Predictors of long-term outcome of first-episode schizophrenia: A ten-year follow-up study

Approaches and challenges to assessing risk of violence in first episode psychosis: A qualitative interview study of clinicians, patients and carers

AIM

Clinical services for early psychosis seek to improve prognosis for a range of adverse outcomes. For some individuals, perpetration of violence is an important potential outcome to reduce. How these clinical services currently assess this risk however is uncertain. This study aimed to address this gap by using qualitative methods to examine in depth current approaches, attitudes and challenges to assessing violence risk in this clinical setting, from the perspectives of multidisciplinary clinicians, patients and carers.

METHODS

Participants were recruited from two UK Early Intervention in Psychosis services. Semi-structured individual interviews were undertaken using a topic guide. In addition, clinical vignettes were presented to clinician participants as a probe to prompt discussion. Data were analysed using thematic analysis, informed by the constant comparative method.

RESULTS

We conducted 30 qualitative interviews, of 18 clinicians and 12 patients and carers. Themes developed from clinician interviews included key difficulties of low confidence, limited training, accessing collateral information and variation in how risk is appraised and communicated. Potential stigma and sensitivity of the topic of violence were perceived as barriers to its discussion. Patient and carer perspectives provided insight into how to address barriers, and highlighted the importance of an open approach, including with families.

CONCLUSIONS

We recommend developing contextually appropriate pathways to collaboratively assess violence risk and identify modifiable needs to reduce this risk, and for practical improvements in training and information-sharing.

Acute and transient psychotic disorders: A review of Indian research

Background

Acute and transient psychotic disorder (ATPD) was recognized as separate from other psychotic disorders and described in the International Classification of Diseases (ICD) tenth revision for the first time. A lot of research on ATPD has been conducted in India over the last six decades, but a review focusing exclusively on Indian research on ATPD is not available.

Aim

This paper aims to review the literature on ATPD emerging from India.

Methodology

A combination of search terms "Acute and Transient Psychosis," "acute psychosis," "non-affective psychosis," "non-affective psychotic disorder," "reactive psychosis," "first-episode psychosis," and "India" were searched on various search engines like PUBMED, Medknow, Hinari, and Google Scholar. We also did a hand search for additional relevant articles, including published abstracts of the Indian Journal of Psychiatry from 2007 to 2023. Relevant papers were selected.

Results

The prevalence of ATPD varies across different study settings, and it tends to have an abrupt to acute onset, and is primarily associated with stress. Few studies have assessed the subtypes of ATPD, and symptom profile has been inconsistently reported. There is a lack of trials on the effectiveness or efficacy of antipsychotics in ATPD patients. In a large proportion of patients initially diagnosed with ATPD, the diagnosis remains stable, with recurrence varying from 10% to 46.6% based on the duration of follow-up.

Conclusion

There is a need for more multicentric studies, studies with larger sample sizes, and consistency in data about risk factors. There is a need to evaluate symptom profile, course, outcome, and treatment outcomes in patients with ATPD using validated instruments to improve our understanding. Further, there is a need for comparative studies to evaluate the risk factors for ATPD.

Are Lipids Possible Markers of Suicide Behaviors?

Suicides and suicidal behaviors are very important causes of mortality and morbidity and have become a serious global problem. More than 800,000 people die from suicide every year. Previous researches have established that lipids play an important role in the pathogenesis of suicide. Moreover, lipid levels might be a biological marker of suicide. A lot of researchers have tried to identify biological markers that might be related to depressive disorder, bipolar disorder or schizophrenia and suicidal behavior. It was also important to consider the usefulness of an additional tool for prevention actions. Metabolic deregulation, particularly low total cholesterol and low-density lipoproteins-cholesterol levels may cause higher suicide risk in patients with these psychiatric disorders.

The burden of disease in early schizophrenia - a systematic literature review

BACKGROUND

Schizophrenia is a heterogeneous disorder with a burden that can vary greatly depending on the severity and the duration. Previous research has suggested that patients in the earlier stages of schizophrenia (typically first-episode schizophrenia) benefit from effective early treatment, however, a comprehensive review of the burden specifically in this population has not been undertaken. A systematic literature review was therefore conducted to characterize the clinical, economic, and humanistic burden, as reported in naturalistic studies of schizophrenia populations specifically at an early stage of disease in comparison with healthy controls, patients with chronic schizophrenia, and patients with other psychiatric disorders.

