Transition to schizophrenia in acute and transient psychotic disorders

Plasma essential amino acid levels in first episode psychosis at baseline and after antipsychotic treatment

This study assessed plasma levels of essential amino acids (EAA) in drug-naïve first episode psychosis (FEP) patients at diagnosis and after 10 weeks of antipsychotic treatment. Forty FEP patients were enrolled at baseline, with blood samples collected before and after a 10-week antipsychotic treatment period. Plasma EAA levels were measured using an LC/MS/MS method. Psychotic symptoms were evaluated using standardized inventories before and after treatment. A decrease in BPRS score of more than 40% was used to indicate treatment response. Thirty-five healthy volunteers served as the control group. Baseline plasma levels of Thr, Met, Leu, Lys, His, and Tyr were higher in FEP patients than in healthy controls. After 10 weeks of treatment, Leu, His, and Tyr increased further, primarily in treatment-responsive patients. Conversely, Val level was lower than controls in patients at baseline and remained unchanged after treatment. Increased EAA levels were correlated with lower (less severe) scores in positive symptom scales. Treatment non-responders had persistently low Tyr/large neutral amino acid (LNAA) ratio. Tyr/LNAA ratio increased after treatment, specifically in treatment-responders. Phe/Tyr ratio decreased post-treatment in both responder and non-responder groups. Elevated EAA levels in FEP patients may signify compensatory responses to increased physiological demand for neurotransmitters or energy. Combining specific EAA supplementation with antipsychotic treatment may enhance treatment response in these patients.

Diagnostic shift in adolescents with first episode psychosis: findings from the 2-year follow-up of the "Parma Early Psychosis" program

PURPOSE

Diagnostic stability for people with First Episode Psychosis (FEP) is essential for treatment, but it remains poorly investigated, especially in adolescents and within a prospective design. The aims of this research were: (a) to examine diagnostic change in Italian adolescents with FEP treated within an "Early Intervention in Psychosis" program during a 2-year follow-up period and (b) to investigate any sociodemographic and clinical predictors at baseline.

METHODS

At baseline, 66 adolescents with FEP was recruited. Their primary diagnosis was formulated both at baseline and at the end of follow-up. At presentation, FEP adolescents completed the Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA). As for diagnostic stability, the Kappa statistic was calculated. The associations of diagnostic change with baseline clinical and sociodemographic features were analyzed using a logistic model with the diagnostic shift as dependent variable. A propensity score was finally calculated based on logistic analysis results.

RESULTS

38 (57.6%) FEP adolescents changed their opening diagnosis. The highest prospective diagnostic stability was for initial diagnosis of schizophrenia (95.4%) and affective spectrum psychoses (75%). Diagnostic instability was high for opening diagnosis of psychosis not otherwise specified, brief psychosis and schizophreniform disorder (100%). The best predictors of diagnostic change were fewer years of education, shorter duration of untreated psychosis and higher baseline levels of psychiatric symptoms.

CONCLUSION

Diagnostic stability is crucial for treatment and clinical decision making. Addressing instability in FEP diagnoses is an important challenge for future diagnostic development in early psychosis, especially in adolescence.

Long-term diagnostic stability, predictors of diagnostic change, and time until diagnostic change of first-episode psychosis: a 21-year follow-up study

BACKGROUND

Although diagnostic instability in first-episode psychosis (FEP) is of major concern, little is known about its determinants. This very long-term follow-up study aimed to examine the diagnostic stability of FEP diagnoses, the baseline predictors of diagnostic change and the timing of diagnostic change.

METHODS

This was a longitudinal and naturalistic study of 243 subjects with FEP who were assessed at baseline and reassessed after a mean follow-up of 21 years. The diagnostic stability of DSM-5 psychotic disorders was examined using prospective and retrospective consistencies, logistic regression was used to establish the predictors of diagnostic change, and survival analysis was used to compare time to diagnostic change across diagnostic categories.

RESULTS

The overall diagnostic stability was 47.7%. Schizophrenia and bipolar disorder were the most stable diagnoses, with other categories having low stability. Predictors of diagnostic change to schizophrenia included a family history of schizophrenia, obstetric complications, developmental delay, poor premorbid functioning in several domains, long duration of untreated continuous psychosis, spontaneous dyskinesia, lack of psychosocial stressors, longer duration of index admission, and poor early treatment response. Most of these variables also predicted diagnostic change to bipolar disorder but in the opposite direction and with lesser effect sizes. There were no significant differences between specific diagnoses regarding time to diagnostic change. At 10-year follow-up, around 80% of the diagnoses had changed.

CONCLUSIONS

FEP diagnoses other than schizophrenia or bipolar disorder should be considered as provisional. Considering baseline predictors of diagnostic change may help to enhance diagnostic accuracy and guide therapeutic interventions.

Predictors of Mortality Following a Schizophrenia Spectrum Diagnosis: Evidence From the 20-Year Follow-up of the OPUS Randomized Controlled Trial

BACKGROUND AND HYPOTHESIS

The life expectancy of patients diagnosed with schizophrenia is 10-12 years lower than in the general population and the mortality gap seems to be worsening. Many of these deaths might be avoidable. We aimed to determine mortality rates and causes of death after a first-episode psychosis, and to examine if clinical characteristics at baseline or during illness could predict mortality.

STUDY DESIGN

The OPUS study was a randomized controlled trial of 578 patients first diagnosed with schizophrenia spectrum disorders. Patients were clinically assessed after 2, 5, 10, and 20 years. Information about time and cause of death was obtained from the Danish Cause of Death Register. Hazard ratios were used to assess predictors of death.

STUDY RESULTS

In total, 82 (14.4%) participants died during 20 years of follow-up. The most common cause of death was suicide (27%). At baseline employment (HR 0.47 P = .049), psychotic disorder other than schizophrenia (HR 0.36, P = .017), and longer duration of untreated psychosis (HR 0.57 P = .042) predicted lower mortality while substance use predicted higher mortality (HR 2.56, P < .001). During follow-up, symptom remission without antipsychotic medication and recovery predicted lower mortality (HR 0.08 P = .013 and HR 0.21, P = .028) while substance use (HR 3.64 P < .001), and all chronic illnesses predicted increased risk.

