Early sustained recovery following first episode psychosis: Evidence from the AESOP10 follow-up study

OBJECTIVE

To describe the characteristics of individuals with early sustained recovery following first episode psychosis.

METHODS

Individuals with a first episode psychosis were followed-up for ten years. Comparisons were made between those with Early Sustained Recovery and those with Other Course types.

RESULTS

Of 345 individuals, n=43 (12.5%) had Early Sustained Recovery. They were more likely than those with Other Course types to be female (OR=2.45; 95% CI: 1.25-4.81); employed (OR=2.39; 95% CI: 1.22-4.69); in a relationship (OR=2.68; 95% CI: 1.35-5.32); have a short DUP (OR=2.86; 95% CI: 1.37-5.88); and have a diagnosis other than schizophrenia, particularly mania (OR=6.39; 95% CI: 2.52-16.18) or brief psychosis (OR=3.64; 95% CI: 1.10-12.10).

CONCLUSIONS

Sustained recovery from first episode psychosis occurs in a minority.

Ten-year outcomes in first episode psychotic major depression patients compared with schizophrenia and bipolar patients

We aimed to investigate long-term outcomes in psychotic major depression patients compared to schizophrenia and bipolar/manic psychosis patients, in an incidence sample, while accounting for diagnostic change. Based on Aetiology and Ethnicity in Schizophrenia and Other Psychoses (ÆSOP and ÆSOP-10), a first episode psychosis cohort was followed-up 10years after first presentation. The Schedules for Clinical Assessment in Neuropsychiatry, WHO Life Chart and Global Assessment of Functioning were used to assess clinical, social and service use outcomes. Seventy-two PMD patients, 218 schizophrenia patients and 70 psychotic bipolar disorder/mania patients were identified at baseline. Differences in outcome between PMD and bipolar patients based on baseline and lifetime diagnosis were minimal. Differences in clinical, social and service use outcomes between PMD and schizophrenia were more substantial with PMD patients showing better outcomes on most variables. However, there was some weak evidence (albeit not quite statistically significant at p<0.05) based on lifetime diagnoses that PMD patients were more likely to attempt suicide (OR 2.31, CI 0.98-5.42, p0.055) and self-harm (OR 2.34, CI 0.97-5.68, p0.060). PMD patients have better social and service use outcomes compared to people with schizophrenia, but may be more likely to attempt suicide or self-harm. This unique profile is important for clinicians to consider in any risk assessment.

Biological and psychosocial risk factors for psychotic major depression

AIMS

Few studies have investigated risk factors for psychotic major depression (PMD). We aimed to investigate the biological and psychosocial risk factors associated with PMD compared with other psychotic disorders.

METHODS

Based on the aetiology and ethnicity in schizophrenia and other psychoses (ÆSOP) study, we used a case-control study to identify and recruit, at baseline and 10-year follow-up, all first episode cases of psychosis, presenting for the first time to specialist mental health services in defined catchment areas in the UK. Population-based controls were recruited from the same areas. Data were collected on: sociodemographics; social isolation; childhood adversity; life events; minor physical anomalies; and neurological soft signs.

RESULTS

Living alone (aOR = 2.26, CI = 1.21-4.23), basic level qualification (aOR = 2.89, CI = 1.08-7.74), being unemployed (aOR = 2.12, CI = 1.13-3.96), having contact with friends less than monthly (aOR = 4.24, CI = 1.62-11.14), having no close confidants (aOR = 4.71, CI = 2.08-10.68), having experienced childhood adversity (aOR = 2.57, CI = 1.02-6.44), family history of mental illness (aOR = 10.68, CI = 5.06-22.52), family history of psychosis (aOR = 12.85, CI = 5.24-31.51), and having more neurological soft signs (aOR = 1.15, CI = 1.07-1.24) were all associated with a follow-up diagnosis of PMD and schizophrenia. Few variables associated with PMD were also associated with a diagnosis of bipolar disorder. Minor physical anomalies were associated with a follow-up diagnosis of schizophrenia and bipolar disorder, but not PMD.

