Opinions of mothers on the first psychotic episode and the start of treatment of their child

Parents, especially mothers, have a critical role in initiating psychiatric treatment for their child with first-episode schizophrenia. Knowledge of attitudes of mothers towards the illness of their child prior to psychiatric treatment and towards the start of treatment is essential for the development of interventions for reducing duration of untreated psychosis (DUP). In the present study, mothers (n = 61) of consecutively admitted patients with recent-onset schizophrenic disorders were interviewed about: their views on the nature of the symptoms at first occurrence of psychotic symptoms in their child and views on the main reason for psychiatric treatment; their perception of problems in initiating psychiatric treatment; and suggestions they might have for getting treatment started at an earlier point in time. About 57% of the mothers did not think that their child had a psychosis at first occurrence of psychotic symptoms. Most of the mothers who immediately thought that their child suffered from a psychotic disorder supposed that this disorder was caused by use of street drugs. About one-third (32.8%) of the mothers thought that the reluctance of patients to acknowledge that they needed help was the major obstacle in initiating psychiatric treatment. More than half of the mothers perceived factors related to the delivery of professional care as problems in initiating psychiatric treatment. Given the reluctance of patients to accept treatment, these problems further complicate the initiating of treatment. Mothers emphasize that a more active approach by professional caregivers could reduce treatment delay.

Development of a stage-dependent prognostic model to predict psychosis in ultra-high-risk patients seeking treatment for co-morbid psychiatric disorders

BACKGROUND

Current ultra-high-risk (UHR) criteria appear insufficient to predict imminent onset of first-episode psychosis, as a meta-analysis showed that about 20% of patients have a psychotic outcome after 2 years. Therefore, we aimed to develop a stage-dependent predictive model in UHR individuals who were seeking help for co-morbid disorders.

METHOD

Baseline data on symptomatology, and environmental and psychological factors of 185 UHR patients (aged 14-35 years) participating in the Dutch Early Detection and Intervention Evaluation study were analysed with Cox proportional hazard analyses.

RESULTS

At 18 months, the overall transition rate was 17.3%. The final predictor model included five variables: observed blunted affect [hazard ratio (HR) 3.39, 95% confidence interval (CI) 1.56-7.35, p < 0.001], subjective complaints of impaired motor function (HR 5.88, 95% CI 1.21-6.10, p = 0.02), beliefs about social marginalization (HR 2.76, 95% CI 1.14-6.72, p = 0.03), decline in social functioning (HR 1.10, 95% CI 1.01-1.17, p = 0.03), and distress associated with suspiciousness (HR 1.02, 95% CI 1.00-1.03, p = 0.01). The positive predictive value of the model was 80.0%. The resulting prognostic index stratified the general risk into three risk classes with significantly different survival curves. In the highest risk class, transition to psychosis emerged on average ⩾8 months earlier than in the lowest risk class.

CONCLUSIONS

Predicting a first-episode psychosis in help-seeking UHR patients was improved using a stage-dependent prognostic model including negative psychotic symptoms (observed flattened affect, subjective impaired motor functioning), impaired social functioning and distress associated with suspiciousness. Treatment intensity may be stratified and personalized using the risk stratification.

Cost-effectiveness of preventing first-episode psychosis in ultra-high-risk subjects: multi-centre randomized controlled trial

BACKGROUND

Although there is evidence for the effectiveness of interventions for psychosis among ultra-high-risk (UHR) groups, health economic evaluations are lacking. This study aimed to determine the cost effectiveness and cost-utility of cognitive-behavioural therapy (CBT) to prevent first-episode psychosis.

METHOD

The Dutch Early Detection and Intervention Evaluation study was a randomized controlled trial of 196 UHR patients with an 18-month follow-up. All participants were treated with routine care (RC) for non-psychotic disorders. The experimental group (n = 95) received add-on CBT to prevent first-episode psychosis. We report the intervention, medical and travel costs, as well as costs arising from loss of productivity. Treatment response was defined as psychosis-free survival and quality-adjusted life years (QALYs) gained.

RESULTS

In the cost-effectiveness analysis, the proportion of averted psychoses was significantly higher in the CBT condition (89.5% v. 76.2%). CBT showed a 63.7% probability of being more cost effective, because it was less costly than RC by US$844 (£551) per prevented psychosis. In the cost-utility analysis, QALY health gains were slightly higher for CBT than for RC (0.60 v. 0.57) and the CBT intervention had a 52.3% probability of being the superior treatment because, for equal or better QALY gains, the costs of CBT were lower than those of RC.

CONCLUSIONS

Add-on preventive CBT for UHR resulted in a significant reduction in the incidence of first psychosis. QALY gains show little difference between the two conditions. The CBT intervention proved to be cost saving.

The Strauss and Carpenter Prognostic Scale in subjects clinically at high risk of psychosis

OBJECTIVE

To investigate the predictive value of the Strauss and Carpenter Prognostic Scale (SCPS) for transition to a first psychotic episode in subjects clinically at high risk (CHR) of psychosis.

METHOD

Two hundred and forty-four CHR subjects participating in the European Prediction of Psychosis Study were assessed with the SCPS, an instrument that has been shown to predict outcome in patients with schizophrenia reliably.

RESULTS

At 18-month follow-up, 37 participants had made the transition to psychosis. The SCPS total score was predictive of a first psychotic episode (P < 0.0001). SCPS items that remained as independent predictors in the Cox proportional hazard model were as follows: most usual quality of useful work in the past year (P = 0.006), quality of social relations (P = 0.006), presence of thought disorder, delusions or hallucinations in the past year (P = 0.001) and reported severity of subjective distress in past month (P = 0.003).

CONCLUSION

The SCPS could make a valuable contribution to a more accurate prediction of psychosis in CHR subjects as a second-step tool. SCPS items assessing quality of useful work and social relations, positive symptoms and subjective distress have predictive value for transition. Further research should focus on investigating whether targeted early interventions directed at the predictive domains may improve outcomes.

Age at onset of non-affective psychosis in relation to cannabis use, other drug use and gender

BACKGROUND

Cannabis use is associated with an earlier age at onset of psychotic illness. The aim of the present study was to examine whether this association is confounded by gender or other substance use in a large cohort of patients with a non-affective psychotic disorder.

METHOD

In 785 patients with a non-affective psychotic disorder, regression analysis was used to investigate the independent effects of gender, cannabis use and other drug use on age at onset of first psychosis.

RESULTS

Age at onset was 1.8 years earlier in cannabis users compared to non-users, controlling for gender and other possible confounders. Use of other drugs did not have an additional effect on age at onset when cannabis use was taken into account. In 63.5% of cannabis-using patients, age at most intense cannabis use preceded the age at onset of first psychosis. In males, the mean age at onset was 1.3 years lower than in females, controlling for cannabis use and other confounders.

CONCLUSIONS

Cannabis use and gender are independently associated with an earlier onset of psychotic illness. Our findings also suggest that cannabis use may precipitate psychosis. More research is needed to clarify the neurobiological factors that make people vulnerable to this precipitating effect of cannabis.