CONCLUSIONS

There is an increased risk of early mortality in schizophrenia compared to the background population, and there is an urgent need for new efforts to improve the disparities in health that lead to this increased mortality.

Diagnostic Stability in Psychiatric Patients From Hospital Admission to Discharge: A 10-Year Retrospective Study

OBJECTIVE

This study aimed to evaluate the consistency or stability of mental disorders diagnosed in the psychiatry ward setting, investigate factors associated with consistency, and observe the disease distribution over the decade.

METHODS

A total of 20,359 psychiatric inpatients were included in this retrospective study from June 2011 to December 2020. Diagnoses from the first admission to discharge were evaluated to determine the diagnostic consistency during hospitalization. Readmissions were selected as the subgroup, whose first and last discharge diagnoses were compared to analyze the relatively long-term diagnostic stability. Demographic and clinical characteristics were collected to identify predictors of diagnostic discrepancy.

RESULTS

From 2011-2020, the hospitalization rate decreased from 42.7% to 20.7% for schizophrenia and grew from 13.3% to 23.8% for depression. Diagnoses were retained by 92.6% of patients at their first discharge diagnosis, ranging from 100% for disorders of psychological development to 16.3% for unspecified mental disorders. About 33.9% of diagnostic conversions were to bipolar disorder in patients having inconsistent diagnoses. However, among rehospitalizations, the diagnostic stability notably dropped to 71.3%. For rehospitalizations, mood disorders and schizophrenia spectrum disorders were relatively stable diagnoses categories, with 72.6% to 76.7% of patients receiving the same diagnosis, although results of specified diagnoses within these categories ranged from 5.9% to 91.0%. Except for mood disorders and schizophrenia spectrum disorders, the diagnoses of all other categories were below 70%. Long lengths of hospitalization and old age were associated with short-term diagnosis alterations.

CONCLUSION

Longitudinal follow-up and integration of multiple aspects of information are essential for accurate diagnosis.

First-episode psychotic disorders in the wake of the COVID-19 pandemic: a descriptive review of casereports

OBJECTIVE

Since the onset of COVID-19 pandemic, many case reports and case series dealt with new-onset psychotic disorders in patients either infected with SARS-CoV-2 or thematically linked to the pandemic, but without an infection. Our aim was to provide a comprehensive collection of these reports to illustrate the nature of these psychoses.

METHODS

We conducted a literature search in MEDLINE, Embase, PsycINFO, using search terms regarding first-episode psychotic disorders in the context of corona.

RESULTS

96 case reports or case series covering 146 patients (62 without and 84 with SARS-CoV-2 infection) were found. Compared to patients without infection, patients with infection showed significantly more often visual hallucinations (28.6% vs 8.1%), confusion (36.9% vs 11.3%), an acute onset of illness (88.5% vs 59.6%) and less often depression (13.1% vs 35.5%) and a delusional content related to the pandemic (29.5% vs 78.3%). Both groups had an equally favourable outcome with a duration of psychosis ≤2 weeks in half and full remission in two-thirds of patients. In patients with infection, signs of inflammation were reported in 78.3% and increased CRP in 58.6%. While reports on patients with infection are continuously published, no report about patients without infection was found after July 2020.

CONCLUSION

Cases without infection were considered reactive and originated all from the first wave of the corona pandemic. In cases with infection, inflammation was considered as the main pathogenetic factor but was not found in all patients. Diagnosis was impeded by the overlap of psychosis with delirium.

Differential Effects of Chronic Methamphetamine Treatment on High-Frequency Oscillations and Responses to Acute Methamphetamine and NMDA Receptor Blockade in Conscious Mice

Dysregulation of high-frequency neuronal oscillations has been implicated in the pathophysiology of schizophrenia. Chronic methamphetamine (METH) use can induce psychosis similar to paranoid schizophrenia. The current study in mice aimed to determine the effect of chronic METH treatment on ongoing and evoked neuronal oscillations. C57BL/6 mice were treated with METH or vehicle control for three weeks and implanted with extradural recording electrodes. Two weeks after the last METH injection, mice underwent three EEG recording sessions to measure ongoing and auditory-evoked gamma and beta oscillatory power in response to an acute challenge with METH (2 mg/kg), the NMDA receptor antagonist MK-801 (0.3 mg/kg), or saline control. A separate group of mice pretreated with METH showed significantly greater locomotor hyperactivity to an acute METH challenge, confirming long-term sensitisation. Chronic METH did not affect ongoing or evoked gamma or beta power. Acute MK-801 challenge reduced ongoing beta power whereas acute METH challenge significantly increased ongoing gamma power. Both MK-801 and METH challenge suppressed evoked gamma power. Chronic METH treatment did not modulate these acute drug effects. There were minor effects of chronic METH and acute METH and MK-801 on selected components of event-related potential (ERP) waves. In conclusion, chronic METH treatment did not exert neuroplastic effects on the regulation of cortical gamma oscillations in a manner consistent with schizophrenia, despite causing behavioural sensitisation.

The predictive validity and outcome of ICD-10 and DSM-5 short-lived psychotic disorders: a review and meta-analysis

The ICD-10 Classification of Mental and Behavioural Disorders introduced the category of 'acute and transient psychotic disorders' (ATPDs) encompassing polymorphic, schizophrenic and predominantly delusional subtypes, and the forthcoming ICD-11 revision has restricted it to polymorphic psychotic disorder, while the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) listed 'brief psychotic disorder' (BPD). To assess the predictive validity and outcome of ATPDs and BPD, relevant papers in English, French and German were searched in PubMed and Web of Science. Where possible meta-analysis of prognostic validators (diagnostic stability, course, outcome and response to treatment) was conducted. Fifty studies published between January 1993 and July 2019 were found. The clinical and functional outcome of ATPDs proved better than in schizophrenia and related disorders, but mortality risk is high, particularly suicide, and treatment trials provide little evidence. Meta-analysis of 25 studies (13,507 cases) revealed that 55% (95% CI 49-62) do not change diagnosis, 25% (95% CI 20-31) converted into schizophrenia and related disorders, and 12% (95% CI 7-16) into affective disorders on average over 6.3 years. Subgroup meta-analysis estimated prospective consistency of polymorphic psychotic disorder (55%; 95% CI 52-58) significantly greater than that of the ATPD subtypes with schizophrenic (OR 1.7; 95% CI 1.4-2.0) and predominantly delusional (OR 1.3; 95% CI 1.1-1.5) symptoms. Moreover, the diagnostic stability of BPD (13 studies; 294 cases) was 45% (95% CI 32-50) over a mean 4.2 years. Although these findings indicate that short-lived psychotic disorders have little predictive validity, significant differences among the ATPD subtypes support the revised ICD-11 ATPD category.

