McLean-Harvard International First-Episode Project: two-year stability of DSM-IV diagnoses in 500 first-episode psychotic disorder patients

Which aspects of long-term outcome are predicted by positive and negative symptoms in early-onset psychosis? An exploratory eight-year follow-up study

BACKGROUND

Early-onset psychoses show substantial variability of diagnostic and functional outcome. Finding reliable prognostic factors may allow to allocate resources to those with the worst prognosis. The aim of the study was to gain new insights regarding the potential value of baseline negative and positive symptoms as predictors of outcome in psychoses of early onset.

METHOD

Sixty-three patients with early-onset schizophrenia spectrum psychosis hospitalized in an adolescent psychiatry unit were assessed with the Positive and Negative Syndrome Scale during the index admission. Associations with diagnosis, illness course and functional outcome were analysed in mean 8 years of follow-up (range 3.4-13.5 years).

RESULTS

The mean age at the index admission and the follow-up was 16.6 ± 1.2 and 24.5 ± 3.0 years, respectively. A significant majority of subjects continued psychiatric treatment (95%) and had been readmitted (71%). The mortality rate was 3% (suicide and accident). Negative symptoms were related to mental health service utilization during the follow-up. General severity of symptoms, specifically positive and cognitive factors were associated with the diagnosis of schizophrenia and inversely with diagnostic shift outside the schizophrenia spectrum at the catamnesis. Poor impulse control at baseline was associated with worse functional outcome. The drug-free subgroup with no occupational/educational activity compared with the drug-treated subjects showed lower levels of baseline negative symptomatology.

CONCLUSION

The study findings suggest that in patients with early-onset psychosis negative and positive symptoms show a differential prognostic value. Pharmacotherapy may attenuate the effect of symptoms on functional outcome. These hypotheses need to be tested in future studies using confirmatory approaches.

Early risk factors for adult bipolar disorder in adolescents with mood disorders: a 15-year follow-up of a community sample

BACKGROUND

We aimed to outline the early risk factors for adult bipolar disorder (BPD) in adolescents with mood disorders.

METHODS

Adolescents (16-17 years old) with mood disorders (n = 287; 90 participants with hypomania spectrum episodes and 197 with major depressive disorder [MDD]) were identified from a community sample. Fifteen years later (at 30-33 years of age), mood episodes were assessed (n = 194). The risk of developing BPD (n = 22), compared with MDD (n = 104) or no mood episodes in adulthood (n = 68), was estimated via logistic regression. Adolescent mood symptoms, non-mood disorders, and family characteristics were assessed as potential risk factors.

RESULTS

Among the adolescents with mood disorders, a family history of BPD was the strongest predictor of developing BPD compared with having no mood episodes in adulthood (OR = 5.94; 95% CI = 1.11-31.73), whereas disruptive disorders significantly increased the risk of developing BPD compared with developing MDD (OR = 2.94; CI = 1.06-8.12). The risk that adolescents with MDD would develop adult BPD, versus having no mood episodes in adulthood, was elevated among those with an early disruptive disorder (OR = 3.62; CI = 1.09-12.07) or multiple somatic symptoms (OR = 6.60; CI = 1.70-25.67). Only disruptive disorders significantly predicted adult BPD among adolescents with MDD versus continued MDD in adulthood (OR = 3.59; CI = 1.17-10.97). Only a few adolescents with hypomania spectrum episodes continued to have BPD as adults, and anxiety disorders appeared to increase this risk.

CONCLUSIONS

Although most of the identified potential risk factors are likely general predictors of continued mood disorders, disruptive disorders emerged as specific predictors of developing adult BPD among adolescents with MDD.

First-episode types in bipolar disorder: predictive associations with later illness

OBJECTIVE

Characteristics of initial illness in bipolar disorder (BD) may predict later morbidity.

METHOD

We reviewed computerized clinical records and life charts of DSM-IV-TR BD-I or BD-II patients at affiliated mood-disorder centers to ascertain relationships of initial major illnesses to later morbidity and other clinical characteristics.

RESULTS

Adult BD patient-subjects (N=1081; 59.8% BD-I; 58.1% women; 43% ever hospitalized) were followed 15.7±12.8 years after onsets ranking: depression (59%)>mania (13%)>psychosis (8.0%)≥anxiety (7.6%)≥hypomania (6.7%)>mixed states (5.5%). Onset types differed in clinical characteristics and strongly predicted later morbidity. By initial episode types, total time-ill ranked: mania≥hypomania≥mixed-states≥psychosis>depression>anxiety. Depression was most prevalent long-term, overall; its ratio to mania-like illness (D/M, by per cent-time-ill) ranked by onset type: anxiety (4.75)>depression (3.27)>mixed states (1.39)>others (all<1.00). The MDI (mania or hypomania-depression-euthymia interval) course-pattern was most common (34.4%) and associated with psychotic or manic onset; the depression before mania (DMI) pattern (25.0%) most often followed anxiety (38.8%), depression (30.8%), or mixed onsets (13.3%); both were predicted by initial mania depression sequences.

CONCLUSION

First-lifetime illnesses and cycles predicted later morbidity patterns among BD patients, indicating value of early morbidity for prognosis and long-term planning.

The schizoaffective disorder diagnosis: a conundrum in the clinical setting

The term schizoaffective was introduced to describe the co-occurrence of both psychotic and affective symptoms. Overtime, as the diagnosis schizoaffective disorder was added to diagnostic manuals, significant concerns were raised as to the reliability and clinical utility of the diagnosis. We recruited 134 psychiatrically hospitalized subjects who had received a diagnosis of schizophrenia, schizoaffective disorder or bipolar disorder with psychotic features by their treating clinician. The subjects were also diagnosed by trained research personnel with the Structured Clinical Interview of the DSM-IV-TR, employing an explicit time threshold for criterion C of the schizoaffective disorder diagnosis. We found significant differences between the clinical and research diagnoses. Clinicians diagnosed 48 patients (36%) with schizophrenia, 50 patients (37%) with schizoaffective disorder and 36 patients (27%) with psychotic bipolar disorder. In contrast, researchers diagnosed 64 patients (48%) with schizophrenia, 38 patients (28%) with schizoaffective disorder and 32 patients (24%) with psychotic bipolar disorder. This was a statistically significant disagreement between the research and clinical diagnoses (p = 0.003) and indicates that clinicians choose the less severe diagnosis for psychotic patients. We conclude that a more stringent criterion C for the schizoaffective disorder diagnosis will address an implicit bias in clinical practice and will affect the prevalence of the psychotic disorder diagnoses.

Capgras' syndrome in first-episode psychotic disorders

BACKGROUND

Misidentification phenomena, including the delusion of 'imposters' named after Joseph Capgras, occur in various major psychiatric and neurological disorders but have rarely been studied systematically in broad samples of modern patients. This study investigated the prevalence and correlated clinical factors of Capgras' phenomenon in a broad sample of patient-subjects with first-lifetime episodes of psychotic affective and nonaffective disorders.

METHODS

We evaluated 517 initially hospitalized, first-episode psychotic-disorder patients for the prevalence of Capgras' phenomenon and its association with DSM-IV-TR diagnoses including schizophreniform, brief psychotic, unspecified psychotic, delusional, and schizoaffective disorders, schizophrenia, bipolar-I disorder and major depression with psychotic features, and with characteristics of interest including antecedent psychiatric and neurological morbidity, onset type and presenting psychopathological phenomena, using standard bivariate and multivariate statistical methods.

