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

PURPOSE

Although the stability of current diagnostic criteria for people with First Episode Psychosis (FEP) is essential for treatment, it still remains poorly investigated. As its examination necessarily requires a prospective evaluation of diagnostic trajectories, the aims of the current longitudinal investigation were: (a) to assess diagnostic changes in an Italian FEP population treated within an "Early Intervention in Psychosis" service during a 2-year follow-up period, and (b) to identify potential sociodemographic and clinical moderators of diagnostic instability at entry.

METHODS

All participants were FEP individuals, aged 12-35 years. Their primary diagnosis was formulated both at baseline and at the end of the follow-up. At entry, they also completed the Positive And Negative Syndrome Scale (PANSS) and the Global Assessment of Functioning (GAF) scale. As measure of diagnostic stability, the Kappa statistic was first calculated. The associations of diagnostic shift with baseline sociodemographic and clinical characteristics were then analyzed using a logistic model with the diagnostic change as dependent variable. Finally, a propensity score was calculated, based on logistic analysis results.

RESULTS

221 (50.1 %) FEP participants changed their initial diagnosis. The highest prospective diagnostic stability was found for initial diagnosis of schizophrenia (93.9 %) and affective spectrum psychoses (92.4 %). Diagnostic instability was high for initial diagnosis of brief psychotic disorder (100 %), schizophreniform disorder (100 %) and psychotic disorder not otherwise specified (92.1 %). The best predictors of diagnostic change were previous contact with neuropsychiatry services, shorter duration of untreated psychosis and higher baseline levels of disorganization.

CONCLUSIONS

Diagnostic stability is crucial for treatment and clinical decision making. Addressing instability in FEP diagnoses and detecting its moderators at entry are important challenges for future diagnostic development of early psychosis.

Weight change following diagnosis with psychosis: a retrospective cohort study in Greater Manchester, UK

INTRODUCTION

Weight gain in the months/years after diagnosis/treatment of severe enduring mental illness (SMI) is a major predictor of future diabetes, dysmetabolic profile and increased risk of cardiometabolic diseases. There is limited data on the longer-term profile of weight change in people with a history of SMI and how this may differ between individuals. We here report a retrospective study on weight change over the 5 years following an SMI diagnosis in Greater Manchester UK, an ethnically and culturally diverse community, with particular focus on comparing non-affective psychosis (NAP) vs affective psychosis (AP) diagnoses.

METHODS

We undertook an anonymised search in the Greater Manchester Care Record (GMCR). We reviewed the health records of anyone who had been diagnosed for the first time with first episode psychosis, schizophrenia, schizoaffective disorder, delusional disorder (non-affective psychosis = NAP) or affective psychosis (AP). We analysed body mass index (BMI) change in the 5-year period following the first prescription of antipsychotic medication. All individuals had taken an antipsychotic agent for at least 3 months. The 5-year follow-up point was anywhere between 2003 and 2023.

RESULTS

We identified 9125 people with the diagnoses above. NAP (n = 5618; 37.3% female) mean age 49.9 years; AP (n = 4131; 60.5% female) mean age 48.7 years. 27.0% of NAP were of non-White ethnicity vs 17.8% of AP individuals. A higher proportion of people diagnosed with NAP were in the highest quintile of social disadvantage 52.4% vs 39.5% for AP. There were no significant differences in baseline BMI profile. In a subsample with HbA1c data (n = 2103), mean HbA1c was higher in NAP at baseline (40.4 mmol/mol in NAP vs 36.7 mmol/mol for AP). At 5-year follow-up, there was similarity in both the overall % of individuals in the obese ≥ 30 kg/m2 category (39.8% NAP vs 39.7% AP), and % progressing from a normal healthy BMI transitioned to obese/overweight BMI (53.6% of NAP vs 55.6% with AP). 43.7% of those NAP with normal BMI remained at a healthy BMI vs 42.7% with AP. At 5-year follow-up for NAP, 83.1% of those with BMI ≥ 30 kg/m2 stayed in this category vs 81.5% of AP.

CONCLUSION

The results of this real-world longitudinal cohort study suggest that the changes in BMI with treatment of non-affective psychosis vs bipolar disorder are not significantly different, while 43% maintain a healthy weight in the first 5 years following antipsychotic prescription.

Association between 14 candidate genes, PM2.5, and affective disorders: a study of the Taiwan Biobank

BACKGROUND

Most studies have focused on the risk factors, treatment, and care of affective psychosis, and several have reported a relationship between ambient air quality and this psychosis. Although an association has been reported between psychosis and genes, studies mainly explored the associations between one type of psychosis and one gene; few have identified genes related to affective psychosis. This study investigates the genetic and environmental factors of affective psychosis.