CONCLUSIONS

Risk factors associated with PMD appear to overlap with those for schizophrenia, but less so for bipolar disorder. Future work on the differential aetiology of PMD, from other psychoses is needed to find the 'specifier' between PMD and other psychoses. Future research on aetiology in PMD, and perhaps other psychoses, should account for diagnostic change.

Diagnostic change 10 years after a first episode of psychosis

BACKGROUND

A lack of an aetiologically based nosology classification has contributed to instability in psychiatric diagnoses over time. This study aimed to examine the diagnostic stability of psychosis diagnoses using data from an incidence sample of psychosis cases, followed up after 10 years and to examine those baseline variables which were associated with diagnostic change.

METHOD

Data were examined from the ÆSOP and ÆSOP-10 studies, an incidence and follow-up study, respectively, of a population-based cohort of first-episode psychosis cases from two sites. Diagnosis was assigned using ICD-10 and DSM-IV-TR. Diagnostic change was examined using prospective and retrospective consistency. Baseline variables associated with change were examined using logistic regression and likelihood ratio tests.

RESULTS

Slightly more (59.6%) cases had the same baseline and lifetime ICD-10 diagnosis compared with DSM-IV-TR (55.3%), but prospective and retrospective consistency was similar. Schizophrenia, psychotic bipolar disorder and drug-induced psychosis were more prospectively consistent than other diagnoses. A substantial number of cases with other diagnoses at baseline (ICD-10, n = 61; DSM-IV-TR, n = 76) were classified as having schizophrenia at 10 years. Many variables were associated with change to schizophrenia but few with overall change in diagnosis.

CONCLUSIONS

Diagnoses other than schizophrenia should to be regarded as potentially provisional.

The involvement of parents in healthcare decisions where adult children are at risk of lacking decision-making capacity: a qualitative study of treatment decisions in epilepsy

BACKGROUND

Patients with intellectual disabilities (ID) receive health care by proxy. It is family members and/or paid support staff who must recognise health problems, communicate with clinicians, and report the benefits, if any, of a particular treatment. At the same time international and national statutes protect and promote the right of people with disabilities to access the highest attainable standards of health on the basis of free and informed consent.

METHODS

To consider the role of parent-proxies in the management of epilepsy in adult children with ID who are at risk of lacking capacity to make decisions about their health care we interviewed 21 mothers.

FINDINGS

These mothers are not pursuing changes in treatment that might improve their son or daughter's epilepsy, nor are they willing to countenance changes in treatment. Clinicians concerned to build and sustain therapeutic alliances with these mothers, our evidence suggests, may well avoid going against their wishes.

DISCUSSION

Our research highlights the interactional contingencies of a hitherto neglected three-way clinical relationship comprising parent-proxy, an adult at risk of lacking decision-making capacity, and a treating clinician. This is a relationship, our findings suggest, where little importance is attached to either patient consent, or involvement in treatment decisions.

Association between pubertal development and depressive symptoms in girls from a UK cohort

BACKGROUND

It is unclear whether pubertal status or timing of puberty explains the increase in depressive symptoms in girls during adolescence.

METHOD

This is a longitudinal study based on 2506 girls from the Avon Longitudinal Study of Parents and Children (ALSPAC). Self-reported depressive symptoms at 10.5, 13 and 14 years were assessed using the Short Mood and Feelings Questionnaire (SMFQ). Pubertal status (Tanner breast and pubic hair stage) and timing of menarche were derived from questionnaires administered from age 8 to 14 years. We used multivariable regression models to examine the relative contributions of pubertal status and timing in accounting for increases in level of depressive symptoms at 14 years.

RESULTS

With increasing age, the association between breast development and depressive symptoms strengthened. Pubertal status (breast stage), rather than timing of menarche, was independently associated with depressive symptoms at 14 years. There was strong evidence for a linear relationship between breast stage and depressive symptoms at 14 years [increase in 0.17 S.D. (range 0.10-0.24) of depressive symptoms for advancement of each breast stage].

CONCLUSIONS

Depressive symptoms in mid-adolescence were more strongly influenced by breast stage than timing of menarche. This could imply that the female rise in depression during adolescence is due to increasing estrogen levels, and might explain why the gender difference in rates of depression emerges at this stage. Future research should be aimed at identifying the mechanism of action of pubertal change, including direct effects of pubertal hormones and indirect effects mediated by psychosocial factors.