Ethnicity and baseline symptomatology in patients with an At Risk Mental State for psychosis

BACKGROUND

Ethnicity has been associated with different incidence rates and different symptom profiles in young patients with psychotic-like disorders. No studies so far have examined the effect of ethnicity on symptoms in people with an At Risk Mental State (ARMS).

METHOD

In this cross-sectional study, we analysed the relationship between ethnicity and baseline data on the severity of psychopathology scores in 201 help-seeking patients who met the ARMS criteria and agreed to participate in the Dutch Early Detection and Intervention (EDIE-NL) trial. Eighty-seven of these patients had a non-Dutch ethnicity. We explored the possible mediating role of ethnic identity.

RESULTS

Higher rates of negative symptoms, and of anhedonia in particular, were found in the ethnic minority group. This result could be attributed mainly to the Moroccan-Dutch and Turkish-Dutch subgroups, who also presented with more depression symptoms when the groups were examined separately. The ethnic minority group displayed a lower level of ethnic group identity compared to the immigrants of the International Comparative Study of Ethnocultural Youth (ICSEY). Ethnic identity was inversely related to symptoms in the Moroccan-Dutch patient group.

CONCLUSIONS

The prevalence of more severe negative symptoms and depression symptoms in ethnic minority groups deserves more attention, as the experience of attenuated positive symptoms when accompanied by negative symptoms or distress has proven to be predictive for transition to a first psychotic episode.

Cannabis use and age at onset of symptoms in subjects at clinical high risk for psychosis

OBJECTIVE

Numerous studies have found a robust association between cannabis use and the onset of psychosis. Nevertheless, the relationship between cannabis use and the onset of early (or, in retrospect, prodromal) symptoms of psychosis remains unclear. The study focused on investigating the relationship between cannabis use and early and high-risk symptoms in subjects at clinical high risk for psychosis.

METHOD

Prospective multicenter, naturalistic field study with an 18-month follow-up period in 245 help-seeking individuals clinically at high risk. The Composite International Diagnostic Interview was used to assess their cannabis use. Age at onset of high risk or certain early symptoms was assessed retrospectively with the Interview for the Retrospective Assessment of the Onset of Schizophrenia.

RESULTS

Younger age at onset of cannabis use or a cannabis use disorder was significantly related to younger age at onset of six symptoms (0.33 < r(s) < 0.83, 0.004 < P < 0.001). Onset of cannabis use preceded symptoms in most participants.

CONCLUSION

Our results provide support that cannabis use plays an important role in the development of psychosis in vulnerable individuals. Cannabis use in early adolescence should be discouraged.

Three-year course of clinical symptomatology in young people at ultra high risk for transition to psychosis

OBJECTIVE

The investigation into the course of ultra high risk (UHR) symptomatology of those patients who eventually do not meet the psychosis-threshold criteria within the 3-year timeframe of the study.

METHOD

The course of UHR symptoms, GAF score and employment status was investigated in 57 patients who did not make a transition to psychosis and who were examined within the Dutch Prediction of Psychosis Study in Amsterdam, the Netherlands.

RESULTS

At the 3-year follow-up, 75% of the patients who did not make a transition to psychosis had remitted from UHR status. With a Generalized Estimation Equation Model it was shown that this group recovered from positive (F = 52.7, P < 0.0001), negative (F = 24.3, P < 0.0001), disorganization (F = 14.4, P < 0.0001) and general symptoms (F = 25.0, P < 0.0001) within the timeframe of the study. In addition, the level of global functioning and likelihood of having a job and/or education significantly improved. The largest improvements occurred within the first year. UHR symptoms did not re-occur after improvement.

CONCLUSION

With the current UHR criteria, a large percentage of the included subjects appear to have transitory complaints and dysfunctioning. A refinement of the UHR criteria may diminish the chance of including 'false positives' in future UHR studies.

Striatal D₂ receptor binding in 22q11 deletion syndrome: an [¹²³I]IBZM SPECT study

It has been hypothesised that in subjects with 22q11 deletion syndrome (22q11DS) disturbances of the dopamine (DA) system contribute to their increased risk for cognitive deficits and psychiatric problems. However, central DAergic neurotransmission in 22q11DS has not been investigated. We measured striatal D₂ receptor binding potential (D₂R BP(ND)) using (S)-(-)-3-iodo-2-hydroxy-6-methoxy-N-[(1-ethyl-2-pyrrolidinyl)methyl] benzamide-single photon emission computed tomography ([¹²³I]IBZM SPECT) in 12 adults with 22q11DS and 12 matched controls. Correlations between D₂R BP(ND) and plasma prolactin (pPRL) levels were also determined. 22q11DS subjects and controls had similar D₂R BP( ND). There was a positive correlation between D₂R BP( ND) and pPRL values in controls, but no such relation was found in 22q11DS subjects. This study suggests that a 22q11 deletion does not affect striatal DAergic neurotransmission in the living human brain. However, the disturbed relationship between D₂R BP(ND) and pPRL values suggests DAergic dysfunction at a different level. Further studies on DAergic function in extra-striatal brain regions and under challenged conditions are needed.

Neurocognitive functioning before and after the first psychotic episode: does psychosis result in cognitive deterioration?

BACKGROUND

Cognitive impairment is considered to be a core characteristic of schizophrenia. The relationship between psychosis and cognitive deterioration, however, remains unclear. This longitudinal study investigated the neuropsychological functioning of patients before and after their first psychotic episode. Cognitive functioning of participants who later developed a psychosis was compared to that of people at ultra-high risk (UHR) for psychosis who did not develop psychosis at follow-up and healthy controls.MethodParticipants were 41 persons at UHR for psychosis (the UHR group), of whom 17 developed psychosis between the first and second assessment. Seventeen healthy controls were included in the study. Cognitive performance was assessed at intake (T0) and again after 18 months (T1). The areas of cognitive functioning assessed include verbal memory and learning, visuospatial working memory, executive function, sustained attention and motor speed.

RESULTS

The transition group did not perform significantly worse at the second assessment than at the first on any of the outcome measures. The UHR group performed better on a verbal learning and memory test at T1 compared to T0. At T0, the control group scored significantly better than the UHR group and the transition group on the verbal learning and memory test and the verbal fluency test.

CONCLUSIONS

The results indicate that no cognitive deterioration occurs during the first psychotic episode. Problems in verbal memory may be present before the first episode of psychosis.

Implicit and explicit affective associations towards cannabis use in patients with recent-onset schizophrenia and healthy controls

BACKGROUND

Cannabis use is common in patients with recent-onset schizophrenia and this is associated with poor disease outcome. More insight in the cognitive-motivational processes related to cannabis use in schizophrenia may inform treatment strategies. The present study is the first known to compare implicit and explicit cannabis associations in individuals with and without psychotic disorder.

METHOD

Participants consisted of 70 patients with recent-onset psychotic disorder and 61 healthy controls with various levels of cannabis use. Three Single-Category Implicit Association Tests (SC-IAT) were used to assess 'relaxed', 'active' and 'negative' implicit associations towards cannabis use. Explicit expectancies of cannabis use were assessed with a questionnaire using the same words as the SC-IAT.

