Influence of diagnostic classification on gender ratio in schizophrenia - a meta-analysis of youths hospitalized for psychosis

Umbrella Review: Atlas of the Meta-Analytical Evidence of Early-Onset Psychosis

OBJECTIVE

Early-onset psychosis (EOP) refers to the development of psychosis before the age of 18 years. We aimed to summarize, for the first time, the meta-analytical evidence in the field of this vulnerable population and to provide evidence-based recommendations.

METHOD

We performed a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-compliant, pre-registered (PROSPERO: CRD42022350868) systematic review of several databases and registers to identify meta-analyses of studies conducted in EOP individuals to conduct an umbrella review. Literature search, screening, data extraction, and quality assessment were carried out independently. Results were narratively reported, clustered across core domains. Quality assessment was performed with the Assessment of Multiple Systematic Reviews-2 (AMSTAR-2) tool.

RESULTS

A total of 30 meta-analyses were included (373 individual studies, 25,983 participants, mean age 15.1 years, 38.3% female). Individuals with EOP showed more cognitive impairments compared with controls and individuals with adult/late-onset psychosis. Abnormalities were observed meta-analytically in neuroimaging markers but not in oxidative stress and inflammatory response markers. In all, 60.1% of EOP individuals had a poor prognosis. Clozapine was the antipsychotic with the highest efficacy for overall, positive, and negative symptoms. Tolerance to medication varied among the evaluated antipsychotics. The risk of discontinuation of antipsychotics for any reason or side effects was low or equal compared to placebo.

CONCLUSION

EOP is associated with cognitive impairment, involuntary admissions, and poor prognosis. Antipsychotics can be efficacious in EOP, but tolerability and safety need to be taken into consideration. Clozapine should be considered in EOP individuals who are resistant to 2 non-clozapine antipsychotics. Further meta-analytical research is needed on response to psychological interventions and other prognostic factors.

PLAIN LANGUAGE SUMMARY

This umbrella review summarized the meta-analytical knowledge from 30 meta-analyses on early-onset psychosis. Early-onset psychosis refers to the development of psychosis before the age of 18 years and is associated with cognitive impairment, hospitalization, and poor prognosis. Individuals with early-onset psychosis show more cognitive impairments and abnormalities compared with controls. Clozapine was the antipsychotic with the highest efficacy for positive, negative, and overall symptoms and should be considered in individuals with early-onset psychosis.

STUDY PREREGISTRATION INFORMATION

Early Onset Psychosis: Umbrella Review on Diagnosis, Prognosis and Treatment factors; https://www.crd.york.ac.uk/PROSPERO/; CRD42022350868.

The slow death of the concept of schizophrenia and the painful birth of the psychosis spectrum

The concept of schizophrenia only covers the 30% poor outcome fraction of a much broader multidimensional psychotic syndrome, yet paradoxically has become the dominant prism through which everything 'psychotic' is observed, even affective states with mild psychosis labelled 'ultra-high risk' (for schizophrenia). The inability of psychiatry to frame psychosis as multidimensional syndromal variation of largely unpredictable course and outcome - within and between individuals - hampers research and recovery-oriented practice. 'Psychosis' remains firmly associated with 'schizophrenia', as evidenced by a vigorous stream of high-impact but non-replicable attempts to 'reverse-engineer' the hypothesized biological disease entity, using case-control paradigms that cannot distinguish between risk for illness onset and risk for poor outcome. In this paper, the main issues surrounding the concept of schizophrenia are described. We tentatively conclude that with the advent of broad spectrum phenotypes covering autism and addiction in DSM5, the prospect for introducing a psychosis spectrum disorder - and modernizing psychiatry - appears to be within reach.

Gender matters in schizophrenia-spectrum disorders: Results from a healthcare users epidemiological study in Malaga, Spain

PURPOSE

Women suffering from schizophrenia-spectrum disorders may differ from men in clinical course and outcome. Still, those differences can only be portrayed accurately by means of studies that derive information from multiple sources. One such study was performed in a well-defined area supported by a Mental Health Clinical Management Unit in Malaga, Spain.