Measuring patients' views: a bifactor model of distinct patient-reported outcomes in psychosis

BACKGROUND

Patient-reported outcomes (PROs) are widely used for evaluating the care of patients with psychosis. Previous studies have reported a considerable overlap in the information captured by measures designed to assess different outcomes. This may impair the validity of PROs and makes an a priori choice of the most appropriate measure difficult when assessing treatment benefits for patients. We aimed to investigate the extent to which four widely established PROs [subjective quality of life (SQOL), needs for care, treatment satisfaction and the therapeutic relationship] provide distinct information independent from this overlap.

METHOD

Analyses, based on item response modelling, were conducted on measures of SQOL, needs for care, treatment satisfaction and the therapeutic relationship in two large samples of patients with psychosis.

RESULTS

In both samples, a bifactor model matched the data best, suggesting sufficiently strong concept factors to allow for four distinct PRO scales. These were independent from overlap across measures due to a general appraisal tendency of patients for positive or negative ratings and shared domain content. The overlap partially impaired the ability of items to discriminate precisely between patients from lower and higher PRO levels. We found that widely used sum scores were strongly affected by the general appraisal tendency.

CONCLUSIONS

Four widely established PROs can provide distinct information independent from overlap across measures. The findings may inform the use and further development of PROs in the evaluation of treatments for psychosis.

Is the incidence of psychotic disorder in decline? Epidemiological evidence from two decades of research

BACKGROUND

It is unclear whether the incidence of first episode psychoses is in decline. We had the opportunity to determine whether incidence had changed over a 20-year period in a single setting, and test whether this could be explained by demographic or clinical changes.

METHODS

The entire population at-risk aged 16-54 in Nottingham over three time periods (1978-80, 1993-95 and 1997-99) were followed up. All participants presenting with an ICD-9/10 first episode psychosis were included. The remainder of the population at-risk formed the denominator. Standardized incidence rates were calculated at each time period with possible change over time assessed via Poisson regression. We studied six outcomes: substance-induced psychoses, schizophrenia, other non-affective psychoses, manic psychoses, depressive psychoses and all psychotic disorders combined.

RESULTS

Three hundred and forty-seven participants with a first episode psychosis during 1.2 million person-years of follow-up over three time periods were identified. The incidence of non-affective or affective psychoses had not changed over time following standardization for age, sex and ethnicity. We observed a linear increase in the incidence of substance-induced psychosis, per annum, over time (incidence rate ratios: 1.15; 95% CI 1.05-1.25). This could not be explained by longitudinal changes in the age, sex and ethnic structure of the population at-risk.

CONCLUSIONS

Our findings suggest psychotic disorders are not in decline, though there has been a change in the syndromal presentation of non-affective disorders, away from schizophrenia towards other non-affective psychoses. The incidence of substance-induced psychosis has increased, consistent with increases in substance toxicity over time, rather than changes in the prevalence or vulnerability to substance misuse. Increased clinical and popular awareness of substance misuse could also not be excluded.

Cognitive behaviour therapy for improving social recovery in psychosis: a report from the ISREP MRC Trial Platform Study (Improving Social Recovery in Early Psychosis)

BACKGROUND

This study reports on a preliminary evaluation of a cognitive behavioural intervention to improve social recovery among young people in the early stages of psychosis showing persistent signs of poor social functioning and unemployment. The study was a single-blind randomized controlled trial (RCT) with two arms, 35 participants receiving cognitive behaviour therapy (CBT) plus treatment as usual (TAU), and 42 participants receiving TAU alone. Participants were assessed at baseline and post-treatment.

METHOD

Seventy-seven participants were recruited from secondary mental health teams after presenting with a history of unemployment and poor social outcome. The cognitive behavioural intervention was delivered over a 9-month period with a mean of 12 sessions. The primary outcomes were weekly hours spent in constructive economic and structured activity. A range of secondary and tertiary outcomes were also assessed.