RESULTS

Capgras' syndrome was identified in 73/517 (14.1%) patients (8.2-50% across diagnoses). Risk was greatest with acute or brief psychotic disorders (schizophreniform psychoses 50%, brief psychoses 34.8%, or unspecified psychoses 23.9%), intermediate in major depression (15%), schizophrenia (11.4%) and delusional disorder (11.1%), and lowest in bipolar-I (10.3%) and schizoaffective disorders (8.2%). Associated were somatosensory, olfactory and tactile hallucinations, Schneiderian (especially delusional perception), and cycloid features including polymorphous psychotic phenomena, rapidly shifting psychomotor and affective symptoms, pananxiety, ecstasy, overconcern with death, and perplexity or confusion, as well as rapid onset, but not sex, age, abuse history, dissociative features, or indications of neurological disorders.

CONCLUSIONS

Capgras' syndrome was prevalent across a broad spectrum of first-episode psychotic disorders, most often in acute psychoses of rapid onset.

Treatment adherence in bipolar I and schizoaffective disorder, bipolar type

BACKGROUND

Poor adherence rates in Bipolar Disorder type I (BDI) and Schizoaffective Disorder, bipolar type (SAD) may be high This study was aimed at comparing the clinical correlates of adherence to treatment and the course of illness in BDI and SAD patients.

METHODS

75 SAD and 150 BDI DSM-IV outpatients were included. Adherence was assessed on the basis of patients' and care-givers' reports and serum levels, when available. Socio-demographic, clinical and treatment variables were collected and compared between diagnostic subsamples and then between goodly and poorly adherent patients. Multiple logistic regressions were performed, controlling for diagnostic subsample differences, to identify correlates of adherence in BDI and SAD groups.

RESULTS

Poor adherence was highly prevalent both in BDI (32%) and in SAD patients (44%), with no significant differences between diagnostic categories. Presence of psychotic symptoms (p=0.029), higher number of manic relapses (p<0.001), comorbidity with personality disorders (p=0.002), and lithium therapy (p=0.003) were associated with poor adherence to treatment. Diagnostic subgroup analyses showed different predictive models, with the BDI poorly adherent subsample being more likely to include comorbid personality and manic recurrences and the SAD poorly adherent subsample being less clinically predictable.

LIMITATIONS

The cross-sectional nature of the study limits de capacity to ascertain the direction of the relationship between certain variables.

CONCLUSIONS

Rates of poor adherence to oral treatments are similar in SAD and BDI. BDI patients with comorbid personality and substance use disorders are likely to be poorly adherent. Treatment adherence may be more difficult to predict in SAD patients.

A five year diagnostic follow-up of 1,840 patients after a first episode non-schizophrenia and non-affective psychosis

OBJECTIVE

It is not clear which patients with a first psychotic episode will develop schizophrenia. We performed a diagnostic follow-up of patients treated for a first time non-affective, non-schizophrenia psychosis and explored potential predictors of a subsequent schizophrenia or schizoaffective diagnosis.

METHODS

This register-based cohort study comprises individuals born between 1973 and 1978 in Sweden, with a first hospital-treated psychosis excluding schizophrenia, schizoaffective disorder, bipolar disorder and depressive disorder with psychotic symptoms (n=1840). The patients were followed for five years regarding subsequent diagnoses. Psychiatric, social, family history of psychiatric illness, premorbid intellectual level, head injuries and obstetrical complications were investigated by logistic regression as predictors of schizophrenia or schizoaffective diagnosis.

RESULTS

During the follow-up, 18% were diagnosed with schizophrenia or schizoaffective disorder, 5% were diagnosed with bipolar disorder, whereas 29% were not re-admitted to a psychiatric clinic. Patients with a first-degree relative hospitalized for schizophrenia and/or bipolar disorder had an increased risk of subsequent diagnosis for schizophrenia or schizoaffective disorder (odds ratio 1.9 and 95% confidence interval 1.1 to 3.0)), whereas previous severe criminality was associated with a decreased risk (odds ratio 0.5, 95% confidence interval 0.3-0.8).

CONCLUSION

Diagnostic outcome was diverse after a first non-schizophrenia and non-affective psychosis. Family history of severe mental illness and no previous conviction for severe criminality were the strongest risk factors for a future schizophrenia or schizoaffective diagnosis.

Diagnostic stability of first-episode psychotic disorders and persistence of comorbid psychiatric disorders over 1 year

OBJECTIVE

Diagnostic stability is an important indicator of the reliability and validity of psychiatric diagnoses and has implications in clinical practice and research. While several studies have investigated the diagnostic stability of first-episode psychosis (FEP) disorders, less is known about psychiatric comorbidity in FEP and the persistence of such comorbid conditions over time. Our study aimed to confirm the diagnostic stability of FEP disorders and determine the variation in persistence of comorbid substance use disorders (SUDs), mood disorders, and anxiety disorders over 1 year.

METHOD

The Structured Clinical Interview for DSM-IV-TR Axis I Disorders-Patient Edition was conducted at first presentation and repeated after 1 year (or reconstructed) for 214 FEP patients at the Prevention and Early Intervention Program for Psychoses-Montreal.

RESULTS

Psychotic disorder diagnoses were retained by 76.2% of patients at 1 year, schizophrenia being the most stable diagnosis (92.1%). Most diagnostic shifts were to schizophrenia and schizophrenia spectrum disorders. Comorbid SUDs, anxiety disorders, and mood disorders persisted for 50.7%, 64.0%, and 16.7% of patients, respectively. Many new cases of each of these disorders also emerged at 1-year follow-up.

CONCLUSIONS

These findings demonstrate the stability of primary psychotic disorder diagnoses and greater fluidity of comorbid psychiatric diagnoses, with anxiety disorders persisting as comorbid conditions more than mood disorders and SUDs. These results highlight the importance of repeating a structured diagnostic assessment longitudinally, especially for consideration of comorbid conditions.

Heterogeneity of schizoaffective disorder compared with schizophrenia and bipolar disorder

OBJECTIVE

Low diagnostic reliability, the need to meet criteria of two disorders, and its status as residual diagnosis in clinical practice led us to hypothesize that schizoaffective disorder (SAD) is characterized by considerable heterogeneity, particularly in comparison with schizophrenia (SZ) and bipolar disorder (BD). As this has not been investigated the aim of this study is to test whether heterogeneity is larger in SAD than in SZ and BD.

METHOD

Systematic search for studies simultaneously comparing all three diagnoses regarding demographic, clinical, psychometric (clinical rating scales and IQ tests), and biological parameters; comparison of heterogeneity as measured by standard deviation (SD).

RESULTS

Standard deviation of SAD samples (N = 47) was smaller than in both differential diagnoses. SDs were 7% higher in BD than in SAD (SZ: 2% higher); in studies employing DSM-IIIR/-IV pooled SD was 4% higher in BD (8% lower in SZ). Differences between diagnoses were limited to the comparison of SAD and BD, and became smaller when only psychotic BD was considered.

CONCLUSION

Heterogeneity of SZ and BD is not smaller than that of SAD. SAD seems not to be more diverse than other functional psychoses. Results are preliminary because of the novelty of the approach and to the small number of studies.

Epidemiological and clinical characterization following a first psychotic episode in major depressive disorder: comparisons with schizophrenia and bipolar I disorder in the Cavan-Monaghan First Episode Psychosis Study (CAMFEPS)

While recent research on psychotic illness has focussed on the nosological, clinical, and biological relationships between schizophrenia and bipolar disorder, little attention has been directed to the most common other psychotic diagnosis, major depressive disorder with psychotic features (MDDP). As this diagnostic category captures the confluence between dimensions of psychotic and affective psychopathology, it is of unappreciated heuristic potential to inform on the nature of psychotic illness. Therefore, the epidemiology and clinical characteristics of MDDP were compared with those of schizophrenia and bipolar disorder within the Cavan-Monaghan First Episode Psychosis Study (n = 370). Epidemiologically, the first psychotic episode of MDDP (n = 77) was uniformly distributed across the adult life span, while schizophrenia (n = 73) and bipolar disorder (n = 73) were primarily disorders of young adulthood; the incidence of MDDP, like bipolar disorder, did not differ between the sexes, while the incidence of schizophrenia was more common in males than in females. Clinically, MDDP was characterized by negative symptoms, executive dysfunction, neurological soft signs (NSS), premorbid intellectual function, premorbid adjustment, and quality of life similar to those for schizophrenia, while bipolar disorder was characterized by less prominent negative symptoms, executive dysfunction and NSS, and better quality of life. These findings suggest that what we currently categorize as MDDP may be more closely aligned with other psychotic diagnoses than has been considered previously. They indicate that differences in how psychosis is manifested vis-à-vis depression and mania may be quantitative rather than qualitative and occur within a dimensional space, rather than validating categorical distinctions.