RESULTS

There were no differences in implicit associations between patients and controls; however, patients scored significantly higher on explicit negative affect expectancies than controls. Both groups demonstrated strong negative implicit associations towards cannabis use. Explicit relaxed expectancies were the strongest predictors of cannabis use and craving. There was a trend for implicit active associations to predict craving.

CONCLUSIONS

The findings indicate that patients suffering from schizophrenia have associations towards cannabis similar to controls, but they have stronger negative explicit cannabis associations. The strong negative implicit associations towards cannabis could imply that users of cannabis engage in a behaviour they do not implicitly like. Explicit relaxing expectancies of cannabis might be an important mediator in the continuation of cannabis use in patients and controls.

White-matter markers for psychosis in a prospective ultra-high-risk cohort

BACKGROUND

Subjects at 'ultra high risk' (UHR) for developing psychosis have differences in white matter (WM) compared with healthy controls. WM integrity has not yet been investigated in UHR subjects in relation to the development of subsequent psychosis. Hence, we investigated a prospective cohort of UHR subjects comparing whole brain fractional anisotropy (FA) of those later developing psychosis (UHR-P) to those who did not (UHR-NP).

METHOD

We recruited 37 subjects fulfilling UHR criteria and 10 healthy controls. Baseline 3 Tesla magnetic resonance imaging (MRI) scans and Positive and Negative Syndrome Scale (PANSS) ratings were obtained. UHR subjects were assessed at 9, 18 and 24 months for development of frank psychosis. We compared baseline FA of UHR-P to controls and UHR-NP subjects. Furthermore, we related clinical data to MRI outcome in the patient population.

RESULTS

Of the 37 UHR subjects, 10 had transition to psychosis. UHR-P subjects showed significantly lower FA values than control subjects in medial frontal lobes bilaterally. UHR-P subjects had lower FA values than UHR-NP subjects, lateral to the right putamen and in the left superior temporal lobe. UHR-P subjects showed higher FA values, compared with UHR-NP, in the left medial temporal lobe. In UHR-P, positive PANSS negatively correlated to FA in the left middle temporal lobe. In the total UHR group positive PANSS negatively correlated to FA in the right superior temporal lobe.

CONCLUSIONS

UHR subjects who later develop psychosis have differences in WM integrity, compared with UHR subjects who do not develop psychosis and to healthy controls, in brain areas associated with schizophrenia.

Increased saccadic rate during smooth pursuit eye movements in patients at Ultra High Risk for developing a psychosis

Abnormalities in eye tracking are consistently observed in schizophrenia patients and their relatives and have been proposed as an endophenotype of the disease. The aim of this study was to investigate the performance of patients at Ultra High Risk (UHR) for developing psychosis on a task of smooth pursuit eye movement (SPEM). Forty-six UHR patients and twenty-eight age and education matched controls were assessed with a task of SPEM and psychiatric questionnaires. Our results showed that both the corrective and non-corrective saccadic rates during pursuit were higher in the UHR group. There were however no differences in smooth pursuit gain between the two groups. The saccadic rate was related to positive UHR symptoms. Our findings indicate that abnormalities in SPEM are already present in UHR patients, prior to a first psychotic episode. These abnormalities occur only in the saccadic system.

[Women, schizophrenia and oestrogen; neurobiological hypotheses and hormonetherapy studies]

BACKGROUND

Gender differences play a role in the origin and course of schizophrenia. It has been hypothesised that the gonadal hormone, oestrogen, may possibly perform a protective function in the development of certain forms of schizophrenia.

AIM

To review neurobiological hypotheses concerning the role of oestrogen in the development and course of schizophrenia.

METHOD

The relevant literature was consulted with the help of PubMed, textbooks and bibliographic references; the search terms used were 'oestrogen', 'schizophrenia', 'gender', 'epigenetics', 'psychosis', 'women' and 'brain'. There were no restrictions with regards to the time-period.

RESULTS

Neuro-imaging, animal experiments and hormone-therapy studies showed several effects of oestrogen in the field of epigenetics, morphology of the brain, interaction with neurotransmitters and neuroprotection.

CONCLUSION

Oestrogen is an important link in a complex of factors that clearly play a role in the varying development of schizophrenia in men and women. So far, however, there is insufficient evidence to support the existence of a specific mechanism that would explain why oestrogen may perform a protective function in schizophrenia.

Polyunsaturated fatty acids and brain white matter anisotropy in recent-onset schizophrenia: a preliminary study

Brain white matter myelin abnormalities and cell membrane fatty acid abnormalities have been implicated in schizophrenia and other psychiatric disorders. We investigated in young adults with a psychotic disorder (n=12) whether (poly)unsaturated fatty acid concentrations in erythrocyte membranes are related to an MRI measure of brain white matter, which depends on the degree of myelination. A significant correlation was found between total (poly)unsaturated fatty acid concentration and fractional anisotropy of a fronto-temporal white matter tract (r=0.503, P=0.048). Unsaturated fatty acids may be necessary for the myelinating activity of oligodendrocytes or for myelin maintenance. These results warrant further investigation.

Early intervention in patients at ultra high risk of psychosis: benefits and risks

OBJECTIVE

Prediction of transition to psychosis in the prodromal phase of schizophrenia has raised interest in intervention prior to the onset of frank psychosis. The aim of this review was to examine whether interventions in the prodromal phase have a favourable benefit/risk ratio.

METHOD

A literature search in PubMed, EMBASE and PsycINFO was performed.

RESULTS

Three randomized clinical trials with antipsychotic medication and/or cognitive behavioural therapy as clinical intervention suggested a positive effect at the end of treatment, but no significant differences were found at the end of follow-up periods from 1 to 4 years. Naturalistic studies present a hypothesis about a possible preventive effect of antidepressive medication. The results of eight other studies are more difficult to interpret. Side-effects of antipsychotic medication and non-adherence with medication are essential problems.

CONCLUSION

At the present time, the data concerning the benefits and risks do not justify prodromal intervention as standard clinical practice.

Reasons for cannabis use and effects of cannabis use as reported by patients with psychotic disorders

BACKGROUND

Cannabis is one of the most commonly used substances in patients with a psychotic disorder and is associated with a higher risk of psychotic relapses. Identifying reasons for cannabis use and subjective effects in patients with psychotic disorders can provide insight into the functions of cannabis use, and this may lead to targeted interventions.

METHODS

A literature search of the PubMed and PsycINFO databases for articles published from 1985 till 2008 was carried out to review studies that examined self-reported reasons for cannabis use and self-reported effects of cannabis use in patients with psychotic disorders.

RESULTS

Only a few studies were found that specifically assessed reasons for and effects of cannabis use. Despite the heterogeneity in the study samples and methodology, patients commonly reported that their reasons for cannabis use were enhancement of positive affect, relief of dysphoria and social enhancement. Fewer patients reported reasons related to relief of psychotic symptoms or relief of side effects of medication. Frequently reported positive effects of cannabis were positive changes in affect and relaxation. A large proportion of patients reported that cannabis negatively affected positive symptoms.