RESULTS

Intention-to-treat analysis on the combined affective and non-affective psychosis sample showed no significant impact of treatment on primary or secondary outcomes. However, analysis of interactions by diagnostic subgroup was significant for secondary symptomatic outcomes on the Positive and Negative Syndrome Scale (PANSS) [F(1, 69)=3.99, p=0.05]. Subsequent exploratory analyses within diagnostic subgroups revealed clinically important and significant improvements in weekly hours in constructive and structured activity and PANSS scores among people with non-affective psychosis.

CONCLUSIONS

The primary study comparison provided no clear evidence for the benefit of CBT in a combined sample of patients. However, planned analyses with diagnostic subgroups showed important benefits for CBT among people with non-affective psychosis who have social recovery problems. These promising results need to be independently replicated in a larger, multi-centre RCT.

Early developmental milestones in adult schizophrenia and other psychoses. A 31-year follow-up of the Northern Finland 1966 Birth Cohort

Delayed childhood development may precede adult psychoses. We tested this hypothesis in a large, general population birth cohort (n=12058) followed to age 31 years. The ages at which individuals learned to stand, walk, speak, and became potty-trained (bowel control) and dry (bladder control), were recorded at a 1-year examination. Psychiatric outcome was ascertained through linkage to a national hospital discharge register. Cumulative incidence of DSM-III-R schizophrenia, other psychoses and non-psychotic disorders were stratified according to the timing of milestones and compared within the cohort using internal standardization. 100 cases of DSM-III-R schizophrenia, 55 other psychoses, and 315 non-psychotic disorders were identified. The ages at learning to stand, walk and become potty-trained were each related to subsequent incidence of schizophrenia and other psychoses. Compared with the whole cohort, earlier milestones reduced, and later milestones increased, the risk in a linear manner. These developmental effects were not seen for non-psychotic outcomes. The findings support hypotheses regarding psychosis as having a developmental dimension with precursors apparent in early life.

Birth order and risk for schizophrenia: a 31-year follow-up of the Northern Finland 1966 Birth Cohort

OBJECTIVE

The Northern Finland 1966 Birth Cohort was studied in order to investigate the association between birth order and schizophrenia.

METHOD

Four categories of birth order status (first-born, last-born, only child and other status) were formed and linked to data on psychiatric morbidity. Effects were adjusted for wantedness of pregnancy, perinatal complications, maternal age at delivery, family type and number of siblings.

RESULTS

The risk for schizophrenia was elevated among male first-borns (ratio 1.5; 95% CI 1.0-2.2) and female last-borns (ratio 1.3; 95% CI 0.9-1.9). The risk was lower than expected among male last-borns (ratio 0.7; 95% CI 0.5-0.9) and females belonging to other status (ratio 0.6; 95% CI 0.3-0.9).

CONCLUSION

These results suggest that specific birth order status is an independent risk factor for schizophrenia. Theoretical explanations may arise from biological factors unidentified here and/or psychological stressors linked with these positions.

Juvenile and early adulthood smoking and adult educational achievements--a 31-year follow-up of the Northern Finland 1966 Birth Cohort

AIMS

To investigate the association between juvenile and early adult cigarette smoking and educational achievements up to the age of 31 years.

METHODS

As a part of the follow-up of the North Finland 1966 Birth Cohort (n = 10542) from 1966 to 1997, smoking was assessed at the ages of 14 and 31 by postal questionnaires. The highest level of educational attainment was obtained from the National Education Registry of Statistics Finland up to the age of 31 years.

RESULTS

Adult smoking (at age 31) and prolonged smoking (at ages 14 and 31) were both associated with an approximately two- to sixfold, adjusted odds for educational underachievement. Smoking only at age 14 showed none of these associations.

CONCLUSION

These results are unlikely to be causal, but may be explained by other characteristics associated with smoking such as personality or lifestyle factors, as well as the effect of knowledge related to smoking gained during higher education.

Aggressive incidents in first-episode psychosis

BACKGROUND

Recent research has reported increased risk of aggressive incidents by individuals with psychotic illness.

AIMS

To examine acts of aggression in first-episode psychosis.

METHOD

Subjects with a first-episode psychosis were ascertained from a defined catchment area (Nottingham, UK) and reassessed at 3 years (n=166) using clinical interview, informants, health care and forensic records.

