood trauma had a slower treatment response for positive and disorganized symptom domains, although differences did not differ significantly at 24 months. While there were no differences in functional outcomes, self-rated quality of life was the domain that most clearly differentiated the high and low childhood trauma groups. High childhood trauma exposure was associated with lower quality of life scores at baseline, a lesser degree of improvement with treatment, and lower quality of life scores at 24 months.

INTREPID II: protocol for a multistudy programme of research on untreated psychosis in India, Nigeria and Trinidad

INTRODUCTION

There are few robust and directly comparable studies of the epidemiology of psychotic disorders in the Global South. INTREPID II is designed to investigate variations in untreated psychotic disorders in the Global South in (1) incidence and presentation (2) 2-year course and outcome, (3) help-seeking and impact, and (4) physical health.

METHODS

INTREPID II is a programme of research incorporating incidence, case-control and cohort studies of psychoses in contiguous urban and rural areas in India, Nigeria and Trinidad. In each country, the target samples are 240 untreated cases with a psychotic disorder, 240 age-matched, sex-matched and neighbourhood-matched controls, and 240 relatives or caregivers. Participants will be followed, in the first instance, for 2 years. In each setting, we have developed and are employing comprehensive case-finding methods to ensure cohorts are representative of the target populations. Using methods developed during pilot work, extensive data are being collected at baseline and 2-year follow-up across several domains: clinical, social, help-seeking and impact, and biological.

ETHICS AND DISSEMINATION

Informed consent is sought, and participants are free to withdraw from the study at any time. Participants are referred to mental health services if not already in contact with these and emergency treatment arranged where necessary. All data collected are confidential, except when a participant presents a serious risk to either themselves or others. This programme has been approved by ethical review boards at all participating centres. Findings will be disseminated through international conferences, publications in international journals, and through local events for key stakeholders.

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.

A systematic review of clinical guidelines on choice, dose, and duration of antipsychotics treatment in first- and multi-episode schizophrenia

Clinical guidelines provide evidence-based recommendations to regulate pharmacological treatment of psychotic disorders. However, the quality of evidence, country of origin, and publication dates of such guidelines vary, which leads to discrepancies between recommendations. This systematic review aimed to examine consensus and disparities between clinical recommendations on the choice, dose, and duration of antipsychotic treatment for first- and multi-episode schizophrenia patients. A literature search through The Cochrane Library, Embase, Medline, PsycINFO, PubMed, Scopus, Web of Sciences, and relevant bibliographies revealed 24 guidelines that met the inclusion criteria. The guidelines indicated mostly consistent recommendations regarding the optimal dose range of antipsychotics, while guidance with regards to the choice and duration of treatment remains somewhat controversial. Current trends in guidelines emphasize that there is simply no 'one-size-fits-all' method to manage schizophrenia patients. Further research is needed not only to address discrepancies between guidelines, but also to justify the gap between theory and practice.

Risperidone Reverses the Downregulation of BDNF in Hippocampal Neurons and MK801-Induced Cognitive Impairment in Rats

MK-801, also known as dizocilpine, is a non-competitive N-methyl-D-aspartic acid (NMDA) receptor antagonist that induces schizophrenia-like symptoms. Our previous study showed that brain-derived neurotrophic factor (BDNF) signaling was upregulated in cultured hippocampal astrocytes in response to MK-801. However, dysfunctional NMDA receptors are mainly expressed in neurons. The effects of MK-801 on neuron-derived BDNF expression and of risperidone on MK-801-induced cognitive impairment and changes in BDNF expression are unclear. To address this issue, we examined BDNF expression in the hippocampus of rats that received repeated injections of MK-801 (0.5 mg/kg body weight for 6 days) and in primary cultured hippocampal neurons incubated with 20 μM MK-801 for 24 h. BDNF expression and cognitive function were also evaluated in rats receiving intraperitoneal injections of risperidone (1 mg/kg body weight) once daily for 7 days and in hippocampal neurons incubated with 10 μM risperidone following MK801 treatment. MK-801 treatment decreased BDNF expression in the rat hippocampus as well as the expression and secretion of BDNF in hippocampal neurons in vitro. However, risperidone reversed the effects of MK801 on BDNF level and improved cognitive function in rats treated with MK801. These findings suggest that risperidone may alleviate cognitive impairment caused by MK801 via upregulation of BNDF signaling in the hippocampus.