METHODS

Data from 1640 patients (1048 men and 592 women) that were in contact with services during 2008 were examined for the purpose of the present analysis. Gender differences in sociodemographic and clinical characteristics and the role of gender for explaining clinical characteristics (diagnosis, disease severity and service use) beyond potential sociodemographic confounders were explored.

RESULTS

The chi-squared analysis results revealed that in comparison to men, women were older, married or widowed/divorced and living as housewives with their families in cities. Genders also differed across diagnoses, with men being at higher risk for suffering from paranoid schizophrenia, while women being at higher risk for persistent delusional, acute/transitory and schizoaffective disorders. Furthermore, men had greater disease severity and higher chances to visit the mental health rehabilitation unit (MHRU). Further regression analyses revealed that after controlling for confounders, gender differences remained significant across diagnoses and severity. However, they lost their significance under the influence of marital, living and occupational status when predicting the use of MHRU.

CONCLUSION

Results confirm the existence of gender differences and highlight the importance of other factors for designing effective psychosocial services that are tailor-made to the patients' needs.

How much do we know about schizophrenia and how well do we know it? Evidence from the Schizophrenia Library

BACKGROUND

True findings about schizophrenia remain elusive; many findings are not replicated and conflicting results are common. Well-conducted systematic reviews have the ability to make robust, generalizable conclusions, with good meta-analyses potentially providing the closest estimate of the true effect size. In this paper, we undertake a systematic approach to synthesising the available evidence from well-conducted systematic reviews on schizophrenia.

METHOD

Reviews were identified by searching Medline, EMBASE, CINAHL, Current Contents and PsycINFO. The decision to include or exclude reviews, data extraction and quality assessments were conducted in duplicate. Evidence was graded as high quality if reviews contained large samples and robust results; and as moderate quality if reviews contained imprecision, inconsistency, smaller samples or study designs that may be prone to bias.

RESULTS

High- and moderate-quality evidence shows that numerous psychosocial and biomedical treatments are effective. Patients have relatively poor cognitive functioning, and subtle, but diverse, structural brain alterations, altered electrophysiological functioning and sleep patterns, minor physical anomalies, neurological soft signs, and sensory alterations. There are markers of infection, inflammation or altered immunological parameters; and there is increased mortality from a range of causes. Risk for schizophrenia is increased with cannabis use, pregnancy and birth complications, prenatal exposure to Toxoplasma gondii, childhood central nervous system viral infections, childhood adversities, urbanicity and immigration (first and second generation), particularly in certain ethnic groups. Developmental motor delays and lower intelligence quotient in childhood and adolescence are apparent.

CONCLUSIONS

We conclude that while our knowledge of schizophrenia is very substantial, our understanding of it remains limited.

Sex differences in first-episode psychosis and in people at ultra-high risk

Sex-related differences in the clinical expression and outcome of schizophrenia have long been recognized; this study set out to evaluate whether they extend to those subjects who are at high risk of developing psychosis. In a sample enrolled in two early intervention programs in northern Italy, patients with first-episode psychosis (FEP; n=152) were compared to patients at ultra-high risk of psychosis (UHR; n=106) on a series of sex-related clinical characteristics of schizophrenia. In both the FEP and the UHR samples, males outnumbered females. In FEP patients, women had been referred at an older age than men and had a shorter duration of untreated illness (DUI) and of untreated psychosis. In UHR patients no sex differences were found in age of onset or DUI. There was no diagnosis by sex interaction on symptoms severity or level of functioning at presentation. The limited number of women in both samples, and the exclusion of people who were older than 30 and of those with substance dependence may have reduced the extent of sex-related differences in this study. Sex differences of precipitating factors for psychosis might be worthy of further investigation.