Schizophrenia is primed for an increased expression of depression through activation of immuno-inflammatory, oxidative and nitrosative stress, and tryptophan catabolite pathways

Schizophrenia and depression are two common and debilitating psychiatric conditions. Up to 61% of schizophrenic patients have comorbid clinical depression, often undiagnosed. Both share significant overlaps in underlying biological processes, which are relevant to the course and treatment of both conditions. Shared processes include changes in cell-mediated immune and inflammatory pathways, e.g. increased levels of pro-inflammatory cytokines and a Th1 response; activation of oxidative and nitrosative stress (O&NS) pathways, e.g. increased lipid peroxidation, damage to proteins and DNA; decreased antioxidant levels, e.g. lowered coenzyme Q10, vitamin E, glutathione and melatonin levels; autoimmune responses; and activation of the tryptophan catabolite (TRYCAT) pathway through induction of indoleamine-2,3-dioxygenase. Both show cognitive and neurostructural evidence of a neuroprogressive process. Here we review the interlinked nature of these biological processes, suggesting that schizophrenia is immunologically primed for an increased expression of depression. Such a conceptualization explains, and incorporates, many of the current perspectives on the nature of schizophrenia and depression, and has implications for the nature of classification and treatment of both disorders. An early developmental etiology to schizophrenia, driven by maternal infection, with subsequent impact on offspring immuno-inflammatory responses, creates alterations in the immune pathways, which although priming for depression, also differentiates the two disorders.

Negative Affective Features in 516 Cases of First Psychotic Disorder Episodes: Relationship to Suicidal Risk

OBJECTIVES

Plausible candidates of psychopathological phenomena that may associate with or anticipate suicidal risk, include negative affects, including admixtures of dysphoria, depression and anxiety described mainly in nonpsychotic disorders. We ascertained the distribution of such affective features in various first-episode psychotic disorders and correlated these and other clinical and antecedent features with intake suicidal status.

METHODS

We evaluated 516 adult subjects in first-lifetime episodes of various DSM-IV-TR psychotic disorders. Blinded, protocol-guided, assessments of clinical features ascertained in SCID examinations, self- and family reports and clinical records supported analyses of associations of suicide attempts at first-psychotic episodes with antecedent and intake clinical characteristics, including negative affects and diagnoses, using standard bivariate and multivariate methods.

RESULTS

Negative affective features in various combinations were prevalent (90%) and at >75% in both affective and nonaffective psychotic disorders; anxious depression was most common (22%). We identified antecedent and intake clinical factors preliminarily associated with suicide attempts. Factors remaining independently associated in multivariate logistic modelling (ranked by OR) were: (a) prior suicide attempt, (b) prior aggressive assault, (c) bipolar-mixed state or psychotic major depression diagnosis, (d) prior dysphoria, (e) intake dysphoric-anxiousdepression, (f) prior impulsivity, (g) previous affective instability, (h) previous nonpsychotic depression, (i) previous decline in vital drive, and (j) prior sleep disturbances.

CONCLUSIONS

Various types and combinations of negative affective features (especially anxious depression with and without dysphoria) were prevalent across nonaffective as well as affective first psychotic episodes and strongly associated with suicide attempts. These findings extend previous observations in nonpsychotic disorders.

Can a targeted psychological intervention be effective for young people following a first manic episode? Results from an 18-month pilot study

AIM

There is a scarce literature describing psychological interventions for a young, first-episode cohort who have experienced psychotic mania. This study aimed to assess whether a manualized psychological intervention could be effective in reducing symptomatology and relapse, and improve functional outcome in this population.

METHODS

The study was an open-label design, drawn from a larger pharmacotherapy trial. All participants in the pharmacotherapy trial were offered a manualized psychological intervention in addition to case management. Inclusion in the psychotherapy group was based on participant's choice, and on completion of four or more of the eight modules offered. All clinical files were audited to ensure accuracy of group allocation. Forty young people aged 15 to 25 years old who had experienced a manic episode with psychotic features were recruited into the study, with 20 people in the combined treatment as usual plus psychotherapy group (P+TAU), and an equal number of matched control participants who received treatment as usual (TAU) within the same service. All participants were prescribed antipsychotic and mood-stabilizing medication. Symptomatic, functional and relapse measures were taken both at baseline and at 18-month follow-up.

RESULTS

Manic symptoms improved significantly for both groups, with no differences between groups. Depression scores and overall symptom severity were significantly lower in the P + TAU group. No differences were evident between groups with regard to numbers or type of relapse. The P + TAU group had significantly better social and occupational functioning after 18 months.

CONCLUSION

This study suggests that a manualized psychological intervention targeted to a first-episode population can be effective in reducing depression and overall symptom severity, and can improve functional outcome following a first episode of psychotic mania.

Increased familiarity of intellectual deficits in early-onset schizophrenia spectrum disorders

OBJECTIVES

Early-onset schizophrenia is considered to be neurobiologically similar to adult-onset forms, although it represents a more severe expression of the disorder. In the present study, we explored putative larger familial vulnerability of intellectual impairments in early-onset schizophrenia spectrum disorders (EOS) when compared to adult-onset (AOS) families.

METHODS

A sample of 340 subjects including schizophrenia spectrum disorder patients, their first degree relatives and age-matched healthy controls was assessed on intelligence quotient (IQ). We used linear regression analysis and intraclass correlation coefficients (ICC) to explore familial aggregation of IQ across age at onset groups.

RESULTS

The relationship between IQ level of patients and their first-degree relatives showed positive linear association (β = 0.43, P < 0.01). High significant familial aggregation was found for intelligence quotient in EOS families (ICC = 0.618, P < 0.01), while AOS families responded to lower estimates (ICC = 0.204, P = 0.26; between ICC comparison z = 1.993, P < 0.05).

CONCLUSIONS

High aggregation of intellectual performance in the EOS group suggests larger familial vulnerability in early-onset forms of the disease when cognitive functions are considered. Within a continuum of psychopathology in schizophrenia spectrum disorders, specific genetic effects are discussed for distinct onset forms that might be in line with a neurodevelopmental model of the disease.

Psychosis Incident Cohort Outcome Study (PICOS). A multisite study of clinical, social and biological characteristics, patterns of care and predictors of outcome in first-episode psychosis. Background, methodology and overview of the patient sample

AIMS

This paper aims at providing an overview of the background, design and initial findings of Psychosis Incident Cohort Outcome Study (PICOS).

METHODS

PICOS is a large multi-site population-based study on first-episode psychosis (FEP) patients attending public mental health services in the Veneto region (Italy) over a 3-year period. PICOS has a naturalistic longitudinal design and it includes three different modules addressing, respectively, clinical and social variables, genetics and brain imaging. Its primary aims are to characterize FEP patients in terms of clinical, psychological and social presentation, and to investigate the relative weight of clinical, environmental and biological factors (i.e. genetics and brain structure/functioning) in predicting the outcome of FEP.

RESULTS

An in-depth description of the research methodology is given first. Details on recruitment phase and baseline and follow-up evaluations are then provided. Initial findings relating to patients' baseline assessments are also presented. Future planned analyses are outlined.