Post COVID-19 Infection Psychosis: Could SARS-CoV-2 Virus Infection Be a Neuropsychiatric Condition That Triggers Psychotic Disorders? - A Case-Based Short Review

Corona virus (COVID-19) is an epidemy of respiratory disease caused by a novel corona virus and it was declared by the World Health Organization (WHO) to be a global health pandemic emergency. Due to the neuropsychiatric manifestation of Covid-19 that have been associated with psychotic disorders, in this paper we choose to present a case from “Elena Doamna” Psychiatric Hospital from Galati, Romania and to correlate it with other cases from literature in a mini review presentation. In our paper, we present the case of a patient of 44-year-old men, with no past psychiatric history whose behavior included psycho-motor agitation, perception and thinking disorders, disorganized behaviour, attempted suicide by stabbing. The last perspectives from the two years of pandemic together with psychiatric disease linked the virus infections with psychosis to the main concern that Covid-19 could determine psychiatric disorders. There were also presented same literature studies of patients with no personal pathological history in the psychiatric field which developed psychiatric disorders after COVID-19 infection. SARS-CoV-2 has a psychological impact on the mental health status of the worldwide and, especially when it is associated with psychotic symptoms and can affect the quality-of-life. In some cases, the virus affected the brain and as a result, the psychosis symptoms could be an emerging phenomenon associated with the corona virus. Based on the DSM V and ICD-10 criteria, the diagnosis was of acute psychiatric disorders with symptoms of schizophrenia (F23.1). The case report and review reliefs that there is a causal link between the SARS CoV-2 infection and mental disorders, which is currently being investigated.

Clinical characterization of brief psychotic disorders triggered by the COVID-19 pandemic: a multicenter observational study

This study aimed to characterize the clinical profile of patients with brief psychotic disorders (BPD) triggered by the psychosocial distress derived from the COVID-19 crisis. A multicenter study was conducted from March 14 to May 14, 2020 (the peak weeks of the pandemic in Europe). All consecutive patients presenting non-affective psychotic episodes with a duration of untreated psychosis of less than 1 month and whose onset was related to the COVID-19 crisis were recruited, but only those patients meeting Diagnostic Statistical Manual 5th edition (DSM-5) criteria for "BPD with marked stressors" (DSM-5 code: 298.8) during follow-up were finally included. Patients' sociodemographic and clinical characteristics were collected at baseline and summarized with descriptive statistics. During the study period, 57 individuals with short-lived psychotic episodes related to the emotional stress of the COVID-19 pandemic were identified, of whom 33 met DSM-5 criteria for "BPD with marked stressors". The mean age was 42.33 ± 14.04 years, the gender distribution was almost the same, and the majority were rated as having good premorbid adjustment. About a quarter of the patients exhibited suicidal symptoms and almost half presented first-rank schizophrenia symptoms. None of them were COVID-19 positive, but in more than half of the cases, the topic of their psychotic features was COVID-19-related. The coronavirus pandemic is triggering a significant number of BPD cases. Their risk of suicidal behavior, their high relapse rate, and their low temporal stability make it necessary to closely monitor these patients over time.

Diagnosis, prognosis, and treatment of brief psychotic episodes: a review and research agenda

Brief psychotic episodes represent an intriguing paradox in clinical psychiatry because they elude the standard knowledge that applies to the persisting psychotic disorders such as schizophrenia. This Review describes key diagnostic considerations such as conceptual foundations, current psychiatric classification versus research-based operationalisations, epidemiology, and sociocultural variations; prognostic aspects including the risk of psychosis recurrence, types of psychotic recurrences, other clinical outcomes, prognostic factors; and therapeutic issues such as treatment guidelines and unmet need of care. The advances and challenges associated with the scientific evidence are used to set a research agenda in this area. We conclude that brief psychotic episodes can be reconceptualised within a clinical staging model to promote innovative translational research and improve our understanding and treatment of psychotic disorders.

Predictors of diagnostic stability in brief psychotic disorders: Findings from a 3-year longitudinal study

INTRODUCTION

Brief psychotic disorder (BPD) is a relatively uncommon and underexplored psychotic condition. Even though BPD has been related to a more favorable outcome than other schizophrenia spectrum disorders (SSD), current knowledge of its predictive factors remains scant. This study aimed to examine its prevalence and find early predictors of BPD diagnostic stability.

METHODS

SSD diagnosis following Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria was explored in a large epidemiological cohort (n = 569) of non-affective first-episode psychosis (FEP) patients enrolled in a three-year longitudinal intervention program (PAFIP). Premorbid, sociodemographic, and clinical information was collected to characterize BPD patients and determine factors predictive of diagnostic stability. Multivariate analysis included predictors selected from clinical knowledge and also those that had achieved marginal significance (p ≤ 0.1) in univariate analysis.

RESULTS

A total of 59 patients enrolled in the PAFIP program (10.4% of the whole cohort) met DSM-IV criteria for BPD, of whom 40 completed the three-year follow-up. The temporal stability of BPD in our sample was as high as 40% (n = 16). Transition from BPD to schizophrenia occurred in 37% (n = 15) of patients. Fewer hallucinations at baseline and better insight independently significantly predicted BPD diagnostic stability over time.

CONCLUSION

Our findings confirm that BPD is a clinical condition with moderate-to-low temporal stability and demonstrate that approximately two-thirds of FEP individuals experiencing BPD will develop a long-lasting psychotic disorder during follow-up, mainly schizophrenia.