METHODS AND MATERIALS

Searches were conducted in MEDLINE, MEDLINE In-Process, Embase, PsycINFO, and EconLit databases for records published between January 2005 and April 2019, and of relevant conference abstracts published between January 2014 and May 2019. Data were extracted from relevant publications and subjected to qualitative evaluation.

RESULTS

Fifty-two publications were identified for inclusion and revealed a considerable burden for early schizophrenia with regards to mortality, psychiatric comorbidities such as substance abuse and depression, poor social functioning, and unemployment. Comparisons with chronic schizophrenia suggested a greater burden with longer disease duration, while comparisons with other psychiatric disorders were inconclusive. This review uncovered various gaps in the available literature, including limited or no data on incarcerations, caregiver burden, and costs associated with early schizophrenia.

CONCLUSIONS

Overall, the burden of schizophrenia is apparent even in the early stages of the disease, although further research is required to quantify the burden with chronic schizophrenia and other psychiatric disorders.

Nature and Correlates of Executive Dysfunction in Schizophrenia: An Exploratory Study

BACKGROUND

Executive function (EF) impairment has been demonstrated in patients with schizophrenia. This study attempted to examine the clinical and demographic correlates associated with the different components of EF in these patients using a comprehensive battery of neuropsychological tests.

MATERIALS AND METHODS

Consecutive inpatients with schizophrenia in remission were recruited. The following instruments were administered: (a) Positive and Negative Syndrome Scale (PANSS), (b)World Health Organization Disability Assessment Schedule 2.0, (c) Tower of London, (d) Stroop Test, (e) Controlled Oral Word Association Test, (f) Animal Names Test, and (g) Verbal N-Back Test. Sociodemographic and clinical details were also recorded. Data was analyzed using standard bivariate and multivariate statistics.

RESULTS

A total of 50 patients were recruited. The mean age of the population was 30 years (standard deviation [SD]: 7.74). The majority were male, literate, single, from a rural background, from a middle socioeconomic background, and unemployed. The mean dose of antipsychotic medication was 618.57 mg (SD: 282.08) of chlorpromazine equivalents per day. Impairment was found in the different sub-components of EF. On multivariate analysis, factors significantly associated with executive dysfunction were lower education, unemployment, lower income, positive PANSS score, higher antipsychotic dose, and history of treatment with electroconvulsive therapy.

CONCLUSION

EFs encompass a wide range of cognitive processes that influence an individual's ability to adapt and function in the society. These are often impaired in patients with schizophrenia. Clinicians need to be aware of these deficits and factors associated with them, to plan appropriate and effective remedial measures.

Depressive symptoms during first episode psychosis and functional outcome: A systematic review and meta-analysis

OBJECTIVES

First episode psychosis (FEP) is associated with functional decline. Existing evidence was synthesised to explore the influence of depressive symptoms during FEP on future social, occupational and global functioning.

METHODS

Medline, Embase, PsychINFO, Cochrane Library, Open Grey, NICE Evidence and Web of Science were searched from inception to May 2018. Longitudinal studies of FEP patients were included. Study quality was assessed using the Downs and Black instrument. Two meta-analyses were performed using random effect models. The first meta-analysis correlates depressive symptoms during FEP with follow-up Global Assessment of Functioning (GAF) scores. The second meta-analysis shows the odds of long-term functional remission if depressive symptoms are present during FEP.

RESULTS

4751 unique abstracts were found. 36 articles were included. The first meta-analysis included 7 studies (932 participants) and showed depressive symptoms during FEP were negatively correlated with follow-up GAF scores (r = -0.16, 95% CI: -0.24 to -0.09, p < 0.001). The second meta-analysis of 9 studies (2265 participants) showed weak evidence of an association between the presence of depressive symptoms in FEP and reduction in functional remission (OR = 0.87, 95% CI: 0.68 to 1.13, p = 0.294).