RESULTS

Of the subjects, 9.6% demonstrated at least one act of serious aggression (defined as weapon use, sexual assault or victim injury) during at least one psychotic episode and 23.5% demonstrated lesser acts of aggression (defined as all other acts of aggression). For all aggressive subjects (33.1%), unemployment (OR=3.6, 95% C11.6-8.0), comorbid substance misuse (OR=3.1, C1 1.1-8.8) and symptoms of overactivity at service contact (OR=6.9,C1 2.7-17.8) had independent effects on risk of aggression.

CONCLUSIONS

We confirmed some previously reported demographic and clinical associations with aggression in first-episode psychosis but no relationship with specific psychotic symptoms or diagnostic groups was observed.

Childhood and adolescent predictors of schizophrenia in the Northern Finland 1966 birth cohort--a descriptive life-span model

Subtle motor, emotional, cognitive and behavioral abnormalities are often present in apparently healthy children and adolescents who later develop schizophrenia. This suggests that some aspects of causation are established long before psychosis is manifest. We aim to develop a descriptive model of the factors contributing to the development of schizophrenia. Our main focus is on genetic factors, pregnancy and delivery complications, early development and scholastic performance. This is done by reviewing the Northern Finland 1966 Birth Cohort, its scientific activities (publications and work in progress) and selected literature.

Three-year outcome of first-episode psychoses in an established community psychiatric service

BACKGROUND

Changes in service provision, secular trends in substance misuse and changing social structures might affect outcome in psychosis.

AIMS

To assess the three-year outcome of an inception cohort of first-episode psychoses treated in a modern, community-oriented service; to compare outcomes with an earlier cohort treated in hospital-based care; and to examine the predictive validity of ICD-10 diagnostic criteria.

METHOD

Three-year follow-up (1995-1997) of an inception cohort of first-episode psychoses and comparison with two-year follow-up (1980-1982) of the Determinants of Outcome of Severe Mental Disorders (DOSMED) Nottingham cohort.

RESULTS

On most outcome measures, non-affective psychoses had a worse outcome than affective psychoses. Affective psychoses had better outcome than previously reported. Substance-related psychoses had very poor occupational outcome. Similar proportions of the current and DOSMED cohort were in remission but the former were rated as having greater disability.

CONCLUSIONS

In a modern community service, 30-60% of patients with first-episode psychoses experience a good three-year outcome. The ICD-10 criteria have good predictive validity.

Outcome of psychosis in people of African-Caribbean family origin. Population-based first-episode study

BACKGROUND

An increased incidence of psychotic disorders has repeatedly been reported among African-Caribbeans in the UK.

AIMS

To test whether the increased incidence of psychotic disorders in first- and second-generation African-Caribbeans in the UK could be caused by a relative excess of affective-related psychoses with good prognosis.

METHOD

Thirty-three patients of African-Caribbean family origin identified in a population-based study of first-episode psychoses were compared with the remaining cases. Three-year outcomes and patterns of course were compared.

RESULTS

There was a trend for better outcomes in African-Caribbean patients for symptoms and social disability, but patterns of course were similar (odds ratio = 0.9 (0.50 to 2.00)) [corrected]. Pattern of course improved after adjustment for confounding by gender, social class, age, diagnosis and duration of untreated illness (odds ratio = 0.59 (0.21 to 1.66)) [corrected]. Diagnostic profiles were similar, with no evidence of greater diagnostic instability in the African-Caribbean group.

CONCLUSION

Pattern of course of psychosis did not differ significantly by ethnic family background. An excess of good-prognosis affective psychoses is an unlikely explanation for increased rates of psychosis in African-Caribbeans.

Evaluating the Health of the Nation Outcome Scales. Reliability and validity in a three-year follow-up of first-onset psychosis

BACKGROUND

The HoNOS has been developed as a routine measure of outcomes in mental health.

AIMS

To explore the validity and interrater reliability of HoNOS in a first-onset psychosis follow-up study.

METHOD

Between 1992 and 1994 we ascertained a cohort of all persons with first-onset psychosis. We re-assessed these people at 3 years (n = 166) with several outcome scales, including HoNOS. Patients' keyworkers also completed the HoNOS. We estimated concurrent validity by calculating correlations between HoNOS and other scales, and interrater reliability.