CONCLUSIONS

Patients suffering from psychotic disorder report using cannabis mainly for affect regulation and socialization, despite the awareness that cannabis has a negative effect on positive symptoms. In spite of the heterogeneity of the studies, the results turned out to be broadly comparable and support the external validity of this review to a broad range of cannabis-using patients with psychotic disorder.

P300 deficits are present in young first-episode patients with schizophrenia and not in their healthy young siblings

OBJECTIVE

To evaluated P300 (P3b) abnormalities in young first episode patients with schizophrenia and their healthy young siblings.

METHODS

An auditory oddball paradigm was used to assess P300 in 53 patients, 27 unaffected siblings and 28 healthy controls. Amplitude and latency of the three midline sites (Fz, Cz, and Pz) were compared between patients, siblings, and controls by a mixed-effects regression model.

RESULTS

P300 amplitude was significantly reduced in patients with schizophrenia but not in healthy siblings, when compared to healthy controls. P300 latency did not significantly differ between the three groups.

CONCLUSIONS

P300 amplitude but not latency was found to be affected in young patients with recent onset schizophrenia. However, P300 amplitude and latency were found not to be affected in healthy unaffected young siblings and, therefore, did not qualify as an endophenotype for schizophrenia.

SIGNIFICANCE

The failure to find the P300 (P3b) abnormality in healthy siblings of patients with schizophrenia is an important finding and should be added to P300 literature.

Effects of a functional COMT polymorphism on brain anatomy and cognitive function in adults with velo-cardio-facial syndrome

BACKGROUND

Velo-cardio-facial syndrome (VCFS) is associated with deletions at chromosome 22q11, abnormalities in brain anatomy and function, and schizophrenia-like psychosis. Thus it is assumed that one or more genes within the deleted region are crucial to brain development. However, relatively little is known about how genetic variation at 22q11 affects brain structure and function. One gene on 22q11 is catechol-O-methyltransferase (COMT): an enzyme that degrades dopamine and contains a functional polymorphism (Val158Met) affecting enzyme activity. Here, we investigated the effect of COMT Val158Met polymorphism on brain anatomy and cognition in adults with VCFS.

METHOD

The COMT Val158Met polymorphism was genotyped for 26 adults with VCFS on whom DNA was available. We explored its effects on regional brain volumes using hand tracing approaches; on regional grey- and white-matter density using computerized voxel-based analyses; and measures of attention, IQ, memory, executive and visuospatial function using a comprehensive neuropsychological test battery.

RESULTS

After corrections for multiple comparisons Val-hemizygous subjects, compared with Met-hemizygotes, had a significantly larger volume of frontal lobes. Also, Val-hemizygotes had significantly increased grey matter density in cerebellum, brainstem, and parahippocampal gyrus, and decreased white matter density in the cerebellum. No significant effects of COMT genotype on neurocognitive performance were found.

CONCLUSIONS

COMT genotype effects on brain anatomy in VCFS are not limited to frontal regions but also involve other structures previously implicated in VCFS. This suggests variation in COMT activity is implicated in brain development in VCFS.

A meta-analysis of P50 studies in patients with schizophrenia and relatives: differences in methodology between research groups

OBJECTIVE

To determine whether patients with schizophrenia as well as their relatives show deficits in sensory gating reflected by an abnormal P50 ratio and to quantify the differences from controls.

METHODS

A systematic search on articles published between 1982 and 2006 was conducted. 28 patient studies that were suitable for analysis including 891 patients and 686 controls were retrieved. Six studies on P50 of relatives of schizophrenic patients were identified, including 317 relatives and 294 controls.

RESULTS

In the patient studies we found an P50 effect size of 1.28 (SD=0.72). We confirmed high variability in outcomes across studies. Almost half of the studies included where published by one laboratory of the University of Colorado and these results differed significantly from the results found in studies performed in other laboratories. We found correlations between effect size outcome and sound intensity, filter settings and subjects' position which could be explained by differences between the Colorado laboratory and the other groups. In the relative studies we found a mean P50 effect size of 0.85 (+/-0.42).

CONCLUSIONS

The differences in methodology and lack of reported demographics and methodology including raters blinding in some studies makes it hard to compare results across studies and to evaluate the validity and reliability of P50 as a candidate endophenotype for schizophrenia. There are large differences in outcomes from Colorado studies and non-Colorado studies. In contrast to the Colorado studies in the non-Colorado studies P50 suppression would not qualify as an endophenotype for schizophrenia. These differences might be explained by the differences in methodology e.g. lower levels of sound intensity, differences in filter settings and subjects' position. Finally we make some recommendations for future research based on the outcomes of this meta-analysis.

Failure to find P50 suppression deficits in young first-episode patients with schizophrenia and clinically unaffected siblings

OBJECTIVE

To evaluate whether the P50 gating deficit is present in young first-episode patients with schizophrenia and their healthy young siblings.

METHODS

An auditory paired-click paradigm was used to assess P50 gating in 53 patients, 27 unaffected siblings, and 28 healthy controls. P50 parameters were compared between patients, sibs, and unrelated controls by a mixed-effects regression model.

RESULTS

P50 gating was not significantly impaired in patients with schizophrenia and healthy siblings as compared with controls.

CONCLUSIONS

P50 gating was not found to be significantly impaired in young first-episode schizophrenia patients and in healthy young siblings. These results are in contrast with the existing literature. We suggest that P50 gating impairment may be developmentally or age dependent.

[Is there any point in detecting high risk factors prior to a first psychosis?]

BACKGROUND

If schizophrenia and related disorders are diagnosed and treated early, symptoms will be less severe and the prognosis will be more favourable. There is little point in screening for schizophrenia in the general population because the illness has such a low incidence. However, we do need to find out whether it is meaningful to screen genetically impaired individuals (high risk group) and specific groups of psychiatric patients (ultra high risk group).

AIM

To survey the research into the (high and ultra high) risk factors for developing a first psychosis and to find out whether it makes good sense to screen certain groups of persons.

METHOD

We conducted extensive desk-research and a wide-ranging search of the literature from 1990 to 2004. The key words we used in our search were 'prodrome', 'high risk', 'ultra high risk', in conjunction with 'psychosis' and 'schizophrenia'.

RESULTS

In the genetically impaired group risk factors for developing schizophrenia seem to be transient psychiatric problems in childhood, schizotypical traits, anxiety, behavioural problems in adolescence, being brought up in an unstable environment and producing deviant results in neurocognitive tests. Among the patients referred to a psychiatrist it is possible to identify a special group of patients with an ultra high risk of developing a psychosis. Within ayear 40% of patients who had mild or short-term psychotic symptoms or who were genetically impaired adolescents with decreased functioning had developed a psychosis.