CONCLUSIONS

Both strengths and limitations of PICOS are discussed in the light of issues not addressed in the current literature on FEP. This study aims at making a substantial contribution to research on FEP patients. It is hoped that the research strategies adopted in PICOS will enhance the convergence of methodologies in ongoing and future studies on FEP.

Delusional disorders--are they simply paranoid schizophrenia?

OBJECTIVES

This article tries to give an answer to the question of whether International Classification of Diseases (ICD-10) persistent delusional disorder (PDD) or Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) delusional disorder (DD) is simply paranoid schizophrenia (PS). Because ICD-10 PDD and DSM-IV DD are identical, we use DD as a synonym.

METHODS

A prospective and longitudinal study compared all inpatients with DD treated at the Halle-Wittenberg university hospital during a 14-year period with a previously investigated selected cohort of patients with PS. Sociodemographic data, symptomatology, course, and outcome parameters were examined using standardized instruments. The duration of the follow-up period in patients with DD was 10.8 years and for the PS patients 12.9 years.

RESULTS

Significant differences between DD and PS were found: DD patients are, in comparison to patients with PS, significantly older at onset. Less of their first-degree relatives have mental disorders. They less frequently come from a broken home situation. First-rank symptoms, relevant negative symptoms, and primary hallucinations did not occur in patients with DD. Patients with DD were less frequently hospitalized, and the duration of their hospitalization was shorter. Their outcome is much better regarding employment, early retirement due to the disorder, and psychopharmacological medication. They more often had stable heterosexual partnerships and were autarkic. They had lower scores in the Disability Assessment Scale and in Positive and Negative Syndrome Scale. The diagnosis of DD is very stable over time.

CONCLUSIONS

The findings of this study support the assumption that DDs are a separate entity and only exceptionally can be a prodrome of schizophrenia.

Meeting report: the Schizophrenia International Research Society (SIRS) South America Conference (August 5-7, 2011)

On August 5-7, 2011, São Paulo was home to the first regional meeting of the Schizophrenia International Research Society (SIRS). Over 400 people from many countries attended the activities and contributed with around 200 submissions for oral and poster presentations. This article summarizes the data presented during the meeting, with an emphasis on the plenary talks and sessions for short oral presentations. For information on the poster presentations, readers are referred to the special issue of Revista de Psiquiatria Clínica (Brazil) dedicated to the conference (available at: http://www.hcnet.usp.br/ipq/revista/vol38/s1/).

Predominant recurrence polarity among 928 adult international bipolar I disorder patients

OBJECTIVE

To test the hypothesis that patients with bipolar disorder (BPD) differ demographically and clinically within subgroups based on the predominant-polarity of major recurrences.

METHOD

We tested factors for association with predominantly (≥2 : 1) depressive vs. mania-like episodes with 928 DSM-IV type-I BPD subjects from five international sites.

RESULTS

Factors preliminarily associated with predominant-depression included: electroconvulsive treatment, longer latency-to-BPD diagnosis, first episode depressive or mixed, more suicide attempts, more Axis-II comorbidity, ever having mixed-states, ever married, and female sex. Predominant-mania was associated with: initial manic or psychotic episodes, more drug abuse, more education, and more family psychiatric history. Of the 47.3% of subjects without polarity-predominance, risks for all factors considered were intermediate. Expanding the definition of polarity-predominance to ≥51% added little, but shifting mixed-states to 'predominant-depression' increased risk of suicidal acts from 2.4- to 4.5-fold excess over predominant-mania-hypomania, and suicidal risk was associated continuously with increasing proportions of depressive or mixed episodes.

CONCLUSION

Subtyping by predominant-polarity yielded predictive associations, including the polarity of first episodes and risk of suicide attempts. Such subtyping may contribute to improve planning of clinical care and to biological studies of BPD.

Intact relational memory and normal hippocampal structure in the early stage of psychosis

BACKGROUND

Previous studies indicate that the transition to psychosis is associated with dynamic changes of hippocampal integrity. Here we explored hippocampal volume and neural activation during a relational memory task in patients who were in the early stage of a psychotic illness.

METHODS

Forty-one early psychosis patients and 34 healthy control subjects completed a transitive inference (TI) task used previously in chronic schizophrenia patients. Participants learned to select the "winner" of two sets of stimulus pairs drawn from an overlapping sequence (A > B > C > D > E) and a nonoverlapping set (a > b, c > d, e > f, g > h). During a functional magnetic resonance imaging scan, participants were tested on the trained pairs and made inferential judgments on novel pairings that could be solved based on training (e.g., B vs. D). Hippocampal volumes were manually segmented and compared between groups. Functional magnetic resonance imaging analyses included 27 early psychosis patients and 30 control subjects who met memory training criteria.

RESULTS

Groups did not differ on inference performance or hippocampal volume and exhibited similar activation of medial temporal regions when judging nonoverlapping pairs. However, patients who failed to meet memory training criteria had smaller hippocampal volumes. Neural activity during TI was less widespread in early psychosis patients, but between-group differences were not significant. Hippocampal activity during TI was positively correlated with inference performance only in control subjects.

CONCLUSIONS

Our results provide evidence that relational memory impairment and hippocampal abnormalities, well established in chronic schizophrenia, are not fully present in early psychosis patients. This provides a rationale for early intervention, targeting the possible delay, reduction, or prevention of these deficits.

Two-year outcomes in first-episode psychotic depression the McLean-Harvard First-Episode Project

OBJECTIVE

Early assessment can guide accurate diagnosis, prognosis, and treatment-planning for patients with major mental illnesses. Longitudinal studies in psychotic depression from onset are rare, encouraging the present study.

METHOD

We followed 56 DSM-IV MDD patients with psychotic features prospectively and systematically to assess course and predictors of operationally-defined syndromal remission, syndromal recovery, symptomatic remission, functional recovery, and new episodes, and to evaluate diagnostic stability.

RESULTS

Among 49/56 cases followed for ≥2 years, 59% retained the initial diagnosis and most achieved syndromal remission (86%) and recovery (84%); 58% remitted symptomatically, and only 35% (17/49) recovered functionally. Syndromal recovery was earlier following subacute onset, lower initial depression scores, and lack of moodincongruent psychotic features. Within 2 years, 45% (22/49) experienced new episodes - earlier with younger onset and higher CGI scores. DSM diagnosis changed in 41%, to bipolar (33%), or schizoaffective disorders (12%), which followed early mania-like or schizophrenia-like features, respectively.

CONCLUSIONS

Within 2 years of first-hospitalizations, 41% of patients initially diagnosed with psychotic-depression met criteria for DSM-IV bipolar or schizoaffective disorders. Of the 59% retaining the initial diagnosis for 2 years, nearly half experienced new episodes, 42% remained symptomatic, and two-thirds failed to regain their own prior functional status.

Episode cycles with increasing recurrences in first-episode bipolar-I disorder patients

BACKGROUND

Preliminary review of a century of studies of the course of manic-depressive syndromes produced 40 reports, of which approximately one-third report evidence of shortening wellness intervals or cycle-lengths with more recurrences, and two-thirds did not.

METHODS

We evaluated inter-episode intervals (cycle-length) in 128 clinically-treated, DSM-IV bipolar-I disorder patients followed prospectively and systematically over 5.7 years, with 6.5 episodes/person.

RESULTS

As expected, cycle-length varied inversely with total cycle-count/person; however, multivariate linear regression found only longer initial hospitalization and fewer total cycles to be associated with cycle-length, whereas cycle-number (1, 2, 3, etc.), sex, intake-age, and first-episode polarity were not. Regression of within-subject cycle-length versus cycle-number yielded individual slope-functions with pseudo-random distribution (28% fell within ±1 month/cycle of the null [zero-slope]). Mean duration of early and late euthymic intervals (cycles 2 vs. 5) in patients with matched recurrence-counts was nearly identical.