Clinical outcomes in brief psychotic episodes: a systematic review and meta-analysis

AIMS

Patients with brief psychotic episodes (BPE) have variable and fluctuating clinical outcomes which challenge psychiatric care. Our meta-analysis aims at providing a comprehensive summary of several clinical outcomes in this patient group.

METHODS

A multistep systematic PRISMA/MOOSE-compliant literature search was performed for articles published from inception until 1st March 2021. Web of Science database was searched, complemented by manual search of original articles reporting relevant outcomes (psychotic recurrence, prospective diagnostic change or stability, remission, quality of life, functional status, mortality and their predictors) for patients diagnosed with acute and transient psychotic disorders (ATPD), brief psychotic disorders (BPD), brief intermittent psychotic symptoms (BIPS) and brief limited intermittent psychotic symptoms (BLIPS). Random-effects methods and Q-statistics were employed, quality assessment with Newcastle-Ottawa Scale, assessment of heterogeneity with I2 index, sensitivity analyses (acute polymorphic psychotic disorders, APPD) and multiple meta-regressions, assessment of publication bias with funnel plot, Egger's test and meta-regression (psychotic recurrence and sample size).

RESULTS

A total of 91 independent articles (n = 94 samples) encompassed 37 ATPD, 24 BPD, 19 BLIPS and 14 BIPS samples, totalling 15 729 individuals (mean age: 30.89 ± 7.33 years, mean female ratio: 60%, 59% conducted in Europe). Meta-analytical risk of psychotic recurrence for all BPE increased from 15% (95% confidence interval (CI) 12-18) at 6 months, 25% (95% CI 22-30) at 12 months, 30% (95% CI 27-33) at 24 months and 33% (95% CI 30-37) at ⩾36 months follow-up, with no differences between ATPD, BPD, BLIPS and BIPS after 2 years of follow-up. Across all BPE, meta-analytical proportion of prospective diagnostic stability (average follow-up 47 months) was 49% (95% CI 42-56); meta-analytical proportion of diagnostic change (average follow-up 47 months) to schizophrenia spectrum psychoses was 19% (95% CI 16-23), affective spectrum psychoses 5% (95% CI 3-7), other psychotic disorders 7% (95% CI 5-9) and other (non-psychotic) mental disorders 14% (95% CI 11-17). Prospective diagnostic change within APPD without symptoms of schizophrenia was 34% (95% CI 24-46) at a mean follow-up of 51 months: 18% (95% CI 11-30) for schizophrenia spectrum psychoses and 17% (95% CI 10-26) for other (non-psychotic) mental disorders. Meta-analytical proportion of baseline employment was 48% (95% CI 38-58), whereas there were not enough data to explore the other outcomes. Heterogeneity was high; female ratio and study quality were negatively and positively associated with risk of psychotic recurrence, respectively. There were no consistent factor predicting clinical outcomes.

CONCLUSIONS

Short-lived psychotic episodes are associated with a high risk of psychotic recurrences, in particular schizophrenia spectrum disorders. Other clinical outcomes remain relatively underinvestigated. There are no consistent prognostic/predictive factors.

Assessment of psychiatrists' approaches regarding disclosure of psychiatric disorders to their patients: a qualitative study

Background: Diagnosis disclosure is the result of a shift in medical approaches from traditional paternalism to participatory and patient-centered decision making. Disclosure of psychiatric diagnosis remained uncommon and controversial. Giving information about psychiatric illnesses is very complicated, and it is affected by several factors. While clinical guidelines provide a clear pathway for treating patients, in practice, the treatment of patients is influenced by cultural and social factors. The aim of the current study was a qualitative assessment of psychiatrists’ approaches regarding the disclosure of psychiatric disorders to their patients.

Methods: The current study was conducted with a qualitative approach. The participants were purposefully selected psychiatrists from three medical universities in Tehran, Iran. The data gathered using the semi-structured interview method. Sixteen interviews with 14 psychiatrists were conducted. Data were analyzed using thematic analysis.

Results: Psychiatrists decide to disclose the diagnosis based on several factors. We summarized these factors in a central theme, passive situational decision making based on paternalism and displacement of responsibility. It has two subthemes, including "passive and situational decision making" and "paternalism and displacement of responsibility." Each theme presented by detailed quotations.

Conclusion: The results of this study showed that psychiatrists did not actively disclose the diagnosis name to patients. Diagnosis disclosure was influenced by several factors, such as the certainty about the diagnosis and the severity of the disease. This passive approach does not respect the patient's rights. The paternalistic nature of this approach mandates psychiatrists to consider themselves as the responsible perosn for their patients’ welfare.

Two-year diagnostic stability in a real-world sample of individuals with early psychosis

OBJECTIVES

Diagnostic shifts in first episode psychosis (FEP) are not uncommon. Many studies examining diagnostic stability use structured diagnostic interviews. Less is known about the stability of FEP diagnoses made clinically.

METHODS

We conducted a retrospective chart review of patients enrolled in a transdiagnostic FEP clinic. For the 96 patients followed clinically at least 2 years, we compared diagnoses at intake and 24 months.

RESULTS

Diagnostic stability was high for bipolar disorder (89%), schizoaffective disorder (89%), and schizophrenia (82%). Psychosis not otherwise specified (13%) was more unstable, with limited baseline differences that would enable clinicians to predict who would convert to a primary psychotic vs affective psychotic disorder.

CONCLUSIONS

Our real-world clinical sample shows that FEP diagnoses, with the exception of unspecified psychosis, are diagnostically stable, even without structured diagnostic interviews.