CONCLUSION

Screening all genetically vulnerable persons in the general population has no consequencesfor treatment. Early diagnosis by psychiatrists is certainly advisable. However, larger groups and longer studies are needed in order to demonstrate conclusively the preventive effect of interventions prior to a first psychosis.

[Residual neuropsychological, structural and functional brain abnormalities after long-term cannabis use]

BACKGROUND

An important question that arises in policy discussions concerning the use of cannabis is whether the possible harmful effects of cannabis are reversible.

AIM

To review studies on residual neuropsychological, structural and functional brain abnormalities that may have resulted from the long-term use of cannabis.

METHOD

When we searched Medline (January 1966 - December 2003) and EMBASE (January 1988 - December 2003) using the key words 'cannabis', 'marijuana', 'neuropsychological test', 'cognition', 'CT-scan', 'MRI', 'PET', 'SPECT' and 'brain', we found 29 studies in our area of interest. We selected only those neuropsychological and functional brain imaging studies in which the patients had a controlled abstinence period longer than 98 hours.

RESULTS

On the basis of six studies we concluded that there was insufficient evidence to prove conclusively that long-term cannabis use causes or does not cause residual abnormalities. The results of our review were also inconclusive whether cannabis use during adolescence may have a lasting effect on cognitive functioning and brain structure. However, we could not rule out the possibility that (1) certain cognitive and cerebral abnormalities existed in patients before cannabis use began and (2) that patients were suffering from subacute effects of cannabis.

CONCLUSION

So far, research into the residual effects of cannabis use has been inadequate. Future studies should concentrate on the effect of cannabis use during early adolescence. More insight should come from longitudinal studies involving neuropsychological measurements and brain imaging before cannabis use begins. The abstinence period should be at least seven weeks.

Electroconvulsive therapy for the treatment of clozapine nonresponders suffering from schizophrenia--an open label study

OBJECTIVE

This open label study describes the efficacy of electroconvulsive therapy (ECT) as adjunctive treatment in clozapine nonresponders suffering from schizophrenia.

METHOD

The results of clozapine and ECT treatment in 11 clozapine nonresponders suffering from schizophrenia are reported in terms of remission and relapse.

RESULTS

Eight patients had a remission with this combination treatment. After remission of symptoms five patients had a relapse. Three of the five patients who relapsed had a second successful ECT course and remained well with maintenance ECT and clozapine. No evidence for adverse effects was found.

CONCLUSION

Adjunctive ECT can be efficacious in clozapine nonresponders suffering from schizophrenia.

A study into predictors for the speed of response to electroconvulsive therapy

The efficacy of electroconvulsive therapy (ECT) has been firmly established in the treatment of depression. However, prediction of the speed of response to ECT is an issue that needs to be further explored. This study aims to examine the presence of predictors for the speed of response. In a retrospective chart review using 57 patients suffering from major depression who received ECT, the relation of several patient and ECT variables with the speed of response was explored. Response was defined as a drop of at least 35% in Hamilton rating scale of depression (HRSD) score from baseline after 3 or 4 ECT sessions. Patients received ECT with an aged-based stimulus dosage in a clinical setting. Multiple regression analysis showed that high baseline HRSD score and high seizure energy index (SEI) were significantly and independently associated with a rapid response. In a regression model, baseline HRSD score and SEI can be used to predict the speed of response to ECT. Rapid responders to ECT achieved remission significantly more often than slow responders did. SEI can be modified by the clinician. This offers the possibility to optimize ECT treatment.

[Schizophrenia and the 22q11 deletion syndrome]

In 10-30% of the patients with the 22q11 deletion syndrome (22q11DS), a psychosis develops in adulthood, often schizophrenia. 22q11DS is a common genetic syndrome which is associated with an interstitial deletion at chromosome 22q11. The syndrome is characterised by a variable phenotype which includes cognitive and behavioural problems, in addition to congenital heart and facial anomalies. The presence of 22q11DS represents one of the highest risk factors for the development of schizophrenia. The study of 22q11DS offers a unique opportunity to increase the understanding of the pathogenesis of schizophrenia.

Psychometric properties of the Subjective Well-Being Under Neuroleptics scale and the Subjective Deficit Syndrome Scale

RATIONALE

Subjective experience of antipsychotic drugs is relevant for medication compliance and quality of life. There is, however, sparse knowledge about the assessment of subjective experience.

OBJECTIVES

To examine the internal consistency, test-retest reliability, sensitivity to medication change and concurrent validity of two test instruments: the Subjective Well-Being Under Neuroleptics (SWN) and the Subjective Deficit Syndrome Scale (SDSS).

METHODS

Both instruments were used at admission and after 6 weeks of medication stabilization in 105 consecutively admitted patients diagnosed with DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th edn) diagnoses of recent-onset schizophrenia, schizophreniform disorder or schizoaffective disorder.

RESULTS

Almost all patients were capable of reproducing their subjective experience in a consistent way both before and after medication stabilization. The internal consistency of both instruments was high. The test-retest reliability was high if medication was not changed, especially for the SWN. The SWN was sensitive for changes in medication and dosage. The short form of the SWN (SWN-20 items) had comparable psychometric qualities to the original instrument (SWN-38 items). The concurrent validity of the SWN and the SDSS was good, indicating that both tests measure the same concept.

CONCLUSIONS

The assessment of subjective experience with the SWN (both versions) may be used in evaluating differential effects of anti-psychotics and dose on subjective well-being.

Clinical and neuropsychological correlates of the P300 in schizophrenia

We investigated the relationship between the P300, neuropsychological test performance and symptomatology in recent-onset schizophrenic patients (n = 45) to gain insight into underlying mechanisms of abnormal P300 in schizophrenia. The P300 was recorded in two sessions with an intermission of five minutes, at the midline frontal, central and parietal electrode site. P300 amplitude and latency were compared with those obtained in 25 controls. Twenty patients were treated with olanzapine and 19 patients with risperidone. P300 amplitude was smaller and latency longer in patients than in controls. In the patient group, parietal P300 amplitude reduction was related to poorer performance on neuropsychological tests of memory. Frontal P300 amplitude reduction was related to impaired selective attention. In patients with negative symptomatology, P300 amplitude was reduced in the second P300 session compared with the first. Patients on risperidone demonstrated a smaller parietal P300 amplitude than patients using olanzapine. Reduced parietal P300 amplitude could signify a dysfunction in the continuous memory updating of current events. Negative symptomatology may be associated with a time dependent decrease in neuronal firing, as indicated by reduced P300 amplitude in the second P300 session.

Social functioning and the course of early-onset schizophrenia: five-year follow-up of a psychosocial intervention

BACKGROUND

Schizophrenia implies severe social impairments. Since the treatment of patients with schizophrenia shifted from long-term hospital admissions to community services, research on social functioning has become increasingly important.

AIMS

Follow-up assessment of social functioning in young patients with schizophrenia during a 5-year period after intervention.

METHOD

During intervention, families were randomised into two conditions: standard intervention and standard plus family intervention.

RESULTS

Although no differential treatment effect with regard to the course of the illness was found, patients from the standard plus family intervention condition stayed for fewer months in institutions for psychiatric patients than patients from the standard intervention condition.