Whole-genome-wide association study in the Bulgarian population reveals HHAT as schizophrenia susceptibility gene

OBJECTIVE

Schizophrenia, the most common major psychiatric disorder (or group of disorders), entails severe decline of higher functions, principally with alterations in cognitive functioning and reality perception. Both genetic and environmental factors are involved in its pathogenesis; however, its genetic background still needs to be clarified. The objective of the study was to reveal genetic markers associated with schizophrenia in the Bulgarian population.

METHODS

We have conducted a genome-wide association study using 554 496 single nucleotide polymorphisms (SNPs) in 188 affected and 376 unaffected Bulgarian individuals. Subsequently, the 100 candidate SNPs that revealed the smallest P-values were further evaluated in an additional set of 99 case and 328 control samples.

RESULTS

We found a significant association between schizophrenia and the intronic SNP rs7527939 in the HHAT gene (P-value of 6.49×10 with an odds ratio of 2.63, 95% confidence interval of 1.89-3.66). We also genotyped additional SNPs within a 58-kb linkage disequilibrium block surrounding the landmark SNP.

CONCLUSION

We suggest rs7527939 to be the strongest indicator of susceptibility to schizophrenia in the Bulgarian population within the HHAT locus.

Testing the psychosis continuum: differential impact of genetic and nongenetic risk factors and comorbid psychopathology across the entire spectrum of psychosis

A growing number of studies demonstrate high rates of subthreshold psychotic experiences, but there is considerable heterogeneity in rates due to study cohort and design factors, obscuring how prevalent psychotic experiences may or may not relate to rare psychotic disorders. In a representative general population sample (n = 4011) in Izmir, Turkey, the full spectrum of expression of psychosis was categorized across 5 groups representing (1) absence of psychosis, (2) subclinical psychotic experiences, (3) low-impact psychotic symptoms, (4) high-impact psychotic symptoms, and (5) full-blown clinical psychotic disorder and analyzed for continuity and discontinuity in relation to (1) other symptom dimensions associated with psychotic disorder and (2) proxies of genetic and nongenetic etiology. Results were tested for linear and extralinear contrasts between clinical and nonclinical and between disorder and nondisorder expression of psychosis. Demographic variables, indexing premorbid social adjustment and socioeconomic status, impacted mostly linearly; proxy variables of genetic loading (more or more severely affected relatives) impacted in a positive extralinear fashion; environmental risk factors sometimes impacted linearly (urbanicity and childhood adversity) and sometimes extralinearly (cannabis), occasioning a disproportional shift in risk at the clinical disorder end of the spectrum. Affective symptoms were associated with a disproportionally higher risk below the disorder threshold, whereas a disproportionally higher risk above the threshold was associated with psychotic symptom load, negative symptoms, disorganization, and visible signs of mental illness. Liability associated with respectively affective and nonaffective symptom domains, in interaction with environmental risks, may operate by impacting differentially over a quasi-continuous extended psychosis phenotype in the population.

Gender and duration of untreated psychosis: a systematic review and meta-analysis

AIM

Duration of untreated psychosis (DUP) can influence the prognosis of schizophrenia. Previous studies have suggested that gender may influence the length of DUP. This study reports the result of the first systematic literature review and meta-analysis on the role of gender in influencing DUP in first-episode psychosis.

METHOD

Systematic literature search in PubMed/Medline and Ovid/PsychINFO. Twenty-seven studies presenting data on 4721 patients diagnosed with psychosis at their first episode (2834 males and 1887 females) were included in the analysis.

RESULTS

Samples had a higher proportion of males: odds ratio = 2.5 (95% confidence interval: 1.8-3.3). Mean age at first contact was 25.4 for males and 27.5 for females. Patients from non-Western countries were older at first contact than patients from Western countries. Average DUP in schizophrenia was 64 weeks and did not differ between genders but was shorter in Western compared with non-Western countries.