Predictors of diagnostic stability in acute and transient psychotic disorders: validation of previous findings and implications for ICD-11

Acute and transient psychotic disorders (ATPD) have moderate prospective diagnostic stability. Female gender, older age at onset, good premorbid adjustment, abrupt onset, shifting polymorphic symptomatology and absence of schizophrenic features have been found to be predictive factors of diagnostic stability in ATPDs. Nevertheless, most of these findings need to be replicated. The purpose of this study was to evaluate the diagnostic stability of patients with ATPD, and to determine whether previously accepted predictors of diagnostic stability for ATPD could be externally validated in our cohort. To that end, a prospective 2-year observational study was conducted on patients with first-episode ATPD. Multivariate analysis was performed to determine factors associated with ATPD diagnostic stability at the end of the follow-up period. The following prior knowledge variables were analyzed: female gender, older age at onset, good premorbid adjustment, abrupt onset, shifting polymorphic symptomatology and absence of schizophrenic features. Sixty-eight patients with first-episode ATPD completed the follow-up, of whom 55.9% (n = 38) retained their diagnosis of ATPD at the end of the study. Multivariate analysis revealed that diagnostic stability was independently significantly associated with the presence of shifting polymorphic symptomatology (OR = 7.42, 95% CI 1.65-33.30; p = 0.009) and the absence of schizophrenic features (OR = 6.37, 95% CI 1.47-27.54; p = 0.013) at the onset of the psychotic disorder. Our findings provide empirical support for the ICD-11 proposal restricting the new ATPD category to the acute polymorphic disorder without schizophrenia symptoms.

Reactive psychoses in the context of the COVID-19 pandemic: Clinical perspectives from a case series

Introduction

The world is currently undergoing an extremely stressful scenario due to the COVID-19 pandemic. This unexpected and dramatic situation could increase the incidence of mental health problems, among them, psychotic disorders. The aim of this paper was to describe a case series of brief reactive psychosis due to the psychological distress from the current coronavirus pandemic.

Materials and methods

We report on a case series including all the patients with reactive psychoses in the context of the COVID-19 crisis who were admitted to the Virgen del Rocío and Virgen Macarena University Hospitals (Seville, Spain) during the first two weeks of compulsory nationwide quarantine.

Results

In that short period, four patients met the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria for a brief reactive psychotic disorder. All of the episodes were directly triggered by stress derived from the COVID-19 pandemic and half of the patients presented severe suicidal behavior at admission.

Conclusions

We may now be witnessing an increasing number of brief reactive psychotic disorders as a result of the COVID-19 pandemic. This type of psychosis has a high risk of suicidal behavior and, although short-lived, has a high rate of psychotic recurrence and low diagnostic stability over time. Therefore, we advocate close monitoring in both the acute phase and long-term follow-up of these patients.

The prognostic role of catatonia, hallucinations, and symptoms of schizophrenia in acute and transient psychosis

OBJECTIVES

To examine the prospective temporal stability of acute and transient psychotic disorders (ATPDs) and analyze whether there are clinical, psychopathological, or sociodemographic characteristics that predict ATPD diagnostic stability.

METHOD

We conducted a prospective, 2-year, observational study of patients presenting a first-episode ATPD. A multivariate logistic regression model was developed to identify independent variables associated with ATPD diagnostic stability. Well-established predictive factors of diagnostic stability, as well as all the psychopathological features included in the ICD-10 Diagnostic Criteria for Research (DCR) descriptions of ATPD, were analyzed.

RESULTS

Sixty-eight patients with a first episode of ATPD completed the study with a diagnostic stability rate as high as 55.9% (n = 38) at the end of the follow-up period. Multivariate analysis revealed that diagnostic stability was independently significantly associated with the baseline presence of motility disturbances (OR = 6.86, 95% CI = 1.10-42.62; P = 0.039), the absence of hallucinations (OR = 5.75, 95% CI = 1.51-21.98; P = 0.010), and the absence of schizophrenic features (OR = 7.13, 95% CI = 1.38-36.90; P = 0.019).

CONCLUSION

A symptom checklist assessing these psychopathological features would enable early identification of those subjects whose initial ATPD diagnosis will remain stable over time.

Acute and Transient Psychotic Disorders: Newer Understanding

PURPOSE OF REVIEW

We review the ongoing research in the area of acute and transient psychotic disorders (ATPDs) with regard to their nosology, epidemiology, clinical description, genetics, and neurobiology, examining evidence for distinctiveness or otherwise of ATPDs. We further highlight the lacuna in research in ATPDs.

RECENT FINDINGS

Studies on ATPDs as defined in the ICD 10 have been reported from different parts of the world, more so from the developing countries. There is consistent evidence that there exist a group of ATPDs that occur more commonly among females, are often precipitated by stressful life events or exposure to physiological stresses like fever, child birth, are associated with well-adjusted premorbid personality, and show complete recovery in a short period. Although in some cases of ATPDs, there is symptomatic overlap with schizophrenic symptoms in the acute phase, they follow a completely different course and outcome, exhibit genetic distinctiveness, and do not share genetic relationship with schizophrenias or bipolar affective disorder (BPAD). Comparative studies on neurophysiology and neuroimaging in ATPDs and schizophrenias have demonstrated evidence of hyper arousal and hyper metabolism in ATPDs vs hypo arousal and hypo metabolism as noted in the P300 response and on FDG PET studies, respectively. Immune markers such as IL-6, TNF-alpha, and TGF-beta show higher levels in ATPDs as compared to healthy controls. Findings on the neurobiological mechanisms underlying ATPDs, so far, point towards significant differences from those in schizophrenia or BPAD. Although the studies are few and far between, nevertheless, these point towards the possibility of ATPDs as a distinct entity and underscore the need for pursuing alternate hypothesis such as neuro inflammatory or metabolic. Research on ATPDs is limited due to many reasons including lack of harmony between the ICD and DSM diagnostic systems and clinician biases. Available research data supports the validity of ATPDs as a distinct clinical entity. There is also evidence that ATPDs are different from schizophrenias or BPAD on genetic, neuroimaging, neurophysiological, and immunological markers and require further studies.

Inefficient neural system stabilization: a theory of spontaneous resolutions and recurrent relapses in psychosis

A striking feature of psychosis is its heterogeneity. Presentations of psychosis vary from transient symptoms with no functional consequence in the general population to a tenacious illness at the other extreme, with a wide range of variable trajectories in between. Even among patients with schizophrenia, who are diagnosed on the basis of persistent deterioration, marked variation is seen in response to treatment, frequency of relapses and degree of eventual recovery. Existing theoretical accounts of psychosis focus almost exclusively on how symptoms are initially formed, with much less emphasis on explaining their variable course. In this review, I present an account that links several existing notions of the biology of psychosis with the variant clinical trajectories. My aim is to incorporate perspectives of systems neuroscience in a staging framework to explain the individual variations in illness course that follow the onset of psychosis.