METHODS

In this retrospective longitudinal study, 27 604 participants aged 30-70 were selected from Taiwan Biobank. The participants' propensity scores were calculated based on their demographic information, and propensity score matching was performed to divide the participants into an experimental (i.e., affective psychosis) and control group at a 1:5 ratio. Plink was used to analyze the major and minor types of gene expression related to affective psychosis, and PM2.5 exposure was incorporated into the analyses.

RESULTS

According to the generalized estimating equation analysis results, 8 single nucleotide polymorphisms (SNPs) belonging to the ANK3, BDNF, CACNA1C, and GRID1 genotypes were significantly correlated with depressive disorder (P < .001), with the majority belonging to the ANK3 and CACNA1C. A total of 5 SNPs belonging to the CACNA1C, GRID1, and SIRT1 genotypes were significantly correlated with bipolar disorder (P < .001), with the majority belonging to the CACNA1C. No significant correlation was identified between ambient air pollution and affective psychosis.

CONCLUSIONS

CACNA1C and GRID1 are common SNP genotypes for depressive disorder and bipolar disorder and should be considered associated with affective psychosis.

Disorganization in first episode affective psychosis: Treatment response and clinical considerations from a 2-year follow-up study in a "real world" setting

INTRODUCTION

Disorganization is a crucial domain in affective psychoses. However, it has received poor research attention, especially at the illness onset. The aims of this study were: (a) to monitor the longitudinal course of disorganization in young people with first episode affective psychosis (FEAP) across 2 years of follow-up, and (b) to investigate any relevant correlation of disorganized symptoms with psychopathology, functioning and the specific treatment elements of an "Early Intervention in Psychosis" (EIP) protocol along the follow-up period.

MATERIALS AND METHODS

Seventy-five FEAP participants (aged 12-35 years) completed the Positive And Negative Syndrome Scale (PANSS) and the Global Assessment of Functioning (GAF). Spearman's rank correlation coefficients were calculated.

RESULTS

During the follow-up, disorganized symptoms showed significant enduring positive correlations with PANSS items representing delusional thought content and uncooperativeness, as well as a persistent negative association with the GAF score. Across the 2-year follow-up period, FEAP individuals also had a relevant reduction in disorganization levels. This symptom decrease was specifically related with the combination of antipsychotic medication with the specific psychosocial components of our EIP intervention offered to FEAP patients during the first 12 months of treatment.

CONCLUSIONS

Disorganization is relevant in FEAP subjects already at their enrollment in specialized EIP protocols. However, it decreases over time, together with the delivery of specific, combined (person-tailored) EIP interventions.

Use of multiple polygenic risk scores for distinguishing schizophrenia-spectrum disorder and affective psychosis categories in a first-episode sample; the EU-GEI study

BACKGROUND

Schizophrenia (SZ), bipolar disorder (BD) and depression (D) run in families. This susceptibility is partly due to hundreds or thousands of common genetic variants, each conferring a fractional risk. The cumulative effects of the associated variants can be summarised as a polygenic risk score (PRS). Using data from the EUropean Network of national schizophrenia networks studying Gene-Environment Interactions (EU-GEI) first episode case-control study, we aimed to test whether PRSs for three major psychiatric disorders (SZ, BD, D) and for intelligent quotient (IQ) as a neurodevelopmental proxy, can discriminate affective psychosis (AP) from schizophrenia-spectrum disorder (SSD).

METHODS

Participants (842 cases, 1284 controls) from 16 European EU-GEI sites were successfully genotyped following standard quality control procedures. The sample was stratified based on genomic ancestry and analyses were done only on the subsample representing the European population (573 cases, 1005 controls). Using PRS for SZ, BD, D, and IQ built from the latest available summary statistics, we performed simple or multinomial logistic regression models adjusted for 10 principal components for the different clinical comparisons.

RESULTS

In case-control comparisons PRS-SZ, PRS-BD and PRS-D distributed differentially across psychotic subcategories. In case-case comparisons, both PRS-SZ [odds ratio (OR) = 0.7, 95% confidence interval (CI) 0.54-0.92] and PRS-D (OR = 1.31, 95% CI 1.06-1.61) differentiated AP from SSD; and within AP categories, only PRS-SZ differentiated BD from psychotic depression (OR = 2.14, 95% CI 1.23-3.74).

CONCLUSIONS

Combining PRS for severe psychiatric disorders in prediction models for psychosis phenotypes can increase discriminative ability and improve our understanding of these phenotypes. Our results point towards the potential usefulness of PRSs in specific populations such as high-risk or early psychosis phases.