RESULTS

Researcher HoNOS correlated highly with other scales (0.46 < p < 0.86; P < 0.001). Keyworker HoNOS correlations were lower (0.41 < p < 0.51; P < 0.05), but still significant for all scores except the HoNOS-social subscale (0.12 < p < 0.28). Agreements between researcher and keyworker HoNOS were modest (0.47 < ICC < 0.85).

CONCLUSIONS

In this research cohort HoNOS correlates well with established outcome scales. Keyworker ratings show similar, but weaker, relationships; its use in routine settings may require further training for calibration of severity.

Perceived ethnicity and the risk of compulsory admission

Black-Caribbean patients are more often admitted compulsorily to psychiatric wards than patients from other ethnic groups. We tested the hypothesis that perceived ethnicity of a patient had no independent effect on the risk of compulsory admission. For all consecutive admissions over a 6-month period to acute psychiatric wards in Nottingham, medical officers responsible for the decision to admit completed a questionnaire recording clinical details of the patients and reasons for admission. The results showed that 43.2% of Black-Caribbean patients and 18.8% of White patients were admitted compulsorily (unadjusted odds ratio 3.29, 95% CI 1.71-6.33). Perceived ethnicity (Black-Caribbean) was significantly associated with being young, receiving a diagnosis of psychosis, and being perceived to be at a risk of violent acting out. A forced entry logistic regression model was used to adjust for hypothesised confounding variables such as age, sex, diagnosis, risk, socio-economic status and level of social support. A diagnosis of psychosis, risk of committing violence and being Black-Caribbean had independent effects on the risk of being compulsorily detained. The odds ratio for compulsory detention of Black-Caribbean patients was 2.16 (95% CI 1.03-4.52) after adjusting for the hypothesised confounding variables.

The predictive validity of a diagnosis of schizophrenia. A report from the International Study of Schizophrenia (ISoS) coordinated by the World Health Organization and the Department of Psychiatry, University of Nottingham

BACKGROUND

Outcome is important in the validation of psychiatric diagnosis, as most disorders lack clinicopathological correlates. We describe the predictive validity of four definitions of schizophrenia (DSM-III-R, ICD-10, ICD-9 and CATEGO S+), in a representative cohort of patients selected during their first episode of psychosis.

METHOD

Each definition of schizophrenia was applied to 99 patients. Their respective ability to predict 13-year outcome (Global Assessment of Functioning scales) was assessed.

RESULTS

DSM-III-R and ICD-10 diagnoses of schizophrenia have high predictive validity for long-term outcome, and both provide relatively stable diagnoses. ICD-9 is reasonably good at predicting disability, but not symptoms, and CATEGO S+ showed no predictive validity. Adding six-month duration criteria to ICD-10, ICD-9 and CATEGO S+ improved their predictive validity, and removing the six-month duration criterion from DSM-III-R commensurately reduced predictive validity.

CONCLUSIONS

Modern diagnostic systems (DSM-III-R and ICD-10) have high predictive validity, and are superior to ICD-9. The six-month duration criterion of DSM-III-R schizophrenia accounts for its predictive validity and stability over 13 years, but restricts its use in first-episode studies. The one-month duration criterion of ICD-10 is less restrictive, without major compromises in predictive validity or stability.

The course of schizophrenia over 13 years. A report from the International Study on Schizophrenia (ISoS) coordinated by the World Health Organization

BACKGROUND

This paper describes the 13 year course of illness in an epidemiologically defined and representative cohort of patients selected when they were experiencing their first episode of schizophrenia.

METHOD

In a 13-year follow-up study of 67 patients with ICD-9 schizophrenia, identified in Nottingham in 1978-80, the course of illness (symptoms, disability and hospitalisation) was assessed using standardised instruments, applied at onset, 1,2, and 13 years. Time to first relapse and first readmission were calculated and plotted as survival curves and patients were assigned to the course types described by Ciompi.

RESULTS

The survival curves show that first relapses and first readmissions occur during the first five years. The amount of time spent in psychotic episodes and in hospital is greatest in the first year of follow-up, but stable thereafter. Social adjustment improves from entry to the study to the first follow-up year, but there is a small deterioration in social adjustment between 2 and 13 years.