Acute transient psychotic disorder precipitated by Brexit vote

A man in his 40s was brought to the accident and emergency department in an acute psychotic state, 3 weeks after the European Union referendum results in the UK were declared. His mental health had deteriorated rapidly following the announcement of the results, with significant concerns about Brexit. He presented as agitated, confused and thought disordered. He had auditory hallucinations, and paranoid, referential, misidentification and bizarre delusions. He recovered completely within 2 weeks after a brief admission and treatment with olanzapine. He had experienced a similar episode of much less severity 13 years previously after major work related stress which resolved completely within a few days. He was experiencing stress related to work and family prior to the current episode which could potentially have been a contributory factor. Political events can act as major psychological stressors and have a significant impact on the mental health of people, especially those with a predisposition to develop mental illness.

Risk and associated factors for a future schizophrenia diagnosis after an index diagnosis of unspecified psychotic disorder: A population-based study

A significant minority of unspecified psychosis presentations progress to schizophrenia. Clinical risk factors can inform targeted referral to specialized treatment programs, but few population studies have examined this. In this study, we used health administrative data for a population-based cohort from Manitoba, Canada to characterize the risk and identify vulnerable subgroups for a future diagnosis of schizophrenia after a diagnosis of unspecified psychotic disorder. Individuals aged 13-60 years with an inpatient or outpatient diagnosis of unspecified psychotic disorder between April 1, 2007 and March 31, 2012, and without any prior diagnosis of schizophrenia or related disorder, were identified (N = 3, 289). The primary outcome was a diagnosis of schizophrenia recorded after the index diagnosis of unspecified psychotic disorder and before March 31, 2015. Adjusted hazard ratios were computed controlling for age, sex, urbanicity, income, prior diagnosis of unspecified psychotic disorder, provider making the diagnosis, prior 12-month psychiatric hospitalization, and prior 12-month diagnoses of mood, anxiety, substance use, or personality disorders, and substance-induced psychosis. A classification tree identified vulnerable subgroups. The cumulative risk of a future diagnosis of schizophrenia was 26% during the follow-up period (mean 4.5 years), with a mean time to diagnosis of 2.0 years. The most vulnerable subgroup was diagnosed by a psychiatrist, younger than 27 years, without a mood or anxiety disorder, male, and residing in a low-income neighborhood; the rate of a subsequent schizophrenia diagnosis was 61.2%. These results support that identification of specific sociodemographic and clinical factors can help clinicians counsel and intervene with those at highest risk.

Predicting one-year outcome in first episode psychosis using machine learning

BACKGROUND

Early illness course correlates with long-term outcome in psychosis. Accurate prediction could allow more focused intervention. Earlier intervention corresponds to significantly better symptomatic and functional outcomes. Our study objective is to use routinely collected baseline demographic and clinical characteristics to predict employment, education or training (EET) status, and symptom remission in patients with first episode psychosis (FEP) at one-year.

METHODS AND FINDINGS

83 FEP patients were recruited from National Health Service (NHS) Glasgow between 2011 and 2014 to a 24-month prospective cohort study with regular assessment of demographic and psychometric measures. An external independent cohort of 79 FEP patients were recruited from NHS Glasgow and Edinburgh during a 12-month study between 2006 and 2009. Elastic net regularised logistic regression models were built to predict binary EET status, period and point remission outcomes at one-year on 83 Glasgow patients (training dataset). Models were externally validated on an independent dataset of 79 patients from Glasgow and Edinburgh (validation dataset). Only baseline predictors shared across both cohorts were made available for model training and validation. After excluding participants with missing outcomes, models were built on the training dataset for EET status, period and point remission outcomes and externally validated on the validation dataset. Models predicted EET status, period and point remission with receiver operating curve (ROC) area under the curve (AUC) performances of 0.876 (95%CI: 0.864, 0.887), 0.630 (95%CI: 0.612, 0.647) and 0.652 (95%CI: 0.635, 0.670) respectively. Positive predictors of EET included baseline EET and living with spouse/children. Negative predictors included higher PANSS suspiciousness, hostility and delusions scores. Positive predictors for symptom remission included living with spouse/children, and affective symptoms on the Positive and Negative Syndrome Scale (PANSS). Negative predictors of remission included passive social withdrawal symptoms on PANSS. A key limitation of this study is the small sample size (n) relative to the number of predictors (p), whereby p approaches n. The use of elastic net regularised regression rather than ordinary least squares regression helped circumvent this difficulty. Further, we did not have information for biological and additional social variables, such as nicotine dependence, which observational studies have linked to outcomes in psychosis.

CONCLUSIONS AND RELEVANCE

Using advanced statistical machine learning techniques, we provide the first externally validated evidence, in a temporally and geographically independent cohort, for the ability to predict one-year EET status and symptom remission in individual FEP patients.

Acute Polymorphic Psychotic Disorder: Concepts, Empirical Findings, and Challenges for ICD-11

The ICD-11 International Classification of Diseases and Related Health Problems will move toward a narrower concept of "acute and transient psychotic disorders" (ATPD) characterized by the remnant "polymorphic psychotic disorder" (APPD) of the current ICD-10 category, also including schizophrenic and predominantly delusional subtypes. To assess the validity of APPD, relevant articles published between January 1993 and September 2017 were found through searches in PubMed and Web of Science. APPD is a rare mental disorder and affects significantly more women than men in early-middle adulthood. Its diagnostic reliability is relatively low, and its consistency reaches just 53.8% on average over 8.8 years, but is significantly greater than either of ATPD subtypes, which are more likely to progress to schizophrenia and related disorders. Although APPD has distinctive features and higher predictive power, its rarity and the fleeting and polymorphic nature of its symptoms could reduce its usefulness in clinical practice and discourage research.