CONCLUSION

Depressive symptoms during FEP are associated with poorer long-term global functioning and may be associated with a reduced chance of achieving functional remission. Clinical trials are needed to identify efficacious management of depressive symptoms in early psychosis.

Very long-term outcome of schizophrenia

PURPOSE

The principal aim is to review recent data concerning the very long-term outcome of schizophrenia and schizophrenia spectrum disorders. We examine factors that influence outcome, including therapeutic interventions.

METHOD

PubMed and Scopus databases were searched for papers published between 2008 and 2017 reporting on prospective studies of schizophrenia or schizophrenia spectrum with a follow-up period ≥5 years with adequate outcome information. Additional publications were found in reference lists and authors' reference libraries.

RESULTS

The average proportion of patients with symptomatic remission at follow-up ranged between 16.4% in never-treated patients to 37.5% in patients who were systematically treated with antipsychotics. Good outcomes at follow-up were observed in schizophrenia and schizophrenia spectrum patients on low doses of antipsychotics and in patients with no pharmacological treatment at that time. Early detection and intensive treatment of the first episode as well as the availability of continued psychosocial treatment and support over subsequent years appeared associated with better outcomes.

CONCLUSION

The long-term outcome of schizophrenia is highly variable, depending on access to mental healthcare, early detection of psychosis and pharmacological treatment. Recent data support the effectiveness of low-dose antipsychotic treatment for long-term maintenance in some patients. A proportion of first-episode schizophrenia patients, perhaps 20%, do not need long-term maintenance antipsychotic treatment. That proportion may be higher in schizophrenia spectrum patients. The reasons why these patients do not need the long-term treatment are not well understood. Methods to predict the membership in this subgroup are not yet good enough for clinical use in individual patients.

Instrumental Activities of Daily Living Dysfunction among People with Schizophrenia

BACKGROUND

Life skills are the basic skills that are needed to live independently and that support meaningful, productive roles. The negative symptoms and cognitive dysfunction seen in schizophrenia may lead to deterioration in the life skills of the patient. The assessment of current life skills of the patient and subsequent intervention becomes necessary for comprehensive rehabilitation of people with mental illness. This study attempted to assess the instrumental activities of daily living among people with schizophrenia in India.

METHODS

One hundred consecutive patients with schizophrenia, between 18 and 60 years, who presented to a tertiary psychiatric facility were assessed using (i) Lawton instrumental activities of daily living scale (LIADL), (ii) positive and negative symptom scale (PANSS), (iii) pro forma for sociodemographic and clinical characteristics.

RESULTS

The majority of the patients were male, young adults, married, with secondary school education, middle socioeconomic status, from nuclear families, unemployed and were diagnosed to have paranoid schizophrenia. The reported IADL dysfunction included difficulties in handling medications (86%), preparing food (85%), shopping (78%), handling finances (61%), doing laundry (52%), housekeeping (47%), using public transport (32%), and using telephones (5%). The dysfunction documented differs from that reported in the west. Total PANSS score (P = 0.015) and its general psychopathology subscale (P = 0.005) correlated inversely with the total LIADL score; PANSS scores and sociodemographic variables were associated with some subscales of LIADL.

CONCLUSIONS

IADL dysfunction, common in people with schizophrenia, demands detailed assessment, and tailored training to ensure optimum functioning.

Remission and recovery from first-episode psychosis in adults: systematic review and meta-analysis of long-term outcome studies

BackgroundRemission and recovery rates for people with first-episode psychosis (FEP) remain uncertain.AimsTo assess pooled prevalence rates of remission and recovery in FEP and to investigate potential moderators.MethodWe conducted a systematic review and meta-analysis to assess pooled prevalence rates of remission and recovery in FEP in longitudinal studies with more than 1 year of follow-up data, and conducted meta-regression analyses to investigate potential moderators.ResultsSeventy-nine studies were included representing 19072 patients with FEP. The pooled rate of remission among 12301 individuals with FEP was 58% (60 studies, mean follow-up 5.5 years). Higher remission rates were moderated by studies from more recent years. The pooled prevalence of recovery among 9642 individuals with FEP was 38% (35 studies, mean follow-up 7.2 years). Recovery rates were higher in North America than in other regions.ConclusionsRemission and recovery rates in FEP may be more favourable than previously thought. We observed stability of recovery rates after the first 2 years, suggesting that a progressive deteriorating course of illness is not typical. Although remission rates have improved over time recovery rates have not, raising questions about the effectiveness of services in achieving improved recovery.