CONCLUSIONS

Family intervention has helped parents to support their children, thereby diminishing institutional care.

Higher occupancy of muscarinic receptors by olanzapine than risperidone in patients with schizophrenia. A[123I]-IDEX SPECT study

RATIONALE

In vitro data have shown anticholinergic properties of the atypical antipsychotic drug olanzapine. Substantial occupancy of muscarinic receptors may be an explanation for the low incidence of extrapyramidal side effects induced by olanzapine.

OBJECTIVES

To obtain an in vivo measurement of muscarinic receptor occupancy by olanzapine compared with risperidone in patients with schizophrenia stabilised on medication.

METHODS

Five patients with schizophrenia treated with olanzapine and five patients treated with risperidone were studied. Muscarinic receptor occupancy in the striatum and cortex was studied in vivo with SPECT using [123I]-IDEX as a radioligand. SPECT data were compared with those of six healthy subjects.

RESULTS

Patients stabilised on olanzapine showed significantly lower mean (+/-SD) striatal and cortical (1.50+/-0.21 and 1.51+/-0.22, respectively) muscarinic receptor binding ratios of [123I]-IDEX (reflecting higher levels of muscarinic receptor occupancy) than controls (3.91+/-0.61 and 3.65+/-0.70, respectively). Furthermore, [123I]-IDEX binding ratios in patients treated with risperidone were slightly lower than controls, reaching significance only in the striatum (2.99+/-0.27 versus 3.91+/-0.61, for risperidone and controls).

CONCLUSIONS

The substantial occupancy of muscarinic receptors in the striatum and cortex by olanzapine may be an explanation for the low incidence and severity of extrapyramidal side effects of this antipsychotic drug. Furthermore, it may also explain the anticholinergic side effects of olanzapine.

Dopamine transporter density in patients with tardive dyskinesia: a single photon emission computed tomography study

RATIONALE

Tardive dyskinesia occurs frequently in schizophrenic patients chronically treated with classical antipsychotic medication. It may be caused by loss of dopaminergic cells, due to free radicals as a product of high synaptic dopamine levels.

OBJECTIVE

To evaluate dopamine transporter density in the striatum in patients with tardive dyskinesia.

METHODS

Striatal [123I]FP-CIT binding was measured with SPECT in seven schizophrenic patients with tardive dyskinesia and eight healthy controls.

RESULTS

No significant difference was found between striatal [123I]FP-CIT binding ratios in patients with tardive dyskinesia and controls.

CONCLUSIONS

This preliminary study indicates no change in striatal dopamine transporter density in schizophrenic patients with tardive dyskinesia. This finding does not support the hypothesis that tardive dyskinesia is caused by dopaminergic cell loss.

Significantly reduced docosahexaenoic and docosapentaenoic acid concentrations in erythrocyte membranes from schizophrenic patients compared with a carefully matched control group

BACKGROUND

Fatty acid research in schizophrenia has demonstrated an altered cell membrane phospholipid metabolism. Erythrocyte membrane phospholipid composition closest reflects that of neuronal membranes.

METHODS

(Poly)(un)saturated fatty acid concentrations were measured in the erythrocyte membranes of 19, consecutively admitted, medicated young schizophrenic patients and then compared with matched control subjects. Psychiatric symptomatology was rated with the Positive and Negative Symptom Scale and Montgomery-Asberg Depression Rating Scale. Because diet, hormones, and cannabis influence fatty acid metabolism, we included these factors in our study.

RESULTS

The most distinctive findings concerned the omega-3 series: C22:5 omega-3, C22:6 omega-3 (docosahexaenoic acid), and the sum of omega-3 fatty acids were significantly decreased. Interestingly, C20:4 omega-6 (arachidonic acid) was not lowered. In the omega-9 series, higher levels of C22:1 omega-9 and lower levels its elongation product, C24:1 omega-9 (nervonic acid), were found. Interestingly, the other arm of the desaturation-elongation sequence of C18:1 omega-9, C20:3 omega-9, was lower in patients. The total omega-9 fatty acid levels were also lower in patients.

CONCLUSIONS

Significant differences in erythrocyte fatty acid composition were found. The differences were not due to diet or hormonal status and could not be explained by the medication or cannabis use. No consistent pattern emerged from the different fatty acid abnormalities and the clinical symptom scores.

Dopamine transporter density in young patients with schizophrenia assessed with [123]FP-CIT SPECT

Disturbances in the dopamine (DA) system are thought to play a major role in schizophrenia. Amphetamine-induced release of endogenous DA is shown to be enhanced in schizophrenia, as is striatal [18F]FDOPA uptake in the striatum. It is not clear if the density of DA neurons is altered in schizophrenia. By studying the DA transporter with [123I]FP-CIT single photon emission computed tomography (SPECT), the density of nigrostriatal dopaminergic cells can be studied. Using [123I]FP-CIT SPECT, DA transporter density in the striatum was studied in 36 young patients with schizophrenia. Ten patients were antipsychotic (AP)-naive, 15 were treated with olanzapine, eight with risperidone and three were AP-free. A control group of 10 age-matched volunteers was included. Striatal [123I]FP-CIT binding was not significantly different between AP-naive patients (2.87), patients treated with olanzapine (2.76), patients treated with risperidone (2.76), AP-free patients (2.68) and controls (2.82) (F=0.07,p=0.98). Unexpectedly, striatal [123I]FP-CIT binding in females was significantly higher than in males (3.29 and 2.70, respectively; t=-2.56, p=0.014).Concluding, functional changes in the dopaminergic system in schizophrenia are not likely to be reflected in a change in DA transporter density. Moreover, DA transporter density does not seem to be altered by AP medication.

Component structure of the positive and negative syndrome scale (PANSS) in patients with recent-onset schizophrenia and spectrum disorders

RATIONALE

Earlier studies have examined the symptom dimensions of the PANSS (Positive And Negative Syndrome Scale) in patients with chronic schizophrenia. Results have suggested that three to eight component solutions best explain underlying symptom dimensions.

OBJECTIVES

To examine the component structure of the PANSS and the MADRS (Montgomery Asberg Depression Rating Scale) in young patients with recent-onset schizophrenia and related disorders and the correlations between the components of both instruments.

METHODS

Symptomatology was measured in 138 patients with recent-onset schizophrenia, by administering the PANSS and the MADRS.

RESULTS

Principal component analysis of the PANSS revealed five components: a positive, negative, depression, agitation-excitement and disorganisation component. The MADRS only showed one component. A high correlation was found between the depression component of the PANSS and the overall score of the MADRS (p=0.87, P<0.001). A moderate correlation was found between the PANSS negative component and the overall score of the MADRS (p=0.51, P<0.001).

CONCLUSIONS

The data suggest a five component structure of the PANSS. The depression component of the PANSS seems to be a valid way of assessing depression in patients with recent-onset schizophrenia.