Diagnostic consistency and interchangeability of schizophrenic disorders and bipolar disorders: A 7-year follow-up study

AIM

The change in psychiatric diagnoses in clinical practice is not an unusual phenomenon. The interchange between the diagnoses of schizophrenic disorders and bipolar disorders is a major clinical issue because of the differences in treatment regimens and long-term prognoses. In this study, we used a nationwide population-based sample to compare the diagnostic consistency and interchange rate between schizophrenic disorders and bipolar disorders.

METHODS

In total, 25 711 and 11 261 patients newly diagnosed as having schizophrenic disorder and bipolar disorder, respectively, were retrospectively enrolled from the Psychiatric Inpatient Medical Claims database between 2001 and 2005. We followed these two cohorts for 7 years to determine whether their diagnoses were consistent throughout subsequent hospitalizations. The interchange between the two diagnoses was analyzed.

RESULTS

In the schizophrenic disorder cohort, the overall diagnostic consistency rate was 87.3% and the rate of change to bipolar disorder was 3.0% during the 7-year follow-up. Additional analyses of subtypes revealed that the change rate from schizoaffective disorder to bipolar disorder was 12.0%. In the bipolar disorder cohort, the overall diagnostic consistency rate was 71.9% and the rate of change to schizophrenic disorder was 8.3%.

CONCLUSION

Changes in the diagnosis of a major psychosis are not uncommon. The interchange between the diagnoses of schizophrenic disorders and bipolar disorders might be attributed to the evolution of clinical symptoms and the observation of preserved social functions that contradict the original diagnosis. While making a psychotic diagnosis, clinicians should be aware of the possibility of the change in diagnosis in the future.

Acute and transient psychoses: clinical and nosological issues

This article examines the clinical, epidemiological and nosological aspects of short-lived psychotic disorders as currently classified under ‘acute and transient psychotic disorders' in ICD-10 and ‘brief psychotic disorder’ in DSM-5. After describing earlier diagnostic concepts such as bouffée délirante, cycloid psychosis, reactive psychosis and schizophreniform psychosis, we present an overview of the literature and discuss implications for classification, diagnosis and treatment of these conditions, pointing out differences from longer-lasting psychotic disorders.

Diagnostic validity of ICD-10 acute and transient psychotic disorders and DSM-5 brief psychotic disorder

BACKGROUND

Short-lived psychotic disorders are currently classified under "acute and transient psychotic disorders" (ATPDs) in ICD-10, and "brief psychotic disorder" (BPD) in DSM-5. This study's aim is to review the literature and address the validity of ATPDs and BPD.

METHOD

Papers published between January 1993 and December 2016 were identified through searches in Web of Science. Reference lists in the located papers provided further sources.

RESULTS

A total of 295 articles were found and 100 were included in the review. There were only a few studies about the epidemiology, vulnerability factors, neurobiological correlates and treatment of these disorders, particularly little interest seems to exist in BPD. The available evidence suggests that short-lived psychotic disorders are rare conditions and more often affect women in early to middle adulthood. They also are neither associated with premorbid dysfunctions nor characteristic family predisposition, while there seems to be greater evidence of environmental factors particularly in developing countries and migrant populations. Follow-up studies report a favourable clinical and functional outcome, but case identification has proved difficult owing to high rates of transition mainly either to schizophrenia and related disorders or, to a lesser extent, affective disorders over the short- and longer-terms.

CONCLUSIONS

Although the lack of neurobiological findings and little predictive power argue against the validity of the above diagnostic categories, it is important that they are kept apart from longer-lasting psychotic disorders both for clinical practice and research. Close overlap between ATPDs and BPD could enhance the understanding of these conditions.

Outcome of acute and transient psychotic disorder in an index episode: A study from a tertiary care centre in North India

BACKGROUND

Acute and Transient Psychotic Disorder (ATPD) is a psychotic disorder of brief duration with acute onset and uncertain diagnostic stability.

AIM

To study the diagnostic stability of ATPD during the index episode.

METHOD

140 patients diagnosed with ATPD as per ICD-10, attending a tertiary care hospital in North India were evaluated at follow ups.

RESULTS

Other acute and transient psychotic disorder (ICD10: F23.8) was the most common (69.3%) subtype of ATPD. In 14.28% patients, there was a past episode of ATPD. In our study, 66.3% patient's episodes resolved as ATPD, 32.7% patients converted into either a mood disorder or schizophrenia spectrum disorders.

CONCLUSION

The diagnostic stability of ATPD during the index episode was 66.3% during three months follow up period. Nearly two third of patients with ATPD evolve to either, schizophrenia or mood disorders during the index episode.

Diagnostic and Prognostic Significance of Brief Limited Intermittent Psychotic Symptoms (BLIPS) in Individuals at Ultra High Risk

BACKGROUND

Brief Limited Intermittent Psychotic Symptoms (BLIPS) are key inclusion criteria to define individuals at ultra high risk for psychosis (UHR). Their diagnostic and prognostic significance is unclear.

OBJECTIVES

To address the baseline diagnostic relationship between BLIPS and the ICD-10 categories and examine the longitudinal prognostic impact of clinical and sociodemographic factors.

METHODS

Prospective long-term study in UHR individuals meeting BLIPS criteria. Sociodemographic and clinical data, including ICD-10 diagnoses, were automatically drawn from electronic health records and analyzed using Kaplan-Meier failure function (1-survival), Cox regression models, bootstrapping methods, and Receiver Operating Characteristics (ROC) curve.

RESULTS

Eighty BLIPS were included. At baseline, two-thirds (68%) of BLIPS met the diagnostic criteria for ICD-10 Acute and Transient Psychotic Disorder (ATPD), most featuring schizophrenic symptoms. The remaining individuals met ICD-10 diagnostic criteria for unspecified nonorganic psychosis (15%), mental and behavioral disorders due to use of cannabinoids (11%), and mania with psychotic symptoms (6%). The overall 5-year risk of psychosis was 0.54. Recurrent episodes of BLIPS were relatively rare (11%) but associated with a higher risk of psychosis (hazard ratio [HR] 3.98) than mono-episodic BLIPS at the univariate analysis. Multivariate analysis revealed that seriously disorganizing or dangerous features increased greatly (HR = 4.39) the risk of psychosis (0.89 at 5-year). Bootstrapping confirmed the robustness of this predictor (area under the ROC = 0.74).