Serum cholesterol and Suicide in first episode psychosis: A preliminary study

BACKGROUND

Low levels of cholesterol have been described in suicide behavior including among those individuals who have an increased tendency for impulsivity. Violent suicide attempters show significantly lower cholesterol levels than nonviolent suicide attempters. The suicide rate is particularly high in the prodromal and early phase of schizophrenia. It is unclear if there is a psychopathological relationship between early psychosis, suicide, and cholesterol levels. The present study examines levels of cholesterol and suicide behavior in a cohort of early psychosis.

METHODOLOGY

Sixty admitted patients with the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, diagnosis of nonaffective schizophrenia spectrum disorder (early psychosis) were assessed in a naturalistic cross-sectional, cohort study. Psychopathology was assessed with the Positive and Negative Symptom Scale for Schizophrenia (PANSS), Hamilton Depression Rating Scale, and Scale for Impact of Suicidality-Management, Assessment and Planning of Care (SIS-MAP). Serum levels of cholesterol were estimated in the cohort as well. The findings were analyzed for a clinical correlation of cholesterol levels, suicidal attempters, and psychopathology.

RESULTS

Out of 60 patients, 13 patients had a suicide attempt in the recent past. No serum cholesterol abnormality (3.7 ± 1.2 mmol/L) was observed in patients as a group and those with low suicidality (SIS-MAP <17, serum cholesterol: 4.1 ± 1.3 mmol/L). However, low levels of cholesterol were observed in a subgroup with severe suicidality (SIS-MAP >33; serum cholesterol: 3.5 ± 1.4 mmol/L). Females with moderate suicidality showed statistically significant lower cholesterol levels than males (P = 0.047).

CONCLUSIONS

The study suggests lower levels of cholesterol in patients of psychosis with severe suicidal thoughts and depression in early psychosis. More research is required in this field to determine the neurochemistry of suicide behavior in psychosis and its significance in the prediction of suicidal behavior.

Mental health starts with physical health: current status and future directions of non-pharmacological interventions to improve physical health in first-episode psychosis

People with psychotic disorders have reduced life expectancy compared with the general population. This difference is primarily due to increased prevalence of cardiovascular disease associated with antipsychotic drugs and with modifiable risk factors, including weight gain, low exercise, poor diet, and high prevalence of cigarette smoking. We review non-pharmacological interventions for physical health behaviour in patients with chronic and first-episode psychosis. Our findings suggest that weight loss and attenuation of weight gain are achievable but limited and might not persist beyond the end of an intervention. Evidence for smoking cessation interventions is scarce. The case for early intervention to prevent deterioration of physical health is strong. We propose a framework for development of interventions, which addresses three main factors largely absent in previous research: (1) examination of aetiological factors related to poor physical health, (2) theory-driven interventions that target aetiological factors, and (3) assessment of feasibility.

Course and outcome of schizophrenia in asian countries: review of research in the past three decades

Considerable variation has been observed in the course and outcome of schizophrenia. With regard to epidemiology of schizophrenia, papers from different Asian countries have reported findings which are in contrast with literature from the western countries. In this background we undertook a narrative review of literature regarding course and outcome of schizophrenia in Asian countries. We conducted Medline search for English-language papers on long-term course and outcome of schizophrenia conducted in Asia in the past 3 decades. We also reviewed data pertaining to Asian countries from the World Health Organization's International Study of Schizophrenia (ISoS). In addition to ISoS, we retrieved 14 reports from 9 Asian countries. While ISoS used comparable methodology across the countries, non-ISoS studies differed substantially in their aims, sampling, follow-up rates and assessment tools used for studying the course and outcome. Overall, the percentage of patients who experienced clinical and functional outcome in the Asian countries were largely comparable to those in the western studies. We observed significant variations in the long-term outcome and mortality in schizophrenia even among the Asian countries. In conclusion, there is substantial variation in the long-term course and outcome and mortality across different Asian countries. The reason for this remains unexplored. Cross-national studies exploring biological and cultural explanations for this variation may provide clues, which may have heuristic, translational and public-health significance.