CONCLUSIONS

The course of bipolar-I disorder from onset was largely random or chaotic over nearly 6 years from onset. Only a minority of patients showed either cycle-acceleration or slowing, without changes in wellness intervals. The findings may be influenced by treatment-effects, but seem to indicate that most current bipolar-I disorder patients are unlikely to show progressive shortening of recurrence-cycles.

Testing the hypothesis that formal thought disorders are severe mood disorders

BACKGROUND

It was recently hypothesized by Lake (Schizophrenia Bulletin 2008; 34: 109-117) that Formal Thought Disorder (FTD) can be accounted for by a single disorder that is currently diagnosed as bipolar disorder.

OBJECTIVES

This study aimed to analyze the underlying dimensions of FTD and to examine to what extent FTD factors can be accounted for by clinical distractibility, attentional impairment, severity of mania, and familial liability of bipolar disorder and schizophrenia.

METHODS

Six hundred and sixty inpatients were assessed using a semistructured interview, and FTDs were assessed with the Thought, Language, and Communication scale. "Inattentiveness during Mental Status Testing" item of the Scale for the Assessment of Negative Symptoms scale and a composite mania score were used. The Family History-Research Diagnostic Criteria was used.

RESULTS

FTD is a multidimensional construct comprised at least 5 dimensions: disorganization, verbosity, poverty of speech, idiosyncratic thinking, and blocking. Clinical distractibility loadings split in 2 factors, disorganization and blocking, but it did not load on the mania-related (verbosity) factor. Attentional disturbance was significantly associated with each FTD factor except for idiosyncratic thinking, and these associations were largely independent from the severity of mania. The associations of FTDs with mania and attentional disturbances were independent from each other. FTD factors were not significantly associated with familial liability to bipolar or to schizophrenia.

CONCLUSIONS

Disorganization was the main FTD component. Distractibility was a core feature of FTD factors but it was not specifically accounted for by mania-related attentional impairment. The hypothesis of mutual interdependence between mania and attentional disturbance leading to FTDs could not be confirmed.

Two-year diagnostic stability in early-onset first-episode psychosis

BACKGROUND

Only one study has used a prospective method to analyze the diagnostic stability of first psychotic episodes in children and adolescents. The Child and Adolescent First-Episode Psychosis Study (CAFEPS) is a 2-year, prospective longitudinal study of early-onset first episodes of psychosis (EO-FEP).

AIM

To describe diagnostic stability and the variables related to diagnostic changes.

METHODS

Participants were 83 patients (aged 9-17 years) with an EO-FEP consecutively attended. They were assessed with a structured interview (Kiddie-Schedule for Affective Disorders and Schizophrenia, Present and Lifetime version) and clinical scales at baseline and after 2 years.

RESULTS

The global consistency for all diagnoses was 63.9%. The small group of bipolar disorder had high stability (92.31%) as did the group with schizophrenia spectrum disorders (90.00%). Depressive disorder had lower stability (37.50%) and the lowest values were for psychotic disorder not otherwise specified (11.76%) and brief psychotic disorder (0%).The most frequent diagnostic shift was to schizophrenia spectrum and bipolar disorders. One group of patients did not meet the criteria for any diagnosis at follow-up. Independent predictors of change to schizophrenia spectrum disorders were lower scores on the Children's Global Assessment Scale (CGAS) and the Hamilton Depression Rating Scale. Predictors of not having a diagnosis at follow-up were the CGAS and the Strauss-Carpenter Outcome Scale.

CONCLUSIONS

Global diagnostic stability was 63.9%. Bipolar and schizophrenia spectrum disorders were the most stable diagnoses, while depressive disorder and other psychosis the least stable. Psychosocial functioning at baseline was a good predictor of diagnosis at follow-up. These data show the need for longitudinal follow-up in EO-FEP before a stable diagnosis is reached.

Early intervention for bipolar disorder: current imperatives, future directions

OBJECTIVES: The objective of this article is to discuss the rationale/background for early intervention in bipolar disorder. METHOD: Narrative review. RESULTS: There are often significant delays before the diagnosis of bipolar disorder is made and effective management initiated. Growing evidence from both preclinical and clinical literature points to a clear need for improved early identification and early intervention in bipolar disorder. Increasing efforts are being applied to the identification of those at high risk of onset of bipolar disorder. It is hoped that identification of an early prodrome of illness will allow preventative measures to be taken. CONCLUSIONS: There is a clear rationale for improved early identification and early intervention in bipolar disorder.

What we know and what we don't know about the treatment of schizoaffective disorder

Schizoaffective disorder (SAD) is a chronic, severe and disabling illness consisting on the concurrent presentation of symptoms of schizophrenia and affective disorders (depression and/or mania). Evidence for the treatment of SAD mostly derives from studies based on mixed samples (i.e. schizophrenic and schizoaffective patients) or on extrapolations from studies on schizophrenia or bipolar disorder. The objective of the present review is to systematically consider and summarize the best evidence-based approaches to the treatment of SAD and extensively point out the gap between treatment research and clinical practice of this disorder. The complex problem of controlling the pleomorphic presentation of SAD's syndromic construct is reflected in the lack of evidence on key topics, including: diagnostic consistency, pharmacological approaches (mood stabilizers, antidepressants, both in acute and maintenance treatment as well as their possible combination), and the adjunctive role of psychosocial and biophysical interventions. Finally, treatment strategies for SAD, both unipolar and bipolar type, are proposed.

Efficacy and safety of second-generation antipsychotics in children and adolescents with psychotic and bipolar spectrum disorders: comprehensive review of prospective head-to-head and placebo-controlled comparisons

OBJECTIVE

To review data on efficacy and safety of second-generation antipsychotics (SGAs) in children and adolescents with psychotic and bipolar spectrum disorders.

METHODS

Medline/PubMed/Google Scholar search for studies comparing efficacy and/or tolerability: (i) between two or more SGAs; (ii) between SGAs and placebo; and (iii) between at least one SGA and one first-generation antipsychotic (FGA). The review focused on three major side-effect clusters: 1. body weight, body mass index, and cardiometabolic parameters, 2. prolactin levels, and 3. neuromotor side effects.

RESULTS

In total, 34 studies with 2719 children and adolescents were included. Studies lasted between 3 weeks and 12 months, with most studies (79.4%) lasting 3 months or less. Nine studies (n=788) were conducted in patients with schizophrenia, 6 (n=719) in subjects with bipolar disorder, and 19 (n=1212) in a mixed population. Data on efficacy showed that, except for clozapine being superior for refractory schizophrenia, there were no significant differences between SGAs. By contrast, safety assessments showed relevant differences between SGAs. Mean weight gain ranged from 3.8 kg to 16.2 kg in patients treated with olanzapine (n=353), from 0.9 kg to 9.5 kg in subjects receiving clozapine (n=97), from 1.9 kg to 7.2 kg in those on risperidone (n=571), from 2.3 kg to 6.1 kg among patients taking quetiapine (n=133), and from 0 kg to 4.4 kg in those treated with aripiprazole (n=451). Prolactin levels increased the most in subjects on risperidone (mean change ranging from 8.3 ng/mL to 49.6 ng/mL), followed by olanzapine (-1.5 ng/mL to +13.7 ng/mL). Treatment with aripiprazole was associated with decreased prolactin levels, while clozapine and quetiapine were found to be mostly neutral. With respect to neuromotor side effects, SGAs were associated with less parkinsonism and akathisia than FGAs. Most of the studies comparing neuromotor side effects between SGAs found no significant differences.

CONCLUSIONS

SGAs do not behave as a homogeneous group in children and adolescents with psychotic and mood disorders. Except for clozapine, the heterogeneity within the SGA group is mainly due to differences in the rates and severity of adverse events, especially regarding weight gain as a proxy for the risk of cardiometabolic disturbances.