Improvement of Theory of Mind in Schizophrenia: A 15-Year Follow-Up Study

Neurocognitive and social cognitive deficits are a hallmark of schizophrenia. The purpose of the present study was to investigate long-term changes in theory of mind (ToM), executive functions, lexical retrieval, and speed of information processing/attention in schizophrenia. We followed-up 31 outpatients with schizophrenia and 31 healthy control subjects for 15 years. ToM was assessed with the Reading the Mind from the Eyes Test (RMET), whereas neurocognitive functions were measured with the verbal fluency (VF) task (executive functions and lexical retrieval) and with the Digit-Symbol Substitution Test (DSST) (speed of information processing/attention). Clinical symptoms and general functioning were rated with the Positive and Negative Syndrome Scale (PANSS) and with the Global Assessment of Functioning (GAF) scale, respectively. At baseline assessment, patients with schizophrenia exhibited significant and generalized impairments on all measures. At follow-up, relative to the baseline, we observed marked improvements in ToM (RMET), stability in executive functions and lexical retrieval (VF), and a significant decline in psychomotor speed/attention (DSST) in schizophrenia. Clinical symptoms and psychosocial functions did not differ at baseline and at follow-up examinations (mild-to-moderate symptoms on the PANSS and moderate difficulty in social and occupational functions on the GAF). These results indicate that patients with schizophrenia with mild-to-moderate symptoms and functional deficits are characterized by improved ToM during over a decade.

Onset of schizophrenia diagnoses in a large clinical cohort

We aimed to describe the diagnostic patterns preceding and following the onset of schizophrenia diagnoses in outpatient clinics. A large clinical sample of 26,163 patients with a diagnosis of schizophrenia in at least one outpatient visit was investigated. We applied a Continuous Time Hidden Markov Model to describe the probability of transition from other diagnoses to schizophrenia considering time proximity. Although the most frequent diagnoses before schizophrenia were anxiety and mood disorders, direct transitions to schizophrenia usually came from psychotic-spectrum disorders. The initial diagnosis of schizophrenia was not likely to change for two of every three patients if it was confirmed some months after its onset. When not confirmed, the most frequent alternative diagnoses were personality, affective or non-schizophrenia psychotic disorders. Misdiagnosis or comorbidity with affective, anxiety and personality disorders are frequent before and after the diagnosis of schizophrenia. Our findings give partial support to a dimensional view of schizophrenia and emphasize the need for longitudinal assessment.

Course and predictors of symptomatic remission in late-life schizophrenia: A 5-year follow-up study in a Dutch psychiatric catchment area

BACKGROUND

The number of older schizophrenia patients is growing, the majority being treated in outpatient settings. Reported symptomatic remission rates in younger cohorts vary largely. Further insight into course trajectories and putative predictors of remission in older persons with schizophrenia is needed.

METHODS

5-year follow-up course trajectories of symptomatic remission were examined in a catchment area-based group of 77 older Dutch patients (mean age 66.0 years) with schizophrenia or schizoaffective disorder. A modified version of the 'Remission in Schizophrenia Working Group' criteria was used to determine remission status. In individuals who did not fulfil remission criteria at baseline (n = 56), predictors of conversion to remission status at 5-year follow-up were analysed using multivariable regression analyses.

RESULTS

A substantial increase in remission rate at 5-year follow-up (27.3% at baseline (T1), 49.4% at follow-up (T2)) was found. Of all participants, 23.4% was in remission at both assessments and 46.8% was in non-remission at both assessments. 26.0% of the participants converted from non-remission at T1 to remission at T2, while 3.9% fell back from remission at T1 to non-remission at T2. Two significant baseline predictors of conversion to remission at follow-up were found: lower score on the PANSS positive symptom subscale, and having a partner.

CONCLUSION

Symptomatic remission was as an attainable goal for almost half of all older patients with schizophrenia or schizoaffective disorder at 5-year follow-up. With a lower PANSS positive symptom subscale score, and having a partner emerging as the only predictors of conversion to remission, there remains a need to search for modifiable predictors.

A comparative study of childhood/adolescent and adult onset schizophrenia: does the neurocognitive and psychosocial outcome differ?