Grouping affective psychoses in early intervention: Justification for specific treatment guidelines

The concept of affective psychosis regroups psychotic disorders with mood syndrome. Previous studies provided evidence to support a dichotomy between affective and non-affective psychoses although questions remain regarding the utility and validity of such a category to develop clinical guidelines. The aim of this study is to explore similarities and differences within affective psychoses to question whether strategies would apply to all the diagnoses falling under this umbrella term. Using Bayesian model comparison methods, we explored the homogeneity of the characteristics of first-episode affective patients (N = 77) treated in a specialized 3-year early intervention in psychosis programme. Our analysis revealed affective psychoses display many similarities regarding socio-demographic variables, the course of positive and manic symptoms over three years, and outcome at discharge. Our results did not support the heterogeneous model. However, despite no significant differences in the course of symptoms with the major depressive disorder group, the schizoaffective disorder group displayed a more severe clinical picture at the beginning of the programme and a poorer functional outcome than the two other groups. Absence of clear boundaries and the several similarities within affective psychoses suggest they can usefully be grouped to define treatment strategies that are easily legible by clinicians.

A word is worth a thousand pictures: A 20-year comparative analysis of aberrant abstraction in schizophrenia, affective psychosis, and non-psychotic depression

thinking is a cognitive process that involves the assimilation of concepts reduced from diffuse sensory input, organized, and interpreted in a manner beyond the obvious. There are multiple facets by which abstraction is measured that include semantic, visual-spatial and social comprehension. This study examined the prevalence and course of abstract and concrete responses to semantic proverbs and aberrant abstraction (composite score of semantic, visual-spatial, and social comprehension) over 20 years in 352 participants diagnosed with schizophrenia, affective psychosis, and unipolar non-psychotic depression. We utilized linear models, two-way ANOVA and contrasts to compare groups and change over time. Linear models with Generalized Estimation Equation (GEE) to determine association. Our findings show that regardless of diagnosis, semantic proverb interpretation improves over time. Participants with schizophrenia give more concrete responses to proverbs when compared to affective psychosis and unipolar depressed without psychosis. We also show that the underlying structure of concretism encompasses increased conceptual overinclusion at index hospitalization and idiosyncratic associations at follow-up; whereas, abstract thinking overtime encompasses increased visual-spatial abstraction at index and rich associations with increased social comprehension scores at follow-up. Regardless of diagnosis, premorbid functioning, descriptive characteristics, and IQ were not associated with aberrant abstraction. Delusions are highly and positively related to aberrant abstraction scores, while hallucinations are mildly and positively related to this score. Lastly, our data point to the importance of examining the underlying interconnected structures of 'established' constructs vis-à-vis mixed methods to provide a description of the rich interior world that may not always map onto current quantitative measures.

Aberrant default mode connectivity in adolescents with early-onset psychosis: A resting state fMRI study

Abnormal default mode network (DMN) connectivity has been found in schizophrenia and other psychotic disorders. However, there are limited studies on early onset psychosis (EOP), and their results show lack of agreement. Here, we investigated within-network DMN connectivity in EOP compared to healthy controls (HC), and its relationship to clinical characteristics. A sample of 68 adolescent patients with EOP (mean age 16.53 ± 1.12 [SD] years, females 66%) and 95 HC (mean age 16.24 ± 1.50 [SD], females 60%) from two Scandinavian cohorts underwent resting state functional magnetic resonance imaging (rsfMRI). A group independent component analysis (ICA) was performed to identify the DMN across all participants. Dual regression was used to estimate spatial maps reflecting each participant's DMN network, which were compared between EOP and HC using voxel-wise general linear models and permutation-based analyses. Subgroup analyses were performed within the patient group, to explore associations between diagnostic subcategories and current use of psychotropic medication in relation to connectivity strength. The analysis revealed significantly reduced DMN connectivity in EOP compared to HC in the posterior cingulate cortex, precuneus, fusiform cortex, putamen, pallidum, amygdala, and insula. The subgroup analysis in the EOP group showed strongest deviations for affective psychosis, followed by other psychotic disorders and schizophrenia. There was no association between DMN connectivity strength and the current use of psychotropic medication. In conclusion, the findings demonstrate weaker DMN connectivity in adolescent patients with EOP compared to healthy peers, and differential effects across diagnostic subcategories, which may inform our understanding of underlying disease mechanisms in EOP.