Adjunctive benzodiazepine treatment of hospitalized schizophrenia patients in Asia from 2001 to 2008

Benzodiazepines are commonly prescribed to patients with schizophrenia in many countries, but as little is known about such treatment in Asia, we evaluated their adjunctive use for 6761 in-patients diagnosed with schizophrenia in nine Asian countries using a cross-sectional study design in 2001, 2004 and 2008. Multivariate logistic regression and multivariate linear regression analyses were performed to assess predictors of benzodiazepine use and dose, respectively. Overall, 54% of the patients received adjunctive benzodiazepines at an average daily dose equivalent to 30.3 mg diazepam, with minor changes over the years sampled. Benzodiazepine use was highest in Taiwan and Japan, lowest in Thailand and China, and was associated with fewer years ill, presence of delusions (OR 1.24), hallucinations (OR 1.22), disorganized speech (OR 1.17), social or occupational dysfunction (OR 1.16), and use of mood stabilizers (OR 3.15), antiparkinsonian (OR 1.79) or antidepressant drugs (OR 1.33), and lower doses of antipsychotics (all p=0.016 to <0.001). Benzodiazepine doses were highest in Taiwan and China, lowest in Korea and Singapore; higher doses were associated with being young, male, physically aggressive, receiving mood stabilizers, and having electroconvulsive treatment (all p=0.019 to <0.001). Benzodiazepine use was associated with neurological and systemic adverse effects. In conclusion, benzodiazepine use was common in Asian patients with schizophrenia. Predictors of benzodiazepine use and dose differed in this population. Critical clinical guidelines should be developed specifically for Asian countries to address sound practices in regard to use of benzodiazepines for psychotic disorders.

Diagnostic stability of first-episode psychosis and predictors of diagnostic shift from non-affective psychosis to bipolar disorder: a retrospective evaluation after recurrence

Diagnostic changes during follow-up are not uncommon with a first-episode psychosis (FEP). This study aimed to evaluate the diagnostic stability of the FEP and to identify factors associated with a diagnostic shift from non-affective psychosis to bipolar disorder. Considering that the diagnosis of FEP is frequently more definite after recurrence in many clinical settings, a retrospective evaluation after recurrence was preformed. Subjects were 150 patients with psychotic disorders who had been admitted to a psychiatric ward both for first episode and recurrence of their psychosis. Consensus diagnosis was made for each episode through a review of hospital records. Patients diagnosed with non-affective psychoses at the first episode were included in the analysis of predictive factors of a diagnostic shift to bipolar disorder. First-episode diagnoses were revised upon recurrence in 20.7% of patients. The most common change was to bipolar disorder accounting for more than half of all diagnostic changes. Schizophrenia exhibited the highest prospective and retrospective diagnostic consistencies. Female gender, short duration of untreated psychosis, high level of premorbid functioning, and several symptoms including lability, mood elation, hyperactivity, and delusions with religious or grandiose nature were identified as predictive factors for a diagnostic shift from non-affective psychosis to bipolar disorder. Clinical features of psychoses seem to evolve during the disease course resulting in diagnostic changes upon recurrence in a significant portion of FEP. Special consideration on a diagnostic shift to bipolar disorder is required in patients exhibiting the predictive factors identified in the current study.

Classification of first-episode schizophrenia patients and healthy subjects by automated MRI measures of regional brain volume and cortical thickness

BACKGROUND

Although structural magnetic resonance imaging (MRI) studies have repeatedly demonstrated regional brain structural abnormalities in patients with schizophrenia, relatively few MRI-based studies have attempted to distinguish between patients with first-episode schizophrenia and healthy controls.

METHOD

Three-dimensional MR images were acquired from 52 (29 males, 23 females) first-episode schizophrenia patients and 40 (22 males, 18 females) healthy subjects. Multiple brain measures (regional brain volume and cortical thickness) were calculated by a fully automated procedure and were used for group comparison and classification by linear discriminant function analysis.

RESULTS

Schizophrenia patients showed gray matter volume reductions and cortical thinning in various brain regions predominantly in prefrontal and temporal cortices compared with controls. The classifiers obtained from 66 subjects of the first group successfully assigned 26 subjects of the second group with accuracy above 80%.

CONCLUSION

Our results showed that combinations of automated brain measures successfully differentiated first-episode schizophrenia patients from healthy controls. Such neuroimaging approaches may provide objective biological information adjunct to clinical diagnosis of early schizophrenia.

Cannabis and first-episode psychosis: different long-term outcomes depending on continued or discontinued use

OBJECTIVE

To examine the influence of cannabis use on long-term outcome in patients with a first psychotic episode, comparing patients who have never used cannabis with (a) those who used cannabis before the first episode but stopped using it during follow-up and (b) those who used cannabis both before the first episode and during follow-up.

METHODS

Patients were studied following their first admission for psychosis. They were interviewed at years 1, 3, and 5. At follow-up after 8 years, functional outcome and alcohol and drug abuse were recorded. Patients were classified according to cannabis use: 25 had cannabis use before their first psychotic episode and continuous use during follow-up (CU), 27 had cannabis use before their first episode but stopped its use during follow-up (CUS), and 40 never used cannabis (NU).

RESULTS

The 3 groups did not differ significantly in symptoms or functional outcome at baseline or during short-term follow-up. The CUS group exhibited better long-term functional outcome compared with the other 2 groups and had fewer negative symptoms than the CU group, after adjusting for potential confounders. For the CUS group, the effect size was 1.26 (95% confidence interval [CI]=0.65 to 1.86) for functional outcome and -0.72 (95% CI=-1.27 to -0.14) for negative symptoms. All patients experienced improvements in positive symptoms during long-term follow-up.

CONCLUSION

Cannabis has a deleterious effect, but stopping use after the first psychotic episode contributes to a clear improvement in outcome. The positive effects of stopping cannabis use can be seen more clearly in the long term.

Initial diagnosis and treatment in first-episode psychosis: can an operationalized diagnostic classification system enhance treating clinicians' diagnosis and the treatment chosen?

AIM

Diagnosis during the initial stages of first-episode psychosis is particularly challenging but crucial in deciding on treatment. This is compounded by important differences in the two major classification systems, International Classification of Diseases, 10th revision (ICD-10) and Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV). We aimed to compare the concordance between an operationalized diagnosis using Operational Criteria Checklist (OPCRIT) and treating clinician-generated diagnosis in first episode psychosis diagnosis and its correlation with treatment prescribed.

METHODS

Operationalized polydiagnostic assessments were conducted on 150 first-episode psychosis patients using OPCRIT. OPCRIT generated ICD-10, DSM-IV and treating clinician diagnoses were compared. The association between these diagnoses and choice of treatment was evaluated.

RESULTS

General agreement between the three classification systems was moderate to good, with kappa values between 0.460 and 0.674. There was a higher frequency of schizophrenia diagnosis in ICD-10 (n = 85) comparing to DSM-IV (n = 45) and similar in clinical diagnosis (n = 76), with moderate to good agreement between classifications (kappa between 0.602 and 0.731). No significant differences were found for ratings of psychotic depressive and manic/bipolar disorders with psychosis, with affective disorders having the higher agreement. Heterogeneous group of 'other disorders' achieved a kappa value from 0.250 (DSM-IV/ICD-10) to 0.566 (DSM-IV/clinical diagnosis).

CONCLUSION

Despite the challenges in first-episode psychosis diagnosis, it is possible to have a good agreement between OPCRIT-generated (DSM-IV and ICD-10) diagnoses and clinician based diagnoses, although some differences exist. The choice of psychopharmacological treatment prescribed matches well with these operationalized diagnoses.