AIMS & OBJECTIVES

The present study aimed to evaluate the neurocognitive functioning and psychosocial outcome (in terms of social functioning, disability and internalized stigma) in patients with schizophrenia with childhood/adolescent onset (age of onset ≤18 years) and adult onset (>18years) schizophrenia and to evaluate the effect of neurocognitive impairment on the outcome variables in patients with youth and adult onset schizophrenia.

METHODOLOGY

34 patients with youth onset schizophrenia (Group-I) and 56 patients with adult onset schizophrenia (Group-II), who were currently in clinical remission were assessed on a comprehensive neurocognitive battery,Positive and Negative syndrome Scale (PANSS), Global Assessment of Functioning Scale (GAF), Indian Disability Evaluation and Assessment Scale (IDEAS),Social and Occupational Functioning Assessment Scale (SOFS) and Internalised Stigma of Mental Illness Scale (ISMIS).

RESULTS

On neurocognitive domains (after adjusting for co-variates) significant differences were noted between the two groups in terms of processing speed (TMT-A; I > II; p-value -0.009), verbal fluency (COWA;I < II;p-value-0.001) and cognitive flexibility (TMT-B; I > II; p -0.031). Compared to patients with adult onset schizophrenia, patients with childhood & adolescent onset schizophrenia had significantly higher PANSS negative score, higher disability in all domains of IDEAS, poorer socio-occupational functioning, low global functioning and reported more stigma in the domains of alienation and discrimination.In patients with childhood & adolescent onset schizophrenia, higher deficits in the processing speed and verbal fluency were associated with significantly lower socio-occupational functioning and higher disability; higher executive dysfunction was associated with higher internalized stigma. Among patients with adult onset schizophrenia, higher disability was related to executive dysfunction only and higher stigma was associated with poor cognitive processing, selective attention and poor executive functioning.

CONCLUSIONS

The present study suggests that compared to adult onset schizophrenia, patients with childhood & adolescent onset schizophrenia have more deficits in neurocognition, have higher level of disability, poorer socio-occupational functioning and have higher level of self-stigma.

Endophenotypes in Schizophrenia: Digging Deeper to Identify Genetic Mechanisms

Schizophrenia (SZ) is a severe psychotic disorder that is highly heritable and common in the general population. The genetic heterogeneity of SZ is substantial, with contributions from common, rare, and de novo variants, in addition to environmental factors. Large genome-wide association studies have detected many variants that are associated with SZ, yet the pathways by which these variants influence risk remain largely unknown. SZ is also clinically heterogeneous, with patients exhibiting a broad range of deficits and symptom severity that vary over the course of illness and treatment, which has complicated efforts to identify risk variants. However, the underlying brain dysfunction forms a more stable trait marker that quantitative neurocognitive and neurophysiological endophenotypes may be able to objectively measure. These endophenotypes are less likely to be heterogeneous than the disorder and provide a neurobiological context to detect risk variants and underlying pathways among genes associated with SZ diagnosis. Furthermore, many endophenotypes are translational into animal model systems, allowing for direct evaluation of the neural circuit dysfunctions and neurobiological substrates. We review a selection of the most promising SZ endophenotypes, including prepulse inhibition, mismatch negativity, oculomotor antisaccade, letter-number sequencing, and continuous performance tests. We also highlight recent findings from large consortia that suggest the potential role of genes, particularly in the neuregulin and glutamate pathways, in several of these endophenotypes. Although endophenotypes require additional time and effort to assess, the insight into the underlying neurobiology that they provide may ultimately reveal the underlying genetic architecture for SZ and suggest novel treatment targets.

Does improvement in symptoms and quality of life in chronic schizophrenia reduce family caregiver burden?

The longitudinal association of changes in clinical status among adults with schizophrenia and changes in family caregiver burden has not been demonstrated. Using data from the NIMH-funded CATIE schizophrenia trial (n = 446 family caregivers), we examined the association of changes in patient symptoms and quality of life with changes in measures of family caregiver burden. Clinical changes in patient symptoms and quality of life were not significantly associated with changes in family caregiver burden. The weak association likely reflects that small clinical changes in chronically ill adults are insufficient to affect long established experiences of burden.

