The development, use, and reliability of the brief psychiatric rating scale (nursing modification)--an assessment procedure for the nursing team in clinical and research settings

Multivariate joint models for the dynamic prediction of psychosis in individuals with clinical high risk

This study attempted to construct and validate dynamic prediction via multivariate joint models and compare the prognostic performance of these models to both static and univariate joint models. Individuals with clinical high risk(CHR)(n = 289) were recruited and re-assessed for positive symptoms, general functions, and conversion to psychosis at 2-months, 1-year, and 2-years to develop the dynamic models. A multivariate joint model of positive psychotic symptoms was assessed using the Structured Interview for Prodromal Symptoms(SIPSp) and general function assessed by global assessment of functioning scores(GAFs) with time-to-conversion to psychosis. The area under the receiver operating characteristic(ROC) curve(AUC) was used to test the accuracy of the models. Among 298 CHR individuals, 68 converted to psychosis within 2 years after the initial assessments. Multivariate joint models showed that declining GAFs and increasing SIPSp corresponded to significant and trending to significantly increased risk of psychosis onset and had much higher prognostic accuracy (cross-validated AUC=0.9) compared to the static model(AUC=0.6) and univariate joint models(cross-validated AUC=0.6-0.8). Our results showed that multivariate joint models could be highly efficient in forecasting psychosis onset for CHR individuals. Longitudinal assessments for psychopathology and general functions can be useful for dynamically predicting the prognosis of the pre-morbid phase of psychosis.

Validity and reliability of the Persian version of Violence Risk Screening-10 Instrument (V-Risk-10) in admitted patients to the psychiatric ward

BACKGROUND

Violence Risk Screening Tool-10 (V-Risk-10) is one of the few instruments available for violence risk assessment in patients with a psychiatric diagnosis. The present study aimed to validate the Persian version of this instrument in patients admitted to the psychiatric ward.

MATERIALS AND METHODS

Eighty patients referred to a psychiatric hospital were enrolled in this cross-sectional methodological study. In the initial phase, seven senior psychiatry residents rated 20 cases independently at the time of their admission and total scale and subscale reliability were examined. Intraclass correlation coefficients were used to assess the inter-rater reliability. After initial confirmation of V-RISK-10 reliability, a senior psychiatry resident assessed 80 patients with V-RISK-10 in the emergency room. The incident of violent behaviors was recorded during the patients' admission period. The receiver operator characteristics curve (ROC-curve) analysis was used to measure the predictive accuracy of the instrument. The convergent validity was assessed by comparing V-RISK-10 scores between the three risk categories and the three outcome recommendations according to clinicians' overall clinical judgment.

RESULTS

A Cronbach's alpha coefficient was 0.99 for the total scale. During the research period, 47.5% of patients demonstrated various degrees of aggression and violent behavior. The ROC area under the curve was 0.89 (P < 0.001) with 87% sensitivity, 69% specificity, 72% positive predictive value, and 85% negative predictive value at the cutoff point of 8.5.

CONCLUSION

Results indicate that the Persian version of V-Risk-10 is a reliable and valid screening tool for violence risk in patients who are admitted into psychiatric wards.

Investigation of structural brain correlates of neurological soft signs in individuals at ultra-high risk for psychosis

Increased severity of neurological soft signs (NSS) in schizophrenia have been associated with abnormal brain morphology in cerebello-thalamo-cortical structures, but it is unclear whether similar structures underlie NSS prior to the onset of psychosis. The present study investigated the relationship between severity of NSS and grey matter volume (GMV) in individuals at ultra-high risk for psychosis (UHR) stratified for later conversion to psychosis. Structural T1-weighted MRI scans were obtained from 56 antipsychotic-naïve UHR individuals and 35 healthy controls (HC). The UHR individuals had follow-up data (mean follow-up: 5.2 years) to ascertain clinical outcome. Using whole-brain voxel-based morphometry, the relationship between NSS and GMV at baseline was assessed in UHR, HC, as well as individuals who later transitioned (UHR-P, n = 25) and did not transition (UHR-NP, n = 31) to psychosis. NSS total and subscale scores except motor coordination were significantly higher in UHR compared to HC. Higher signs were also found in UHR-P, but not UHR-NP. Total NSS was not associated with GMV in the whole sample or in each group. However, in UHR-P individuals, greater deficits in sensory integration was associated with lower GMV in the left cerebellum, right insula, and right middle frontal gyrus. In conclusion, NSS are present in UHR individuals, particularly those who later transitioned to a psychotic disorder. While these signs show little overall variation with GMV, the association of sensory integration deficits with lower GMV in UHR-P suggests that certain brain areas may be implicated in the development of specific neurological abnormalities in the psychosis prodrome.