Neuropsychological and clinical correlates of antisaccade task performance in schizophrenia

OBJECTIVES

To elucidate pathophysiologic mechanisms involved in abnormal antisaccade task performance in schizophrenia by investigating a possible relationship among antisaccade task performance, neuropsychological test results, and symptomatology in a group of young patients with recent-onset schizophrenia; to compare the effects of olanzapine and risperidone on antisaccades and reflexive saccades.

BACKGROUND

Patients with schizophrenia consistently perform worse than controls on the antisaccade task in which the subject is required to inhibit a reflexive saccade to a suddenly appearing visual target and look in the opposite direction.

METHODS

In 37 young (mean age 21 years), medicated patients with recent-onset schizophrenia the authors assessed antisaccades, reflexive saccades, neuropsychological test performance, and symptomatology. A subgroup of 18 patients was treated with olanzapine, and 15 patients were treated with risperidone. Reflexive-saccade and antisaccade task results were compared with those obtained in 13 control subjects.

RESULTS

The antisaccade error rate was significantly higher in the patients than in the control subjects. In the patients, poor working memory function was related to increased antisaccade error rate. Severity of disorganization symptoms at intake was related to prolonged mean latency of the correct antisaccades. Patients on risperidone had a prolonged mean latency in the reflexive saccade task compared with patients using olanzapine.

CONCLUSIONS

Abnormal antisaccade task performance is already present in early schizophrenia and may reflect working memory dysfunction. In future studies, medication effects should be considered in interpreting eye movement test results of patients with schizophrenia.

Dopamine D2 receptor occupancy by olanzapine or risperidone in young patients with schizophrenia

A crucial characteristic of antipsychotic medication is the occupancy of the dopamine (DA) D2 receptor. We assessed striatal DA D2 receptor occupancy by olanzapine and risperidone in 36 young patients [31 males, 5 females; mean age 21.1 years (16-28)] with first episode schizophrenia, using [123I]iodobenzamide (IBZM) SPECT. The occupancy of DA D2 receptors was not significantly different between olanzapine and risperidone. However, in subgroups of most prescribed doses, DA D2 occupancy was higher in the risperidone 4-mg group (79%) compared to the olanzapine 15-mg group (62%). [123I]IBZM binding ratios decreased with olanzapine dose (r = -0.551; P < 0.01), indicating higher DA D2 receptor occupancy with higher olanzapine dose. Akathisia and positive symptoms were correlated with [123I]IBZM binding ratio (r = -0.442; P < 0.01; and r = -0.360; P < 0.05, respectively). Prolactin (PRL) levels were elevated in the risperidone, but not in the olanzapine group, at comparable D2 receptor occupancy levels. In the olanzapine group, PRL levels were correlated with [123I]IBZM binding ratio (r = -0.551; P < 0.01). In conclusion, both olanzapine and risperidone induce a high striatal D2 receptor occupancy, dependent on dose and group formation. The lower incidence of prolactin elevation with olanzapine, compared to risperidone, may not be attributed to a lower D2 receptor occupancy.

Clozapine and obsessions in patients with recent-onset schizophrenia and other psychotic disorders

BACKGROUND

The increase or emergence of obsessions was compared in young patients with recent-onset schizophrenia or other psychotic disorders taking clozapine and other antipsychotic drugs.

METHOD

We conducted a retrospective cohort study. Subjects were 121 consecutively admitted patients diagnosed with DSM-III-R schizophrenia, schizoaffective disorder, schizophreniform disorder, or psychotic disorder not otherwise specified. Obsessions were diagnosed according to DSM-IV criteria.

RESULTS

More clozapine-treated subjects (20.6%) than subjects treated with other antipsychotic drugs (1.3%) experienced an emergence or increase of obsessions (p<.01).

CONCLUSION

Use of clozapine is associated with the emergence or increase of obsessions in early-phase schizophrenia.

Early detection and intervention in schizophrenia

During the course of schizophrenia, symptoms tend to increase at the highest rate during the first 5 years of the disease. Moreover, 10% of suicides by schizophrenic patients occur within the first 10 years of schizophrenia being diagnosed. These facts emphasize the importance of early intervention to improve the course of the disease before further deterioration. The use of psychosocial interventions and drug management programmes, in addition to maintenance antipsychotic medication, reduces the risk of psychotic relapse. Continuity of care from inpatient to outpatient treatment also significantly improves outcome, largely as a result of better drug compliance. It appears, however, that the addition of a behavioural family intervention alone to a standard programme offers little additional benefit. The benefits of intervention programmes last only as long as the programme, and patients should continue with such intensive treatment strategies for at least the duration of the critical phase. Under these circumstances, very mild psychotic complaints may be recognized at an early stage so that treatment can begin even earlier, further increasing the chance of an optimal long-term outcome. Further studies of early intervention and relapse prevention are required to support these findings.

The relationships between expressed emotion, affective style and communication deviance in recent-onset schizophrenia

The relationships between expressed emotion (EE), affective style (AS) and communication deviance (CD) were studied during hospitalization and after discharge. EE was measured with both the Camberwell Family Interview (CFI) and the Five-Minutes Speech Sample (FMSS). The study subjects were patients with recent-onset schizophrenia and related disorders, who were consecutively admitted to an in-patient unit for adolescents, and their parents. The results revealed that CFI/EE was significantly correlated with AS criticism scores during hospitalization, but did not predict AS scores after discharge. FMSS/EE correlated significantly with AS criticism when both measures were administered after discharge. During hospitalization, FMSS/EE was not significantly correlated with AS. No consistent relationship was found between CD and both affective factors (EE and AS). It is concluded that EE and AS overlap with regard to level of criticism when both measures are administered over a short period of time and independent of the time of assessment. In addition, the results indicate that affective and communication factors identify independent family attributes.

Assessment of endogenous dopamine release by methylphenidate challenge using iodine-123 iodobenzamide single-photon emission tomography

This double-blind, placebo-controlled study assessed pharmacologically induced endogenous dopamine (DA) release in healthy male volunteers (n=12). Changes in endogenous DA release after injection of the psychostimulant drug methylphenidate were evaluated by single-photon emission tomography (SPET) and constant infusion of iodine-123 iodobenzamide ([123I]IBZM), a D2 receptor radioligand that is sensitive to endogenous DA release. Methylphenidate induced displacement of striatal [123I]IBZM binding, resulting in a significantly decrease in the specific to non-specific [123I]IBZM uptake ratio (average: 8.6%) in comparison with placebo (average: -1.9%). Moreover, injection of methylphenidate induced significant behavioural responses on the following items: excitement, anxiety, tension, and mannerisms and posturing. The results of this study demonstrate the feasibility of using constant infusion of [123I]IBZM and SPET imaging to measure endogenous DA release after methylphenidate challenge and to investigate neurochemical aspects of behaviour.