The modern perspective for long-acting injectables antipsychotics in the patient-centered care of schizophrenia

Schizophrenia is a chronic syndrome involving different clinical dimensions, and causes significant disability with a negative impact on the quality of life of patients and their caregivers. Current guidelines for the treatment of schizophrenia focus on maximizing a patient's adaptive functioning and quality of life in a recovery-oriented approach that encourages active collaboration among patients, caregivers, and mental health professionals to design and manage a customized and comprehensive care plan. In the present study, a panel of experts (psychiatrists, psychologists, nurse, and social worker) gathered to review and explore the need for contemporary use of second-generation antipsychotic long-acting injectables (SGA LAIs) in "recovery-oriented" and "patient-centered" care of schizophrenia. Starting from the available data and from sharing personal attitudes and experiences, the panel selected three clinical dimensions considered useful in characterizing each patient: phase of disease, adherence to treatment, and level of functioning. For each clinical dimension, perspectives of patients and caregivers with regard to needs, expectations, and personal experiences were reviewed and the role of SGA LAIs in achieving shared goals examined. The experts concluded that from today's modern perspectives, SGA-LAIs may play an important role in breaking the spiral of desocialization and functional decline in schizophrenia, thus favoring the recovery process.

Parcellating cognitive heterogeneity in early psychosis-spectrum illnesses: A cluster analysis

Cognitive impairment is argued to represent a core feature of psychosis-spectrum illnesses. However, within-diagnosis heterogeneity is common, and risk factors for poor cognition remain to be examined after statistically accounting for heterogeneity. Accordingly, we used a data-driven technique (cluster analysis) to empirically-derive cognitive clusters across diagnoses and examined whether concurrent substance use or a history of a neurodevelopmental/behavioral disorder differed between clusters. Data from 135 young help-seekers (aged 12-30 years) with a psychosis-spectrum illness were retrospectively analyzed. Ward's hierarchical cluster analysis classified three cognitive clusters characterized by: (1) normal-range; (2) mixed; and (3) grossly-impaired performance. Despite mostly comparable clinical and demographic measures, cluster 1 had superior socio-occupational functioning and the highest estimated premorbid IQ, followed sequentially by clusters 2 and 3. Proportions of cannabis and amphetamine users did not differ significantly across clusters, nor did rates of patients with a neurodevelopmental/behavioral disorder history. Cluster 3 was however comprised of fewer 'risky' drinkers, possibly reflecting reduced opportunity for social drinking associated with cognitive impairment. Estimated premorbid IQ predicted cluster membership (2 vs. 1 & 3 vs. 1), as did clinician-rated socio-occupational functioning and 'not being enrolled in school or tertiary education' (3 vs. 1). Our results suggest that concurrent substance use and history of a neurodevelopmental/behavioral disorder do not adequately explain cluster-level cognitive variance in this sample. Future work should integrate neurobiological measures associated with cognition (e.g. white matter integrity) to discern whether clusters reflect neurobiological subtypes better representative of pathophysiology than present symptom-based classifications.

Neurocognition and functional outcome in patients with psychotic, non-psychotic bipolar I disorder, and schizophrenia. A five-year follow-up

Background:

Bipolar disorder (BD) and schizophrenia (SZ) are characterized by neurocognitive and functional deficits with marked heterogeneity. It has been suggested that BD with a history of psychotic symptoms (BD-P) could constitute a phenotypically homogeneous subtype characterized by greater neurocognitive and functional impairments, or by a distinct trajectory of such deficits. The aim of this study was to compare the neurocognitive and functional course of euthymic BD-P, euthymic BD patients without a history of psychosis (BD-NP), stabilized patients with schizophrenia and healthy subjects, during a five-year follow-up.

Methods:

Neurocognitive and psychosocial function was examined in 100 euthymic patients with BD (50 BD-P, 50 BD-NP), 50 stabilized patients with schizophrenia (SZ), and 51 healthy controls (HC) at baseline (T1), and after a 5-year follow-up (T2).

Results:

The course of both neurocognitive performance and functional outcome of patients with SZ and BD (BD-P and BD-NP) is stable. The profile of neurocognitive impairment of patients with SZ or BD (BD-P and BD-NP), is similar, with only quantitative differences circumscribed to certain domains, such as working memory. The subgroup of patients with BD-NP does not show functional deterioration.

Conclusions:

We have not found evidence of progression in the neurocognitive or psychosocial impairment in any of the three groups of patients, although it cannot be dismissed the possibility of a subset of patients with a progressive course. Other longitudinal studies with larger samples and longer duration are necessary to confirm these findings.