Schizophrenia and gastroesophageal reflux symptoms

BACKGROUND

Psychological factors and psychiatric disorders play a role in a variety of gastrointestinal illnesses, including esophageal diseases.

AIM

The aim of the present study was to evaluate the frequency of gastroesophageal reflux disease symptoms in patients with schizophrenia in Turkey.

PATIENTS AND METHODS

Ninety-eight patients with schizophrenia and one hundred control individuals were enrolled in the study, which was undertaken at the Manisa State Hospital for Mental Health and Neurological Disorders and Celal Bayar University Gastroenterology Department. Case and control subjects alike underwent 30-45 min oral interviews conducted by a designated study coordinator (E.K.). The coordinator gathered information about demographic characteristics, social habits, and a large variety of symptoms suggestive of reflux disease or other gastrointestinal conditions.

RESULTS

In terms of reflux symptoms, cough was the only significant association in schizophrenic patients than controls. Heartburn and regurgitation were more frequent in schizophrenic patients who smoked than in controls who were smokers. However, the prevalence of reflux symptoms in cigarette smokers versus nonsmoker patients with schizophrenia was similar. Heartburn and/or regurgitation occurred more frequently in patients with schizophrenic than controls with alcohol use.

CONCLUSIONS

Psychiatric disorders might indirectly affect esophageal physiology through increased consumption of alcohol and nicotine.

Changes in aspects of cognitive functioning in young patients with schizophrenia during group psychodynamic psychotherapy: a preliminary study

BACKGROUND

The "Sveti Ivan" psychiatric hospital in Zagreb, Croatia, offers an outpatient Early Intervention Program for psychotic patients. This program consists of psycho-educational workshops and group psychodynamic psychotherapy. Two important objectives of the program are improving and maintaining adequate cognitive functioning.

AIMS

The current study examined changes in aspects of cognitive functioning in young patients with schizophrenia after 18 months and after 3 years of psychodynamic group psychotherapy.

METHODS

The study included 28 patients who attended the Early Intervention Program for young patients with psychotic disorders; 10 patients had completed only the psycho-educational part of the program (comparative group), and 18 patients continued with group psychodynamic psychotherapy (experimental group). All patients completed the Revised Beta Examination.

RESULTS

We observed a trend in the experimental group to achieve higher scores than the comparative group. The results for both groups tended to increase with time, and this increase was greater in the experimental group.

CONCLUSIONS

While acknowledging the limitations of this preliminary study, we conclude that participating in psychodynamic group psychotherapy is related to increases in the cognitive functioning of patients with schizophrenia, and our results provide a sound basis for future research.

Trajectories of antipsychotic response in drug-naive schizophrenia patients: results from the 6-month ESPASS follow-up study

OBJECTIVE

The aim of this study was to explore any heterogeneity in the 6-month clinical response in patients with antipsychotic drug-naive schizophrenia and to determine predictors of that outcome.

METHOD

467 patients with antipsychotic drug-naive schizophrenia were included in France nationwide and followed up over 6 months. To identify trajectories of clinical response, a latent class growth analysis (LCGA) was performed using the Clinical Global Impression-Severity (CGI-S) scores at baseline, 1, 3, and 6 months. Regression models were used to identify predictors of trajectory membership.

RESULTS

Five trajectory groups were identified: a rapid response group (n = 45), a gradual response group (n = 204), patients remaining mildly ill (n = 133), patients remaining very ill (n = 23), and a group with unsustained clinical response (n = 62). Predictors of the 6-month clinical response were baseline CGI-S score (odds ratio: 3.1; 95% confidence interval, 2.1-4.4) and negative symptoms (OR, 1.5; 95% CI, 1.2-1.9). The sole predictor of rapid response as compared to gradual response was employment (OR, 2.5; 95% CI, 1.2-4.9).