Dysbindin-1 gene contributes differentially to early- and adult-onset forms of functional psychosis

Dysbindin-1 is a relatively ubiquitous protein in the brain which is involved in the modulation of synaptic homeostasis. The dysbindin-1 gene (DTNBP1) has been associated with schizophrenia and bipolar disorder diagnoses. However, its contribution to the severity of the clinical and neurocognitive expression of these disorders remains controversial. We aimed to explore the association between DTNBP1 and the phenotypes which are more directly linked with the underlying biology, such as age at onset and neurocognitive impairment. The present family sample comprised 894 Caucasian individuals: 268 patients affected by functional psychosis [58% with illness onset before 18 years, mean age at onset (SD): 14.71 (2.10)], 483 parents and 143 siblings. Ten DTNBP1 single nucleotide polymorphisms were genotyped in all individuals and their transmission disequilibrium was tested in relation to: (i) the risk for psychosis; (ii) patients' age at onset; and (iii) familial neurocognitive performance (including IQ estimation and executive functioning). In early-onset families a 5-marker haplotype encompassing exons 2-4 and the surrounding introns was significantly over-transmitted to cases, while in adult-onset families two haplotypes corresponding to the region between introns 4 and 7 were over-transmitted to cases. Estimated IQ was associated with the rs760666 marker in the whole sample, whereas a significant association between executive functioning and the rs2619522 marker appeared in early-onset families. Our findings confirm the role of the dysbindin-1 gene in the risk for functional psychosis and show a differential haplotypic risk pattern in families with early as opposed to adult onset in the affected offspring.

McLean-Harvard International First-Episode Project: two-year stability of ICD-10 diagnoses in 500 first-episode psychotic disorder patients

OBJECTIVE

Because clinical and biologic research and optimal clinical practice require stability of diagnoses over time, we determined stability of ICD-10 psychotic disorder diagnoses and sought predictors of diagnostic instability.

METHOD

Patients from the McLean-Harvard International First-Episode Project, conducted from 1989 to 2003, who were hospitalized for first psychotic illnesses (N = 500) were diagnosed by ICD-10 criteria at baseline and 24 months, on the basis of extensive prospective assessments, to evaluate the longitudinal stability of specific categorical diagnoses and predictors of diagnostic change.

RESULTS

Diagnostic stability averaged 90.4%, ranking as follows: schizoaffective disorder (100.0%) > mania with psychosis (99.0%) > mixed affective episode (94.9%) > schizophrenia (94.6%) > delusional disorder (88.2%) > severe depressive episode with psychotic symptoms (85.2%) > acute psychosis with/without schizophrenia symptoms = unspecified psychosis (all 66.7%) >> acute schizophrenia-like psychosis (28.6%). Diagnoses changed by 24 months of follow-up to schizoaffective disorder (37.5%), bipolar disorder (25.0%), schizophrenia (16.7%), or unspecified nonorganic psychosis (8.3%), mainly through emerging affective features. By logistic regression, diagnostic change was associated with Schneiderian first-rank psychotic symptoms at intake > lack of premorbid substance use.

CONCLUSIONS

We found some psychotic disorder diagnoses to be more stable by ICD-10 than DSM-IV criteria in the same patients, with implications for revisions of both diagnostic systems.

Course and outcome of bipolar disorder

Bipolar disorder (BPD) is capricious illness. For some, it is a condition of few episodes; for others, it is unremitting. For some, elevated moods predominate; for others, depression is the major key. For a minority, the condition is predictably cyclical; for most, it is unpredictably chaotic. This chapter examines those studies that have attempted to draw coherence from this enigmatic disorder. Where possible, we will focus on data derived from prospective longitudinal investigations, while using as necessary the more limited retrospective or cross-sectional reports. For the sake of parsimony, we will limit discussion to those studies that have used the conservative historical definitions of BPD (as used in DSM-IIIR, DSM-IV, and ICD-10), eschewing the recent controversial concepts of "pediatric" BPD and "soft BPD spectrum."

Premorbid personality and insight in first-episode psychosis

BACKGROUND

Insight in psychosis and schizophrenia is considered a complex biopsychosocial phenomenon. Premorbid personality is regarded by some authors as part of the substrate to many psychiatric phenomena, but it is not clear if this applies to insight.

AIM

To examine longitudinal relationships between personality traits and insight dimensions in first-episode psychosis.

METHODS

One hundred consecutive antipsychotic-naïve first-episode nonaffective psychotic patients admitted to hospital were included in the study. Eighty-one patients completed at 1 month a premorbid personality evaluation, plus baseline, and 6-month insight assessments. We used the Assessment and Documentation of Psychopathology inventory for assessing insight dimensions (not feeling ill, lack of insight, and refusal of treatment) and the Personality Assessment Schedule for ascertaining 5 dimensions of premorbid personality (schizoid, passive-dependent, anancastic, sociopathic, and schizotypy).

RESULTS

At baseline, personality dimensions did not show any association with insight dimensions, with the exception of schizotypy traits. At 6 months, schizoid and sociopathic personality showed a significant association with not feeling ill (r = .30, P ≤ .007; r = .27, P = .01) and lack of insight (r = .36, P = .001; r = .41, P < .001), respectively. When we calculated insight change, schizoid and sociopathic personality had moderate correlation with the lack of insight dimension (r = -.34, P = .002; r = .38, P < .001, respectively). After applying partial correlations for potential confounders and Bonferroni correction, the associations remained significant. Moreover, using a regression model, sociopathic and schizoid personality significantly predicted lack of insight at 6 months and change from baseline to the 6 months assessment.

CONCLUSIONS

Sociopathic and schizoid personality dimensions were not only significantly associated with lack of insight at 6 months but also predicted change on lack of insight over 6 months. Therefore, exploring premorbid personality traits at the beginning of a psychotic episode may be helpful in identifying patients at high risk for lack of insight during the initial course of the illness.

Validation and use of the functioning assessment short test in first psychotic episodes

Numerous studies have documented high rates of functional impairment in patients with schizophrenia and bipolar disorder. However, this impairment appears early in the course of the illness. The purpose of the present study was to validate the Functioning Assessment Short Test (FAST) by comparing it with the Strauss-Carpenter Scale for use as an instrument to assess functional impairment in subjects with first psychotic episodes. The study was conducted on 53 patients admitted to Santiago Apostol Hospital because of a first psychotic episode. The FAST showed high internal consistency both at baseline and at 6 months as well as at 1 year. Concurrent validity showed a highly significant negative correlation at each time point. The FAST also showed good reliability and discriminant validity. The FAST showed strong psychometric properties and is a valid instrument for use in clinical practice, clinical trials, and research settings in subjects with first psychotic episodes.

Role of paliperidone extended-release in treatment of schizoaffective disorder

Schizoaffective disorder is characterized by the presence of symptoms of both schizophrenia and a major mood disorder. The coexistence of these symptoms can be difficult to manage, and these patients are generally treated with antipsychotics as well as mood stabilizers and/or antidepressants. Additionally, no established treatment guidelines exist for this disorder. This review describes the combined results of two international, double-blind, placebo-controlled clinical studies of paliperidone extended-release (ER), an atypical antipsychotic recently approved in the US for the treatment of schizoaffective disorder. Subjects in these six-week trials were aged 18-65 years, had a diagnosis of schizoaffective disorder based on the Structural Clinical Interview for DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th Edition) Disorders, and were experiencing an acute exacerbation. The subjects from these studies had significant symptomatology as evidenced by a mean (standard deviation) baseline Positive and Negative Syndrome Scale total score of 92.8 (13.0). Based on Young Mania Rating Scale and/or a 21-item Hamilton Rating Scale for Depression score of ≥16 at baseline, 79.5% and 66.9% of subjects presented with prominent manic and depressive symptoms, respectively, and 46.4% presented with mixed symptoms. Approximately half (45%) of subjects were taking adjunctive mood stabilizers and/or antidepressants. Paliperidone ER was found to be effective in improving psychotic and mood symptoms in these subjects. Paliperidone ER was also effective as monotherapy or adjunctive to mood stabilizers and/or antidepressants for subjects with prominent manic, depressive, or mixed symptoms at baseline. No new tolerability signals were observed in this population. To the best of our awareness, these pooled data provide the largest data set of patients with schizoaffective disorder, and extend our knowledge of disease characteristics and treatment response.