CONCLUSIONS

The findings reported suggest that after the initial episode the course of schizophrenia is relatively stable. The data support neither concepts of progressive deterioration nor progressive amelioration. There was no evidence of a "late recovery'.

Predicting the long-term outcome of schizophrenia

Predictors of long-term (13 year) outcome of schizophrenia are reported for a representative cohort of 'treated incidence' patients ascertained on their first contact with Nottingham psychiatric services between 1978-80. An initial (baseline) model including previously reported predictors of 2-year outcome (age, gender, ever married, acuteness of onset) and length of untreated illness was used to predict a range of outcome measures covering the domains of disability, psychopathology, hospitalization, employment, social activity, and global outcome. This model demonstrated significant prognostic ability across all non-hospitalization outcomes under both ICD-10 and ICD-9 diagnoses of schizophrenia, but was attenuated under broad (ICD-9 and CATEGO S, P or O) and restrictive (S+) diagnostic classifications. Female gender predicted more favourable outcome under all diagnostic classifications except S+. In an extended analysis, the addition of initial 2-year course type substantially increased the prognostic ability of the model under all diagnostic classifications and enabled over 30% of the variance in global ratings of disability and symptoms to be predicted. In this extended model female gender predicted more favourable outcome over and above the effect of course type, across most domains under ICD-10, and for disability and psychopathology under other diagnostic classifications. The inclusion of measures of psychopathology at the time of first assessment, pre-morbid functioning, and duration of index admission conferred only marginal additional predictive ability for respective outcomes in the domains of psychopathology, social activity, employment and hospitalization. Hospitalization during the past year was the most difficult outcome to predict under any model suggesting that resource utilization represents the 'administrative outcome' of schizophrenia and serves as a poor proxy for broader concerns in the era of community care. These data demonstrate that key demographic variables and the mode of onset influence the long-term course of schizophrenia, but that early course type is a particularly strong predictor.

Characteristics of outcome in schizophrenia at 13 years

BACKGROUND

This paper describes the 13-year outcome of an epidemiologically defined and representative cohort of patients selected when they were experiencing their first episode of schizophrenia.

METHOD

In a 13-year follow-up study of a cohort identified in Nottingham in 1978-80, the outcome (symptoms, disability, residence and treatment) was assessed using standardised instruments.

RESULTS

Four of the original 67 patients with ICD-9 schizophrenia were lost to follow-up and five were dead: 52% were without psychotic symptoms in the last two years of follow-up, 52% were without negative symptoms and 55% showed good/fair social functioning. However, only 17% were alive at follow-up, without symptoms and disability, and receiving no treatment.

CONCLUSIONS

The findings reported are similar to those of other long-term follow-up studies of schizophrenia and also to 5-year follow-up studies. Kraepelin's emphasis on the longitudinal implications of a diagnosis of schizophrenia are supported, but may be over-pessimistic.

Residence of incident cohort of psychotic patients after 13 years of follow up

OBJECTIVE

To establish the residential history of an incident cohort of psychotic patients 13 years after their first contact with the psychiatric services.

DESIGN

Tracing of all patients admitted to the WHO study on determinants of outcome of severe mental disorders in Nottingham between 1978 and 1980. Patients were assessed using standardised and comparable instruments, and extra information was obtained from key informants and medical records.

SETTING

Catchment area of Nottingham psychiatric services.

MAIN OUTCOME MEASURES

Main place of residence over the previous two years and residential history over 13 years in terms of homelessness, imprisonment, and use of high dependency psychiatric facilities.

RESULTS

95 patients were traced. At the point of follow up no patients were in long stay psychiatric wards, two were in supervised residence, none was homeless, and none was in prison or a high security hospital. 85 patients were living either independently alone or with their family or friends in the community. Of these, 44 had had no contact with the psychiatric services at the point of follow up.

CONCLUSIONS

Although many patients experienced a difficult early course of illness, the longer term outcome of the disorder was associated with remarkably low periods of homelessness and imprisonment and low use of intensive care facilities. These findings offer some reassurance, given the concerns about the effectiveness of community oriented care for this potentially most vulnerable group of psychiatric patients.