SARS-CoV-2-associated first episode of acute mania with psychotic features

Despite neuropsychiatric outcomes of SARS-CoV-2 infection are now under close scrutiny, psychoneuroimmunological characteristics of COVID-19 and precise pathophysiology of neuropsychiatric manifestations of the infection are still obscure. Moreover, there still exists a shortfall in demonstrating specific clinical manifestations of the brain involvement of the virus. Here, we presented a 33-year-old female patient with COVID-19, reporting acute-onset paranoid delusions symptoms, insomnia and irritability. Cranial MRI showed an hyperintense signal in the splenium of the corpus callosum with decreased apparent diffusion coefficient, which might possibly indicate the presence of cytotoxic edema related to the brain involvement of the infection. Following the completion of SARS-CoV-2 treatment, both cytotoxic edema and psychiatric symptoms resolved. In light of this report, we suggest that either heightened immune response and direct viral infection that SARS-CoV-2 may lead to such psychiatric manifestations and neuropsychiatric monitoring should be performed in patients with COVID-19. Prompt recognition of psychiatric consequences of COVID-19 may help clinicians provide guidance for differential diagnosis and manage them accordingly.

Relational memory in the early stage of psychotic bipolar disorder

Relational memory is impaired in psychotic disorders. In non-affective psychotic disorders, relational memory deficits are present in the early stage of illness and become more pronounced in the chronic stage. Previous studies have demonstrated cognitive deficits in early-stage psychotic bipolar disorder, but it is unclear whether relational memory is impaired. We examined relational memory using a face-scene binding task in early-stage psychotic bipolar disorder patients (n = 33) and compared their performance with healthy control (n = 40) and early-stage non-affective psychosis participants (n = 40). During training, participants learned to associate faces with background scenes. During testing, participants viewed a scene overlaid by three faces and were asked to recall the matching face. Relational memory was assessed indirectly using eye movements and explicitly using forced-choice recognition. Preferential viewing of the matching face, as captured by overall proportion of viewing and viewing across time, was significantly lower in psychotic bipolar disorder than in the healthy control group. However, preferential viewing of the matching face in psychotic bipolar disorder was significantly better than in non-affective psychosis. These findings provide novel evidence that relational memory in patients with early-stage psychotic bipolar disorder is intermediate between healthy control and early-stage non-affective psychosis subjects.

Young women are the most vulnerable to postpartum mental illness: A retrospective cohort study in UK primary care

BACKGROUND

Whilst childbirth is a leading cause of mental illness in women, how it affects women at different ages is unknown.

AIMS

We examine whether the effect of childbirth on mental illness varies at different ages.

METHODS

From 2,657,751 women identified from a UK population-based primary care database, 355,864 postpartum periods, with no history of mental illness, were matched on year of birth and general practice to 1,420,350 non-postpartum periods. Cox regression models were used to compare incident mental illness between postpartum and non-postpartum periods. These were measured using hazard ratios (HR) and hazard ratios adjusted for parity and prior pregnancy loss (aHR).

RESULTS

Strong evidence is presented that the effect of livebirth on mental illness was age-dependant for depression (p <0·001), anxiety (p 0·048) and affective psychosis (p 0·031). In 15-19 year olds, depression was over seven times more likely to occur in postpartum periods than non-postpartum periods (aHR 7·09, 95%CI 6·65-7·56); twice the effect in women overall (aHR 3·24 95%CI 3·18-3·29). 15-19 year olds were 50% more likely to develop anxiety in postpartum periods than non-postpartum periods (aHR 1·52, 95%CI 1·38-1·67), with little effect in women overall (aHR 1·07 95%CI 1·04-1·10). Livebirth had over twice the effect on affective psychosis in women aged 15-24 (15-19 year olds: aHR 2·71 95%CI 1·23-5·97; 20-24 year olds: aHR 2·79 95%CI 1·68-4·63) compared to women overall (aHR 1·66, 95%CI 1·29-2·14).

CONCLUSIONS

Younger women are far more vulnerable to the effect of childbirth on their mental health, particularly depression and anxiety.

Altered syntactic abilities in first episode patients: An inner phenomenon characterizing psychosis

BACKGROUND

Research has consistently shown that language abilities represent a core dimension of psychosis; however, to date, very little is known about syntactic comprehension performance in the early stages of psychosis. This study aims to compare the linguistic abilities involved in syntactic comprehension in a large group of First Episode Psychosis (FEP) patients and healthy controls (HCs).

METHODS

A multiple choice test of comprehension of syntax was administered to 218 FEP patients (166 non-affective FEP patients [FEP-NA] and 52 affective FEP patients [FEP-A]) and 106 HCs. All participants were asked to match a sentence they listen with one out of four vignettes on a pc screen. Only one vignette represents the stimulus target, while the others are grammatical or non-grammatical (visual) distractors. Both grammatical and non-grammatical errors and performance in different syntactic constructions were considered.