CONCLUSION

Clinical response in patients with schizophrenia 6 months after a first-ever antipsychotic drug initiation is heterogeneous. Therapeutic strategies in first episode should take account of symptom severity and early clinical response, to maximize the chances of recovery.

Short-term functional outcome and premorbid adjustment in clinical high-risk patients. Results of the EPOS project

PURPOSE

In patients with schizophrenia, premorbid psychosocial adjustment is an important predictor of functional outcome. We studied functional outcome in young clinical high-risk (CHR) patients and how this was predicted by their childhood to adolescence premorbid adjustment.

METHODS

In all, 245 young help-seeking CHR patients were assessed with the Premorbid Adjustment Scale, the Structured Interview for Prodromal Syndromes (SIPS) and the Schizophrenia Proneness Instrument (SPI-A). The SIPS assesses positive, negative, disorganised, general symptoms, and the Global Assessment of Functioning (GAF), the SPI-A self-experienced basic symptoms; they were carried out at baseline, at 9-month and 18-month follow-up. Transitions to psychosis were identified. In the hierarchical linear model, associations between premorbid adjustment, background data, symptoms, transitions to psychosis and GAF scores were analysed.

RESULTS

During the 18-month follow-up, GAF scores improved significantly, and the proportion of patients with poor functioning decreased from 74% to 37%. Poor premorbid adjustment, single marital status, poor work status, and symptoms were associated with low baseline GAF scores. Low GAF scores were predicted by poor premorbid adjustment, negative, positive and basic symptoms, and poor baseline work status. The association between premorbid adjustment and follow-up GAF scores remained significant, even when baseline GAF and transition to psychosis were included in the model.

CONCLUSION

A great majority of help-seeking CHR patients suffer from deficits in their functioning. In CHR patients, premorbid psychosocial adjustment, baseline positive, negative, basic symptoms and poor working/schooling situation predict poor short-term functional outcome. These aspects should be taken into account when acute intervention and long-term rehabilitation for improving outcome in CHR patients are carried out.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

A systematic review of the evidence of clozapine's anti-aggressive effects

Reducing the risk of violent and aggressive behaviour in patients with schizophrenia remains a clinical priority. There is emerging evidence to suggest that the second-generation antipsychotic, clozapine, is effective at reducing this risk in patients with schizophrenia and some evidence to suggest that it may be best in selected patients. We conducted a systematic literature search in March 2011 of all prospective and retrospective studies, which investigated clozapine's anti-aggressive effects in a variety of mental disorders. The review identified six animal studies, four randomized controlled trials, 12 prospective non-controlled studies and 22 retrospective studies, with four case studies. We found considerable evidence in support of clozapine's ability to reduce violent and aggressive behaviour. Clozapine's anti-aggressive effect was most commonly explored in patients with schizophrenia, with less evidence available for other psychiatric disorders, including borderline personality disorder, autistic spectrum disorders, post-traumatic stress disorder, bipolar disorder and learning disability. There was mixed evidence to address the question of whether or not clozapine was any more effective than other antipsychotics. In the case of schizophrenia, there was evidence to suggest that clozapine's anti-aggressive effect was more marked particularly in those with treatment-resistant illness. Its anti-aggressive effects appeared to be 'specific', being to some extent greater than both its more general antipsychotic and sedative effects. There were significant methodological inconsistencies in the studies we identified, particularly surrounding patient recruitment criteria, the definition and measurement of violence and the lack of randomized, controlled trials. Data on therapeutic monitoring were also limited. Clozapine can reduce violence and persistent aggression in patients with schizophrenia and other psychiatric disorders. It may offer an advantage over other antipsychotics, although perhaps exclusively in the case of traditionally defined 'treatment resistance' or more broadly defined 'complex cases' with co-morbidity. Larger, randomized, blinded, controlled studies with robust characterization of participants, and standardized measures of violence and aggression are, however, needed to fully understand this link and explore the possible mechanisms.

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

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