CONCLUSION

Earlier age at first contact and larger incidence in males support the existence of specific gender differences in first-episode psychosis; however, these are not associated with DUP length.

The role of environmental influences on schizophrenia admissions in Israel

OBJECTIVE

The role of environmental factors in hospitalization of patients with schizophrenia is incompletely understood. This study attempts to relate the pattern of hospital admissions to environmental variables such as season and to social factors such as nationally celebrated holidays.

METHODS

Charts of all adults (n = 4,331) with a discharge diagnosis of schizophrenia admitted to the Abarbanel Mental Health Centre (Bat Yam, Israel) between 1 January 2001 and 31 December 2005 were reviewed. Hospitalizations were classified by gender, first or repeat admission, month and season of admission, and whether or not the admission coincided with a major Jewish holiday period.

RESULTS

There was a significant reduction (p < 0.05) in first admissions for men during April, the month corresponding to Passover, the most widely celebrated holiday in Israel. This pattern was not seen for women or for repeat admissions. There was no significant effect of the season upon admission rates, using two different methods of defining the season.

CONCLUSIONS

This study demonstrated significant monthly variability in admission rates and a possible protective effect of a widely celebrated public religious holiday. A consistent effect of season upon rates of admission was not found. Future studies need to identify which specific social factors exert a protective or harmful effect and study how knowledge of these effects can be translated into clinical practice.

Differences among Men and Women with Schizophrenia: A Study of US and Indian Samples

OBJECTIVE

To test the hypothesis that similar differences in psychopathology are present across cultures among men and women with schizophrenia (SZ).

METHODS

Sex based differences were tested systematically in two independent samples from the Northeastern USA and North India using the same procedures. The clinical variables were obtained from five interview instruments.

RESULTS

Among the US participants, the number of significant differences exceeded chance predictions (15/240 variables significant at p<0.02, 6.25%; expected number of significant differences: 5). Similarly, a greater than expected number of variables differed significantly between men and women among the Indian subjects (13/230 differences at p<0.02, 5.65%; expected: 5). One of these variables significantly differed in both samples (lifetime abuse of cannabis). When multivariate analyses were conducted in the combined US and Indian samples sex based differences remained for only four variables: course of the illness, history of inappropriate emotions, marital status and number of children.

CONCLUSION

Sex based differences in SZ/schizoaffective disorder are present in the USA and India at greater than chance probabilities. The majority of the variables differ across the samples. The biological underpinnings of these variables need further investigation.

A comparison of delusions and overvalued ideas

The relationship between delusions and overvalued ideas is uncertain, and has clinical as well as conceptual implications. This study aims to compare delusions and overvalued ideas on several characteristics that might further describe and distinguish them. A total of 24 individuals with delusions and 27 with overvalued ideas were recruited from a psychiatric service and assessed using a semistructured interview. Deluded individuals were less likely to identify what might modify their belief, less preoccupied, and less concerned about others' reactions than those with overvalued ideas. Delusions were less plausible and their onset less likely to appear reasonable. Delusions were more likely to have abrupt onset and overvalued ideas a gradual onset. Conviction and insight were similar in the 2 groups. Belief conviction and insight may be an inadequate basis for separating delusions from overvalued ideas. Abrupt onset, implausible content, and relative indifference to the opinions of others may be better distinguishing features.