RESULTS

FEP committed greater number of errors in the majority of TCGB language domains compared to HCs. Moreover, FEP-NA patients committed significantly more non-grammatical (z = -3.2, p = 0.007), locative (z = -4.7, p < 0.001), passive-negative (z = -3.2, p = 0.02), and relative (z = -4.6, p < 0.001) errors compared to HCs as well as more passive-affirmative errors compared to both HCs (z = -4.3, p < 0.001) and FEP-A (z = 3.1, p = 0.04). Finally, we also found that both FEP-NA and FEP-A committed more grammatical (FEP-NA: z = -9.2, p < 0.001 and FEP-A: z = -4.4, p < 0.001), total (FEP-NA: z = -8.2, p < 0.001 and FEP-A: z = 3.9, p =  0.002), and active-negative (FEP-NA: z = -5.8, p < 0.001 and FEP-A: z = -3.5, p = 0.01) errors compared to HCs.

CONCLUSIONS

This study shows that the access to syntactic structures is already impaired in FEP patients, especially in those with FEP-NA, ultimately suggesting that language impairments represent a core and inner feature of psychosis even at early stages.

Auditory steady state response deficits are associated with symptom severity and poor functioning in patients with psychotic disorder

OBJECTIVES

Gamma oscillation is important for cortico-cortical coordination and the integration of information across neural networks. The 40 Hz auditory steady-state response (ASSR), which reflects neural synchrony in the gamma band (30-100 Hz), is abnormal in patients with schizophrenia (SZ). The present study used the ASSR at multiple frequencies to examine (1) gamma dysfunction in patients with SZ, schizoaffective (SA), and bipolar disorder (BD) compared with controls, (2) the relationship between ASSR measures and clinical symptom severity, and (3) the relationship between ASSR measures and real-life community functioning.

METHODS

EEG was recorded from 75 controls, 52 SZ, 55 SA, and 89 BD patients during 20-30-40-Hz binaural click trains. ANCOVA was used to compare ASSR measures between groups controlling for age, sex, and education. Associations between ASSR measures, symptom severity, and community functioning were examined using linear regression and Pearson partial correlations.

RESULTS

ASSR deficits at gamma frequency were observed in all patient groups. SA patients showed additional specific deficit in the 20 Hz ASSR. Severity of manic, depressive, and anxiety symptoms mediated ASSR deficits. Severity of hallucinatory symptom and community functioning, particularly independent living/meaningful activity, were significantly and independently associated with the 40 Hz ASSR.

CONCLUSIONS

SZ, SA and BD patients are likely to share the same abnormalities in neural processes that generate gamma oscillations. 40 Hz ASSR are associated with community functioning across patients and may serve as a biomarker for predicting functional outcome.

Adverse obstetric and neonatal outcomes complicated by psychosis among pregnant women in the United States

Background

Adverse obstetric and neonatal outcomes among women with psychosis, particularly affective psychosis, has rarely been studied at the population level. We aimed to assess the risk of adverse obstetric and neonatal outcomes among women with psychosis (schizophrenia, affective psychosis, and other psychoses).

Methods

From the 2007 – 2012 National (Nationwide) Inpatient Sample, 23,507,597 delivery hospitalizations were identified. From the same hospitalization, International Classification of Diseases diagnosis codes were used to identify maternal psychosis and outcomes. Adjusted odds ratios (aOR) and 95% confidence intervals (CI) were obtained using logistic regression.

Results

The prevalence of psychosis at delivery was 698.76 per 100,000 hospitalizations. After adjusting for sociodemographic characteristics, smoking, alcohol/substance abuse, and pregnancy-related hypertension, women with psychosis were at a heightened risk for cesarean delivery (aOR = 1.26; 95% CI: 1.23 - 1.29), induced labor (aOR = 1.05; 95% CI: 1.02 - 1.09), antepartum hemorrhage (aOR = 1.22; 95% CI: 1.14 - 1.31), placental abruption (aOR = 1.22; 95% CI: 1.13 - 1.32), postpartum hemorrhage (aOR = 1.18; 95% CI: 1.10 - 1.27), premature delivery (aOR = 1.40; 95% CI: 1.36 - 1.46), stillbirth (aOR = 1.37; 95% CI: 1.23 - 1.53), premature rupture of membranes (aOR = 1.22; 95% CI: 1.15 - 1.29), fetal abnormalities (aOR = 1.49; 95% CI: 1.38 - 1.61), poor fetal growth (aOR = 1.26; 95% CI: 1.19 - 1.34), and fetal distress (aOR = 1.14; 95% CI: 1.10 - 1.18). Maternal death during hospitalizations (aOR = 1.00; 95% CI: 0.30 - 3.31) and excessive fetal growth (aOR = 1.06; 95% CI: 0.98 - 1.14) were not statistically significantly associated with psychosis.