Quality of Life-a Goal for Schizophrenia's Therapy

Quality of Life (QOL) assessment represents a good instrument to monitor the evolution of schizophrenia and the treatment’s outcomes. The present study has evaluated the relationship between the level of the QOL and different socio-demographical and clinical factors. Lower QOL for schizophrenic persons was influenced by the severity of symptoms and cognitive deficits, while same low level of QOL could be considered an indicator for suicidal behavior. The correct therapeutically management of individuals with schizophrenia could lead to better outcomes in terms of life satisfaction of patients and response to the treatment’s strategies.

[Symptomatic remission and its relationship to social functioning in Tunisian out-patients with schizophrenia]

INTRODUCTION

The concept of symptomatic and functional remission represents an important challenge in the care of the mentally ill, particularly in patients with schizophrenia. Operational criteria for symptomatic remission in schizophrenia have been proposed by Andreasen et al. (2005). Over the last decade, these criteria have been widely validated; however few studies have been conducted outside developed countries. Moreover, the association of symptomatic remission with functional outcome has not yet been established in developing countries including Tunisia, as there may be variability in the social and familial environment.

OBJECTIVES

To determine the frequency and associated factors of symptomatic remission in a sample of Tunisian out-patients with schizophrenia and to explore the relationship between symptomatic remission and some indicators of social functioning.

METHODS

A cross-sectional study was carried-out on 115 out-patients with schizophrenia (87 males, 28 females, mean age=37.56±10.2 years) in the psychiatry department of the university hospital in Monastir (Tunisia). Nearly all of the patients (98.26%) had been hospitalized at least once in a psychiatric unit. The last hospitalization dated back to 39 months on average (range=6 months to 16 years). Symptomatic remission was assessed by the eight core items of the positive and negative syndrome scale (PANSS). These are the items P1 "Delusions"; P3 "Hallucinatory behavior" and G9 "Unusual thought content" for the positive dimension, the items P2 "Conceptual disorganization" and G5 "Mannerism and disorders of posture" for the disorganization dimension and the items N1 "Blunted affect", N4 "Social withdrawal" and N6 "Lack of spontaneity and flow of conversation" for the negative dimension. A score of mild or less on all eight-core symptoms constitutes symptomatic remission. This symptom level should have been maintained for six months. The social functioning was assessed by the Social and Occupational Functioning Assessment Scale (SOFAS) and the Social Autonomy Scale (SAS) exploring personal care, management of daily life, resource management, the relationship with the outside and the emotional life and relationships social. A multivariate analysis using a binary logistic regression was conducted with as a dependent variable "symptomatic remission" and as explanatory variables the associated variables with symptomatic remission in bivariate analysis with age and gender.

RESULTS

The symptomatic remission was observed in 50.4% of patients. The items corresponding to positive dimension (P1, P3 and G9) and the item P2 "conceptual disorganization" had a better predictive value of symptomatic remission. After multivariate analysis, the associated factors of symptomatic remission were the acute of onset (P=0.026), the low score of negative symptoms during the last hospitalization (P=0.017) and the episodic course (P<0.0001). However, age or gender of the patients, educational or socioeconomic level, psychiatric family history, age of onset, duration of untreated psychosis, number and duration of previous hospitalizations, antipsychotic treatment dosage were not associated with symptomatic remission in our sample. The mean score of the SOFAS was 48.47±14.44, and the mean score of the SAS was 56.6±16.84. A significant association was shown between the SOFAS score and the symptomatic remission (P<0.0001) and between the SAS score and the symptomatic remission (P<0.0001). Moreover, a significant association was found between symptomatic remission and occupational activity (P=0.03).

CONCLUSION

The frequency of symptomatic remission according the PANSS criteria in our sample is above the average of the reported rates in literature (30 to 60%). This can be explained by the frequency of symptomatic remission in outpatient versus inpatients, or in relation to the notion of a more favorable course of schizophrenia in developing countries, although this notion is controversial. Remitter patients had significantly an acute onset of disorders, a low score of negative symptoms during the last hospitalization and an episodic course. They also showed a significant trend for better social functioning. In fact, a significant association was shown in our sample between symptomatic remission and social functioning. These results suggest that the concept of remission has important implications for the treatment of patients with schizophrenia.