Schizophrenia

Schizophrenia is still one of the most mysterious and costliest mental disorders in terms of human suffering and societal expenditure. Here, we focus on the key developments in biology, epidemiology, and pharmacology of schizophrenia and provide a syndromal framework in which these aspects can be understood together. Symptoms typically emerge in adolescence and early adulthood. The incidence of the disorder varies greatly across places and migrant groups, as do symptoms, course, and treatment response across individuals. Genetic vulnerability is shared in part with bipolar disorder and recent molecular genetic findings also indicate an overlap with developmental disorders such as autism. The diagnosis of schizophrenia is associated with demonstrable alterations in brain structure and changes in dopamine neurotransmission, the latter being directly related to hallucinations and delusions. Pharmacological treatments, which block the dopamine system, are effective for delusions and hallucinations but less so for disabling cognitive and motivational impairments. Specific vocational and psychological interventions, in combination with antipsychotic medication in a context of community-case management, can improve functional outcome but are not widely available. 100 years after being so named, research is beginning to understand the biological mechanisms underlying the symptoms of schizophrenia and the psychosocial factors that moderate their expression. Although current treatments provide control rather than cure, long-term hospitalisation is not required and prognosis is better than traditionally assumed.

Programma 2000: celebrating 10 years of activity of an Italian pilot programme on early intervention in psychosis

OBJECTIVE

This paper describes the structure and the organization of the single Italian programme specifically targeted at the early detection of and interventions for subjects at onset of or at high risk of psychosis, Programma 2000.

METHODS

Programma 2000 is a comprehensive multi-modal protocol of early intervention in psychosis, set up in Milan in 1999. The service has been very active since its opening, and at the time of writing (spring (April) 2008), more than 300 young patients have been evaluated through a detailed protocol that embraces Health of the Nation Outcome Scale (HoNOS), Brief Psychiatric Rating Scale (BPRS), Cognitive Behavioural Assessment 2.0, Disability Assessment Schedule, Camberwell Family Interview, Wechsler Adult Intelligence Scale and the Early Recognition Inventory Retrospective Assessment of Symptoms. The treatment includes psychoeducation, cognitive behavioural therapy (CBT), both structured and unstructured psychosocial interventions and pharmacotherapy, when necessary.

RESULTS

The programme focuses on young people aged 17-30 years: to date, a total of 132 subjects with definite psychosis or within the high-risk category have been enrolled in treatment after assessment. Patients with first-episode psychosis were, on average and expectedly, more severe than those in the at-risk group, and were more likely to be prescribed antipsychotic drugs. A large majority of patients in both groups received tailored CBT; individual sessions of skills training were provided to two-thirds of patients. In both groups, improvement was found in both the BPRS and HoNOS, and in the level of global functioning as assessed on Global Assessment of Functioning at 6 month and 1 year follow up. Global functioning was more sensitive to change than symptom severity, reflecting the intensive and personalized efforts to improve social and role functioning in patients.

CONCLUSIONS

Programma 2000 is still in development but it has already gained the support of therapists and other relevant people involved in the life of subjects at onset, or at high risk of psychosis.

Schizophrenia, "Just the Facts": what we know in 2008 part 1: overview

For every disorder, there is a set of established findings and accepted constructs upon which further understanding is built. The concept of schizophrenia as a disease entity has been with us for a little more than a century, although descriptions resembling this condition predate this conceptualization. In 1988, for the inaugural issue of Schizophrenia Research, at the invitation of the founding editors, a senior researcher, since deceased (RJ Wyatt) published a summary of generally accepted ideas about the disorder, which he termed "the facts" of schizophrenia. Ten years later, in conjunction with two of the authors (MSK, RT), he compiled a more extensive set of "facts" for the purpose of evaluating conceptual models or theoretical constructs developed to understand the nature of schizophrenia. On the 20th anniversary of this journal, we update and substantially expand our effort to periodically summarize the current body of information about schizophrenia. We compile a body of seventy-seven representative major findings and group them in terms of their specific relevance to schizophrenia -- etiologies, pathophysiology, clinical manifestations, and treatments. We rate each such "fact" on a 0-3 scale for measures of reproducibility, whether primary to schizophrenia, and durability over time. We also pose one or more critical questions with reference to each "fact", answers to which might help better elucidate the meaning of that finding for our understanding of schizophrenia. We intend to follow this paper with the submission to the journal of a series of topic-specific articles, critically reviewing the evidence.