Conclusions

Pregnant women with psychosis have elevated risk of several adverse obstetric and neonatal outcomes. Efforts to identify and manage pregnancies complicated by psychosis may contribute to improved outcomes.

Electronic supplementary material

The online version of this article (10.1186/s12884-018-1750-0) contains supplementary material, which is available to authorized users.

The impact of current cannabis use on general cognitive function in people with psychotic illness

BACKGROUND

Despite growing research, it remains unclear if cannabis use is associated with additive cognitive impairment in people with psychotic illness and whether exposure in early adolescence is associated with poorer cognitive performance in adulthood.

METHODS

This cross-sectional study of a nationally representative sample of 1199 adults with psychotic illness compared current cognition (digit symbol coding) of 297 current users of cannabis (used in the past year), 460 past users (used previously but not in the past year) and 442 non-users (never used). Multiple logistic regression was used to examine whether cognitive performance of cannabis-user groups varied by exposure age and diagnosis (non-affective/affective psychoses).

RESULTS

Unadjusted analysis showed current cannabis users had significantly higher odds of impaired cognitive function compared to non-users (odds ratio=1.52, 95%CI=1.04-2.22). After adjusting for potential confounders, differences between the three groups were not significant. Exposure age was not significant in adjusted analysis. In participants with nonaffective psychoses, cognitive ability of current cannabis users did not differ from non-users. However, in participants with affective psychoses, using cannabis in the last year was a significant predictor of impaired cognitive function (odds ratio=2.25, 95%CI=1.05-4.84).

CONCLUSION

Among people with psychotic illness, there was no significant difference in cognitive function between current, past and non-users of cannabis. However, when we compared cognitive performance of the three cannabis groups by diagnostic grouping, current cannabis use had a significant negative relationship with cognitive function in people with affective psychoses, but not in those with non-affective psychoses. This finding requires replication and further investigation.

The interplay of childhood behavior problems and IQ in the development of later schizophrenia and affective psychoses

Schizophrenia and affective psychoses are both associated with impaired social functioning, but the extent to which childhood behavioral impairments are present prior to onset of illness is less well studied. Moreover, the concurrent relationship of childhood behavior problems and premorbid IQ with subsequent psychotic disorder has not been established. We investigated whether childhood behavior problems are associated with increased risk for adult schizophrenia or affective psychosis, independently and in combination with IQ. The study included individuals with schizophrenia (N=47), affective psychoses (N=45) and non-psychotic controls (N=1496) from the New England Family Study. Behavior problems were prospectively assessed from standardized clinician observations at ages 4 and 7. IQ was assessed with the Stanford-Binet at age 4 and the Wechsler Intelligence Scale for Children at age 7. We found externalizing problems at age 4 and externalizing and internalizing problems at age 7 were associated with later schizophrenia, and both internalizing and externalizing problems at ages 4 and 7 were associated with later development of affective psychoses. Lower IQ at ages 4 and 7 was associated with schizophrenia, while lower IQ was associated with affective psychoses at age 7 only. Examined simultaneously, both lower IQ and behavior problems remained associated with risk of schizophrenia, while only behavior problems remained associated with affective psychoses. Behavior problems appear to be a general marker of risk of adult psychotic disorder, while lower childhood IQ is more specific to risk of schizophrenia. Future research should clarify the premorbid evolution of behavior and cognitive problems into adult psychosis.

Twenty year multi-follow-up of different types of hallucinations in schizophrenia, schizoaffective disorder, bipolar disorder, and depression