CONCLUSIONS

BLIPS are most likely to fulfill the ATPD criteria, mainly acute schizophrenic subtypes. About half of BLIPS cases develops a psychotic disorder during follow-up. Recurrent BLIPS are relatively rare but tend to develop into psychosis. BLIPS with seriously disorganizing or dangerous features have an extreme high risk of psychosis.

Diagnostic Stability of ICD/DSM First Episode Psychosis Diagnoses: Meta-analysis

BACKGROUND

Validity of current International Classification of Disease/Diagnostic and Statistical Manual of Mental Disorders (ICD/DSM) first episode psychosis diagnoses is essential in clinical practice, research, training and public health.

METHOD

We provide a meta-analytical estimate of prospective diagnostic stability and instability in ICD-10 or DSM-IV first episode diagnoses of functional psychoses. Independent extraction by multiple observers. Random effect meta-analysis conducted with the "metaprop," "metaninf," "metafunnel," "metabias," and "metareg" packages of STATA13.1. Moderators were tested with meta-regression analyses. Heterogeneity was assessed with the I ² index. Sensitivity analyses tested robustness of results. Publication biases were assessed with funnel plots and Egger's test.

FINDINGS

42 studies and 45 samples were included, for a total of 14 484 first episode patients and an average follow-up of 4.5 years. Prospective diagnostic stability ranked: schizophrenia 0.90 (95% CI 0.85-0.95), affective spectrum psychoses 0.84 (95% CI 0.79-0.89), schizoaffective disorder 0.72 (95% CI 0.61-0.73), substance-induced psychotic disorder 0.66 (95% CI 0.51-0.81), delusional disorder 0.59 (95% CI 0.47-0.71), acute and transient psychotic disorder/brief psychotic disorder 0.56 (95% CI 0.62-0.60), psychosis not otherwise specified 0.36 (95% CI 0.27-0.45, schizophreniform disorder 0.29 (95% CI 0.22-0.38). Diagnostic stability within schizophrenia spectrum psychoses was 0.93 (95% CI 0.89-0.97); changes to affective spectrum psychoses were 0.05 (95% CI 0.01-0.08). About 0.10 (95% CI 0.05-0.15) of affective spectrum psychoses changed to schizophrenia spectrum psychosis. Across the other psychotic diagnoses there was high diagnostic instability, mostly to schizophrenia.

INTERPRETATION

There is meta-analytical evidence for high prospective diagnostic stability in schizophrenia spectrum and affective spectrum psychoses, with no significant ICD/DSM differences. These results may inform the development of new treatment guidelines for early psychosis and impact drug licensing from regulatory agencies.

Towards diagnostic markers for the psychoses

Psychotic disorders are currently grouped under broad phenomenological diagnostic rubrics. Researchers hope that progress in identifying aetiological mechanisms will ultimately enable more precise division of heterogeneous diagnoses into specific and valid subgroups. This goal has been an aim of psychiatry since the 19th century, when patients with general paresis were thought to have "insanity" similar to dementia praecox and manic depressive illness. Nowadays, the constructs of organic-induced and substance-induced psychotic disorder show that our diagnostic classification system already reflects, in part, aetiological factors. Most recently, gene copy number variation and autoimmunity have been associated with schizophrenia. We suggest how, on the basis of recent scientific advances, we can progress the identification of further putative subgroups and make the most of currently available interventions. Prompt diagnosis and treatment, and a more routine search for causes, could preserve function and improve outcome, and therefore be more acceptable to patients and carers.

Short-term course and outcome of acute and transient psychotic disorders: Differences from other types of psychosis with acute onset

BACKGROUND

The category of 'acute and transient psychotic disorders' (ATPDs) appeared in the ICD-10 Classification of Mental and Behavioural Disorders (ICD-10), but its distinctive features remain uncertain.

AIM

To examine the course and outcome of ATPDs, pointing out differences from other types of psychosis.

METHODS

A one-year follow-up investigation of patients enrolled at the former World Health Organization (WHO) Centre for Research and Training in Mental Health in Aarhus (Denmark) for the WHO collaborative study on acute psychoses.

RESULTS

Of 91 patients aged 15-60 years presenting with acute psychosis, 47 (51.6%) were diagnosed with ATPD, and it occurred more commonly in females; yet, the other acute psychoses featured mainly mood disorders and affected equally both genders. After 1 year, the ATPD diagnosis did not change in 28 cases (59.6%); the remaining developed either affective psychoses (27.7%), or schizophrenia and schizoaffective disorder (12.8%). Nearly, all patients with unchanged diagnosis of ATPD enjoyed full recovery, while those with other types of acute psychosis had significantly higher rates of recurrence or incomplete remission. Duration of illness within 4 weeks and stressful events in the 3 months before symptom onset predicted 1-year favourable clinical outcome for acute psychoses.

CONCLUSION

Although ATPDs fared better over the short-term than other acute psychoses, their diagnostic stability is relatively low.

Duration of untreated psychosis and need for admission in patients who engage with mental health services in the prodromal phase

BACKGROUND

It is unknown whether prodromal services improve outcomes in those who go on to develop psychosis, and whether these patients are demographically different from the overall first-episode population.

AIMS

To compare sociodemographic features, duration of untreated psychosis, hospital admission and frequency of compulsory treatment in the first year after the onset of psychosis in patients who present to prodromal services with patients who did not present to services until the first episode of psychosis.

METHOD

We compared two groups of patients with first-episode psychosis: one who made transition after presenting in the prodromal phase and the other who had presented with a first episode.

RESULTS

The patients who had presented before the first episode were more likely to be employed and less likely to belong to an ethnic minority group. They had a shorter duration of untreated psychosis, and were less likely to have been admitted to hospital and to have required compulsory treatment.

CONCLUSIONS

Patients who develop psychosis after being engaged in the prodromal phase have a better short-term clinical outcome than patients who do not present until the first episode. Patients who present during first episodes may be more likely to have sociodemographic features associated with relatively poor outcomes.