Diagnóstico diferencial de primeiro episódio psicótico: importância da abordagem otimizada nas emergências psiquiátricas

OBJETIVO: Revisar dados da literatura relativos ao diagnóstico de primeiro episódio psicótico no contexto das emergências psiquiátricas. MÉTODO: Revisão de artigos empíricos e de revisão selecionados por meio de busca eletrônica no indexador PubMed. RESULTADOS: Características específicas de atendimento de emergência - avaliação única e breve, em corte transversal e com poucas informações disponíveis - podem dificultar o processo diagnóstico. Essas limitações podem ser contornadas por meio da aplicação adequada de critérios diagnósticos operacionais, do uso de escalas e entrevistas diagnósticas padronizadas e de um tempo mínimo de observação de 24 a 72 horas. Diagnósticosdetranstornobipolar,esquizofrenia,depressãopsicóticaetranstorno delirante elaborados em contexto de emergência apresentam boa estabilidade temporal, não ocorrendo o mesmo com diagnósticos de transtorno psicótico breve, transtorno esquizofreniforme e transtorno esquizoafetivo. Primeiro episódio psicótico pode ocorrer na vigência do uso de substâncias psicoativas, sendo relativamente frequente a manutenção do quadro psicótico mesmo após cessação do uso. A utilização racional de exames complementares pode ajudar no diagnóstico diferencial com episódios psicóticos devido a condições médicas gerais. CONCLUSÃO: Diagnósticos de primeiro episódio psicótico podem ser adequadamente realizados durante emergências psiquiátricas, desde que sejam implementadas rotinas baseadas em evidências científicas.

Paliperidone extended-release in schizoaffective disorder: a randomized, controlled study comparing a flexible dose with placebo in patients treated with and without antidepressants and/or mood stabilizers

This 6-week, double-blind, placebo-controlled study evaluated paliperidone extended-release (ER) as both monotherapy and adjunctive therapy to mood stabilizers and/or antidepressants (MS/ADs) for schizoaffective disorder. Included subjects had a schizoaffective disorder diagnosis; a Positive and Negative Syndrome Scale (PANSS) total score of 60 or higher; a score of 4 or higher on 2 or more of the PANSS items for hostility, excitement, tension, uncooperativeness, or poor impulse control; and prominent mood symptoms (≥16 on the Young Mania Rating Scale and/or the 21-item Hamilton Rating Scale for Depression). Subjects were randomized to 6 mg/d paliperidone ER or placebo with flexible dosing (3-12 mg/d) until day 15. Randomization was stratified by use of MS/AD and study site. The primary analysis outcome was change in PANSS total score at week 6 last observation carried forward end point. A total of 311 subjects received paliperidone ER (n = 216) or placebo (n = 95); 52.0% received MS/AD. The mean (SD) modal dose of paliperidone ER was 8.6 (2.5) mg/d. Greater improvement was observed with paliperidone ER than placebo on mean (SE) PANSS total scores: -20.0 (1.3) and -10.8 (1.9), respectively. Subjects with prominent manic or depressive symptoms showed greater improvement with paliperidone ER versus placebo: mean (SE) Young Mania Rating Scale (-10.6 [0.9] vs -5.7 [1.2], respectively) and 21-item Hamilton Rating Scale for Depression (-10.2 [0.7] vs -6.2 [1.1], respectively). The most common adverse events with paliperidone ER were headache, akathisia, dizziness, insomnia, and dyspepsia. Paliperidone ER improved psychotic and affective symptoms both as monotherapy and as an adjunct to MS/AD. No new safety findings were observed in this population.

Dissimilar morbidity following initial mania versus mixed-states in type-I bipolar disorder

BACKGROUND

Mixed-states of bipolar disorders (BPD) may predict worse future illness and more depressive than manic morbidity, challenging a tendency to conflate mixed-states and mania.

METHODS

Patients (N=247) were followed-up systematically for 24 months following hospitalization for initial major episodes of DSM-IV type-I BPD and scored for weekly interval morbidity-types.

RESULTS

Overall morbidity during follow-up was 1.6-times greater following mixed (n=97) versus manic (n=150) first-episodes of BPD (60.0 vs. 37.8%-of-weeks; p<0.0001). Patients with initial mixed-states had a nearly 12-fold later excess of mixed-states, 6.5-times more major depression, and 69% more dysthymia during follow-up than those presenting in mania. In contrast, manic first-episodes were followed by over 10-times more mania, 6-times more hypomania, and 35% more psychotic illness.

LIMITATIONS

Estimates of longitudinal morbidity may be inaccurate, and ongoing treatment may distort them.

CONCLUSIONS

Based on detailed, prospective assessments among first-episode BPD patients, those presenting in mixed-states were more ill, and much more likely to experience mixed, depressive and dysthymic morbidity during follow-up, versus much more mania, hypomania, and perhaps more psychosis following mania. The findings support two markedly dissimilar subtypes of BPD, and call for more explicit therapeutic studies of mixed-states.

The development of the S-QoL 18: a shortened quality of life questionnaire for patients with schizophrenia

OBJECTIVE

The S-QoL 41 is a French self-administered questionnaire that assesses quality of life (QoL) among people with schizophrenia. This study aims to validate a shortened version of the S-QoL for more widespread use in clinical practice.

METHODS

We used data from four studies conducted in four psychiatric hospitals in France (n=507). The item reduction and validation processes were based on both item response theory and classical test theory. The final version of the S-QoL was tested for construct validity, reliability, external validity, reproducibility and sensitivity to change. In addition, differential item functioning (DIF) analyses were performed to see whether all items behave in the same way in subgroups divided by age, gender, educational level and clinical form.

RESULTS

The S-QoL 18 evaluates eight dimensions: psychological well-being, self-esteem, family relationships, relationships with friends, resilience, physical well-being, autonomy and sentimental life. The factor structure accounted for 78% of the total variance. Internal consistency was satisfactory (item-internal consistency greater than 0.40; Cronbach's alpha coefficients ranged from 0.72 to 0.84). The scalability was satisfactory, with INFIT statistics within an acceptable range. In addition, the results confirmed the absence of DIF and supported the invariance of the item calibrations.

CONCLUSIONS

The S-QoL 18 is a short self-administered QoL instrument that has a high degree of comparability with S-QoL 41 and presents satisfactory psychometric properties. Future studies should confirm its sensitivity to change.

Age at onset in 3014 Sardinian bipolar and major depressive disorder patients

OBJECTIVE

To test if onset age in major affective illnesses is younger in bipolar disorder (BPD) than unipolar-major depressive disorder (UP-MDD), and is a useful measure.

METHOD

We evaluated onset-age for DSM-IV-TR major illnesses in 3014 adults (18.5% BP-I, 12.5% BP-II, 69.0% UP-MDD; 64% women) at a mood-disorders center.

RESULTS

Median and interquartile range (IQR) onset-age ranked: BP-I = 24 (19-32) < BP-II = 29 (20-40) < UP-MDD = 32 (23-47) years (P < 0.0001), and has remained stable since the 1970s. In BP-I patients, onset was latest for hypomania, and depression presented earlier than in BP-II or UP-MDD cases. Factors associated with younger onset included: i) being unmarried, ii) more education, iii) BPD-diagnosis, iv) family-history, v) being employed, vi) ever-suicidal, vii) substance-abuse and viii) ever-hospitalized. Onset-age distinguished BP-I from UP-MDD depressive onsets with weak sensitivity and specificity.

CONCLUSION

Onset age was younger among BPD than MDD patients, and very early onset may distinguish BPD vs. UP-MDD with depressive-onset.