Hallucinations are a salient feature of both psychotic and mood disorders. Currently there is a call for more research on the phenomenology of different forms of hallucinations, in a broader array of disorders, to further both theoretical knowledge and clinical utility. We investigated auditory, visual, and olfactory hallucinations at index hospitalization and auditory and visual hallucinations prospectively for 20years in 150 young patients, namely 51 schizophrenia, 25 schizoaffective, 28 bipolar, and 79 unipolar depression. For the index hospitalization, the data showed schizophrenia and schizoaffective patients had a greater rate of auditory and visual hallucinations than bipolar and depression patients. However, over the longitudinal trajectory of their illness, a greater percentage of schizophrenia patients had auditory and visual hallucinations than schizoaffective patients, as well as bipolar and depression patients. Also, in contrast to the initial period, schizoaffective patients did not differentiate themselves over the follow-up period from bipolar patients. Bipolar and depression patients did not significantly differ at index hospitalization or at follow-up. We found visual hallucinations differentiated the groups to a greater degree over the 20year course than did auditory hallucinations. These findings suggest the longitudinal course is more important for differentiating schizophrenia and schizoaffective disorder, whereas the initial years may be more useful to differentiate schizoaffective disorder from bipolar disorder. Furthermore, we found that the early presence of auditory hallucinations was associated with a reduced likelihood for a future period of recovery. No olfactory hallucinations were present at the index hospitalization in any patients. Over the course of 20years, a minority of schizophrenia patients presented with olfactory hallucinations, and very few schizoaffective and bipolar patients presented with olfactory hallucinations. This study underscores the importance of the longitudinal course of symptoms to understand the relationship between related disorders and recovery.

Subjective quality of life in first-episode psychosis. A ten year follow-up study

Subjective quality of life (S-QoL) is an important outcome measure in first episode psychosis (FEP). The aims of this study were to describe S-QoL-development the first 10-years in FEP patients and to identify predictors of this development.

METHODS

A representative sample of 272 patients with a first episode psychotic disorder was included from 1997 through 2000. At 10 year follow-up 186 patients participated. QoL was measured by the Lehman's Quality of Life Interview. Linear mixed model analyses were performed to investigate longitudinal effects of baseline psychiatric symptoms and socio-economic variables and the effects of changes in the same variables on S-QoL-development.

RESULTS

S-QoL improved significantly over the follow-up period. More contact with family and a better financial situation at baseline had a positive and longstanding effect on S-QoL-development, but changes in these variables were not associated with S-QoL-development. Higher depressive symptoms and less daily activities at baseline both had a negative independent effect, but a positive interaction effect with time on S-QoL-development indicating that the independent negative effect diminished over time. In the change analysis, increased daily activities and a decrease in depressive symptoms were associated with a positive S-QoL-development.

CONCLUSIONS

Treatment of depressive symptoms and measures aimed at increasing daily activities seem important to improve S-QoL in patients with psychosis. More contact with family and a better financial situation at baseline have a long-standing effect on S-QoL-development in FEP patients.

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Classification of first-episode psychosis in a large cohort of patients using support vector machine and multiple kernel learning techniques

First episode psychosis (FEP) patients are of particular interest for neuroimaging investigations because of the absence of confounding effects due to medications and chronicity. Nonetheless, imaging data are prone to heterogeneity because for example of age, gender or parameter setting differences. With this work, we wanted to take into account possible nuisance effects of age and gender differences across dataset, not correcting the data as a pre-processing step, but including the effect of nuisance covariates in the classification phase. To this aim, we developed a method which, based on multiple kernel learning (MKL), exploits the effect of these confounding variables with a subject-depending kernel weighting procedure. We applied this method to a dataset of cortical thickness obtained from structural magnetic resonance images (MRI) of 127 FEP patients and 127 healthy controls, who underwent either a 3Tesla (T) or a 1.5T MRI acquisition. We obtained good accuracies, notably better than those obtained with standard SVM or MKL methods, up to more than 80% for frontal and temporal areas. To our best knowledge, this is the largest classification study in FEP population, showing that fronto-temporal cortical thickness can be used as a potential marker to classify patients with psychosis.

Functional deterioration from the premorbid period to 2 years after the first episode of psychosis in early-onset psychosis

The aim of the study was to analyze changes in functional adjustment from childhood to 2 years after the first episode of psychosis (FEP) in patients with early-onset schizophrenia spectrum disorders (SSD) and affective psychoses (AFP) and a good or intermediate level of premorbid adjustment. We followed 106 adolescents (aged 12-17 years) with FEP for 2 years after recruitment. Premorbid adjustment in childhood was assessed in 98 patients with the childhood subscale of the Cannon-Spoor Premorbid Adjustment Scale (c-PAS). Global functioning was assessed 2 years after the FEP with the Children's Global Assessment Scale (c-GAS) or the Global Assessment of Functioning scale (GAF), as appropriate. Functional deterioration was defined as a downward shift in the level of functional adjustment from childhood to 2 years after the FEP. In patients with good or intermediate premorbid adjustment, functional deterioration was observed in 28.2 % (26.5 % of the AFP group, 29.4 % of the SSD group). Longer duration of untreated psychosis (Beta = 0.01; P = 0.01) and higher symptom severity at the FEP, as measured with the Clinical Global Impression Scale (Beta = 1.12; P = 0.02), significantly predicted the presence of functional deterioration, accounting for 21.4 % of the variance. Irrespective of diagnosis (SSD or AFP), almost one-third of adolescents with FEP and good or intermediate premorbid adjustment showed functional deterioration from the premorbid period to 2 years after the FEP.