A quantitative measure for expressed emotion

The items of the Five Minute Speech Sample, an instrument to elicit relatives' expressed emotion, were investigated in a follow-up study of 120 parents of adolescents with recent-onset schizophrenia. A composite scale was constructed using Mokken scale analysis. From the 9 available items, 6 formed a unidimensional and cumulative scale. This scale was applicable for the total parent group, as well as for fathers and mothers separately. A second scale of 2 items did not meet the criteria for the Mokken model completely and was applicable for the parent group as a whole, but not for fathers and mothers as separate groups. The configuration of the subscales as found with the Mokken scale analysis was comparable with the results of principal component analysis. A quantitative measure may detect smaller differences in expressed emotion than the dichotomous index and expands the possibilities for statistical tests.

Parental communication deviance: its stability and the effect of family treatment in recent-onset schizophrenia

The influence of a behavioural family treatment on parental communication deviance (CD) was investigated in a longitudinal treatment study. Subjects were the parents of young patients with recent-onset schizophrenia or related disorders. Parents and patients were randomly assigned to one of two treatment conditions: individual out-patient treatment or a combination of individual out-patient and family treatment. Parental CD was assessed with the Thematic Apperception Test (TAT) both at the start of the out-patient treatment and after completion of treatment 1 year later. Most families had high levels of CD, a finding which is in agreement with previous CD studies. These high CD levels remained stable over the 12-month period. Family treatment was not effective in influencing the level of CD. The findings suggest that high CD is a stable trait-marker of parents, and they support the notion that high levels of CD may precede the onset of serious psychotic disorders. Studies with more chronic patients are needed to replicate the findings.

Patient attributes and expressed emotion as risk factors for psychotic relapse

In the context of a prospective, controlled treatment study, contrasting family interventions with individual treatment, the role of expressed emotion (EE) as a predictor of relapse was examined in patients with recent-onset schizophrenia and related disorders (n = 97). EE was compared with 13 predictor variables. The variables, taken from EE and family intervention studies, related to demography, premorbid functioning, present and past illness history, and comorbid substance abuse. Psychotic relapse was operationalized with a conservatively measured relapse criterion, composed of monthly ratings based on the Brief Psychiatric Rating Scale and on clinical judgment during the 12 months of outpatient treatment. Of the 14 predictor variables entered in stepwise survival analyses, 6 variables had probable predictive power on the conservative relapse criterion. These variables were entered in a Cox regression model. EE turned out to be the major predictor of relapse in the overall sample (hazard ratio [HR] 4.90; confidence interval [CI] 1.05-22.92). This finding remained when only patients with a first psychotic episode (p = 0.02) and patients in the individual treatment condition (p = 0.001) were examined. Cannabis abuse was the major predictor of relapse in patients with high-EE families (HR 4.27; CI 1.12-16.29).

Symptoms, cognitive and social functioning in recent-onset schizophrenia: a longitudinal study

The relationships among symptoms, cognitive functioning and social functioning were investigated in patients with schizophrenia over a period of 15 months. Patients with a mood disorder, a normal control group and a sample of parents of the schizophrenic patients also completed the cognitive tests. In the schizophrenia sample, only disorganisation was correlated with cognitive performance, which was interpreted as further evidence that disorganisation is a separate symptom dimension of schizophrenia. Against expectations, with two of three measurements no significant correlations were found between negative symptoms and cognitive performance. With these two measurements, however, a curvilinear association between negative symptoms and cognitive performance was observed, suggesting that negative symptoms are not a unitary concept. Finally, tentative evidence could be obtained for speed of information processing and selective attention as markers for vulnerability, although the latter is not specific for schizophrenia.

Component structure of the expanded Brief Psychiatric Rating Scale (BPRS-E)

The component structure of the expanded Brief Psychiatric Rating Scale (BPRS-E) was analyzed in a sample (n = 150) of consecutively admitted general psychiatric inpatients and compared with a group (n = 97) of adolescent patients with schizophrenia spectrum diagnoses. A stable five-component solution, of which four were interpretable, was found across groups. The component scales of the 24-item version of the BPRS had good internal consistency, allowed better coverage of schizophrenia and affective symptoms than the 18-item version but did not distinguish the schizophrenia diagnostic subgroups. The implications of the findings are discussed.

Dimensions and subtypes of recent-onset schizophrenia. A longitudinal analysis

A sample of young patients with schizophrenia was studied in a longitudinal design to investigate the stability of an earlier reported four-dimensional symptom model (positive symptoms, negative symptoms, disorganization, and depression). Symptoms were measured in an acute phase soon after hospitalization, in a remitted stage 3 months later, and in a "mixed" phase 1 year after the second assessment. A different factor structure was found at each measurement, but a stable four-dimensional structure could be defined that closely resembled the factor structure of the first assessment. The symptom dimensions were uncorrelated, except disorganization and depression. Whether meaningful subtypes could be defined using statistical criteria also was investigated. With cluster analysis, four subtypes were defined that could be characterized as follows: rapid treatment responders, slower responders, and two relapse groups. Although some indication of the validity of these subtypes was found, it is concluded that there is a high risk of creating artificial boundaries with this approach.

Relapse criteria in schizophrenic disorders: different perspectives

Relapse and exacerbation of psychotic symptoms were investigated in a prospective study of 88 patients with recent-onset schizophrenia and related disorders. Relapse definitions were derived from expressed emotion and family intervention studies and based on the Brief Psychiatric Rating Scale (BPRS), the Present State Examination, and clinical judgment. Results indicate that research and clinical criteria represent different perspectives on relapse. Clinical criteria provide a validity check that can verify BPRS-rated changes in partially remitted patients.

Cannabis abuse and the course of recent-onset schizophrenic disorders

OBJECTIVE

We sought to examine the relation between cannabis abuse and the symptomatic course of recent-onset schizophrenia and related disorders.

DESIGN

A prospective cohort study over a year using monthly Brief Psychiatric Rating Scale assessments.

PARTICIPANTS

Cannabis-abusing patients (n = 24) were compared with nonabusers (n = 69). Eleven patients were mild and 13 were heavy cannabis-abusing patients.

RESULTS

Significantly more and earlier psychotic relapses occurred in the cannabis-abusing group (P = .03). This association became stronger when mild and heavy cannabis abuse were distinguished (P = .002). No confounding effect of other variables, eg, other street drugs, was found. In all but one patient, cannabis abuse preceded the onset of the first psychotic symptoms for at least 1 year.

CONCLUSIONS

Cannabis abuse and particularly heavy abuse can be considered a stressor eliciting relapse in patients with schizophrenia and related disorders and possibly a premorbid precipitant.

A dimensional and categorical approach to the symptomatology of recent-onset schizophrenia

Sixty-five patients with recent-onset schizophrenia were assessed with two widely used symptom scales, the Brief Psychiatric Rating Scale-Expanded (BPRS-E) and the Psychiatric Assessment Scale (Manchester scale). Principal components analysis of the BPRS-E scores yielded a four-dimensional structure: positive symptoms, negative symptoms, disorganization, and depression. With the Psychiatric Assessment Scale, three dimensions were found: the positive symptoms (delusions, hallucinations) and disorganization (incoherence) appeared in one dimension. A categorical analysis resulted in predominantly positive, negative, and disorganized clusters, but more than half of the sample could not be allocated to any of these groups.