Cognitive markers of psychotic unipolar depression: a meta-analytic study

BACKGROUND

The goal of the current meta-analysis was to review and examine in detail the features of cognitive performance in psychotic (MDDP) versus non-psychotic (MDD) major depressive disorder.

METHODS

An electronic literature search was performed to find studies comparing cognitive performance in MDDP versus MDD. A meta-analysis of broad cognitive domains (processing speed, reasoning/problem solving, verbal learning, visual learning, attention/working memory) and individual cognitive tasks was conducted on all included studies (n=12). Demographic and clinical features were investigated via meta-regression analysis as moderators of cognitive performance.

RESULTS

No difference in socio-demographic and clinical variables was detected between groups. In general, a poorer cognitive performance was detected in MDDP versus MDD subjects (ES=0.38), with a greater effect size in drug-free patients (ES=0.69). MDDP patients were more impaired in verbal learning (ES=0.67), visual learning (ES=0.62) and processing speed (ES=0.71) tasks. A significantly poorer performance was also detected in MDDP patients for individual tasks as Trail Making Test A, WAIS-R digit span backward and WAIS-R digit symbol. Age resulted to have a negative effect on tasks involved in working memory performance.

CONCLUSION

In line with previous meta-analyses, our findings seem to support an association between psychosis and cognitive deficits in the context of affective disorders. Psychosis during the course of MDD is associated with poorer cognitive performance in some specific cognitive domains, such as visual and verbal learning and executive functions.

Sustained attention in psychosis: Neuroimaging findings

To provide a systematic review of scientific literature on functional magnetic resonance imaging (fMRI) studies on sustained attention in psychosis. We searched PubMed to identify fMRI studies pertaining sustained attention in both affective and non-affective psychosis. Only studies conducted on adult patients using a sustained attention task during fMRI scanning were included in the final review. The search was conducted on September 10^th, 2013. 15 fMRI studies met our inclusion criteria: 12 studies were focused on Schizophrenia and 3 on Bipolar Disorder Type I (BDI). Only half of the Schizophrenia studies and two of the BDI studies reported behavioral abnormalities, but all of them evidenced significant functional differences in brain regions related to the sustained attention system. Altered functioning of the insula was found in both Schizophrenia and BDI, and therefore proposed as a candidate trait marker for psychosis in general. On the other hand, other brain regions were differently impaired in affective and non-affective psychosis: alterations of cingulate cortex and thalamus seemed to be more common in Schizophrenia and amygdala dysfunctions in BDI. Neural correlates of sustained attention seem to be of great interest in the study of psychosis, highlighting differences and similarities between Schizophrenia and BDI.

Duration of untreated psychosis predicts functional and clinical outcome in children and adolescents with first-episode psychosis: a 2-year longitudinal study

Longer duration of untreated psychosis (DUP) in adult patients with first-episode psychosis (FEP) has been associated with poor clinical and social outcomes. We aimed to estimate the influence of DUP on outcome at 2-year follow-up in subjects with an early-onset (less than 18 years of age) FEP of less than 6 months' duration. A total of 80 subjects (31.3% females, mean age 16.0±1.8 years) were enrolled in the study. The influence of DUP on outcome was estimated using multiple regression models (two linear models for influence of DUP on the C-GAF at 2 years and C-GAF change through the follow-up period, and a logistic model for influence of DUP on 41 PANSS remission at 2 years in schizophrenia patients (n=47)). Mean DUP was 65.3±54.7 days. Median DUP was 49.5 days. For the whole sample (n=80), DUP was the only variable significantly related to C-GAF score at 2-year follow-up (Beta=-0.13, p<0.01), while DUP and premorbid adjustment (Beta=-0.01, p<0.01; and Beta=-0.09, p=0.04, respectively) were the only variables significantly related to C-GAF change. In schizophrenia patients, DUP predicted both C-GAF score at 2 years and C-GAF change, while in patients with affective psychosis (n=22), DUP was unrelated to outcome. Lower baseline C-GAF score (OR=0.91, p<0.01) and shorter DUP (OR=0.98, p=<0.01) were the only variables that significantly predicted clinical remission in schizophrenia patients. In conclusion, longer DUP was associated with lower C-GAF at 2 years, less increase in C-GAF, and lower rates of clinical remission in early-onset FEP. Our findings support the importance of early detection programs, which help shorten DUP.