Dynamic prediction systems of transition to psychosis using joint modelling: extensions to the base system

Seeking risk factors and constructing prediction models for transition to psychosis in individuals at ultra-high risk (UHR) has been an important research area. Our previous work showed that dynamic prediction could perform better than the conventional approach of using only baseline predictors in predicting transition to a psychotic disorder in UHR individuals. Dynamic prediction is the prediction of the occurrence of an event outcome using longitudinal data and has been made possible using a statistical methodology called joint modelling. The application of joint modelling and dynamic prediction in our previous work was relatively simple. In this paper, we examined extensions to our previous work in three ways: how to use the estimated changes in transition probability at repeated assessments over time to perform prediction, how to model the trajectory of the longitudinal data and how to model the relationship between the longitudinal data and the risk of transition to psychosis. Data from the Pace400 study (n = 398 UHR individuals), a follow-up study with transition to psychosis as the primary outcome, were used to investigate these extensions. Our results indicated that these extensions can enhance improvement in terms of model fit and sensitivity and specificity values. We have shown that dynamic prediction through joint modelling not only can utilize the richness of longitudinal data but also offers versatility in how prediction can be conducted. Our results have again confirmed that dynamic prediction via joint modelling should be considered as a useful tool for predicting transition to psychosis.

Dynamic prediction of transition to psychosis using joint modelling

Considerable research has been conducted seeking risk factors and constructing prediction models for transition to psychosis in individuals at ultra-high risk (UHR). Nearly all such research has only employed baseline predictors, i.e. data collected at the baseline time point, even though longitudinal data on relevant measures such as psychopathology have often been collected at various time points. Dynamic prediction, which is the updating of prediction at a post-baseline assessment using baseline and longitudinal data accumulated up to that assessment, has not been utilized in the UHR context. This study explored the use of dynamic prediction and determined if it could enhance the prediction of frank psychosis onset in UHR individuals. An emerging statistical methodology called joint modelling was used to implement the dynamic prediction. Data from the NEURAPRO study (n = 304 UHR individuals), an intervention study with transition to psychosis study as the primary outcome, were used to investigate dynamic predictors. Compared with the conventional approach of using only baseline predictors, dynamic prediction using joint modelling showed significantly better sensitivity, specificity and likelihood ratios. As dynamic prediction can provide an up-to-date prediction for each individual at each new assessment post entry, it can be a useful tool to help clinicians adjust their prognostic judgements based on the unfolding clinical symptomatology of the patients. This study has shown that a dynamic approach to psychosis prediction using joint modelling has the potential to aid clinicians in making decisions about the provision of timely and personalized treatment to patients concerned.

Long-term follow-up of all-cause and unnatural death in young people with first-episode psychosis

OBJECTIVE

To determine mortality-related estimates and causes of death in young people with first-episode psychosis (FEP), and to identify baseline predictors of mortality.

METHOD

Mortality outcomes in 723 young people presenting to an early psychosis service were prospectively ascertained up to 20 years. Predictors of all-cause and unnatural death were investigated using survival techniques.

RESULTS

Forty-nine participants died by study end. Most deaths (n=41) occurred within 10 years of service entry. All-cause mortality was 5.5% at 10 years, rising to 8.0% after 20 years. Unnatural death rates at 10 and 20 years were 5.0% and 5.9%, respectively. Three risk factors consistently predicted all-cause mortality and unnatural deaths.

CONCLUSION

A substantial proportion of excess mortality was due to non-suicide unnatural death, and, later, natural deaths. This suggests that mental health services should expand their current focus on suicide to incorporate strategies to prevent accidental death and promote healthier lifestyles.

Markers of vulnerability to obsessive-compulsive disorder in an ultra-high risk sample of patients who developed psychosis

AIMS

The study aims to identify markers of vulnerability to obsessive-compulsive disorder (OCD) in an ultra-high risk sample of patients who developed psychosis.

METHODS

Three hundred and eleven patients at ultra-high risk for psychosis were examined at baseline and after a mean of 7.4 years follow-up. Patients who developed psychosis with OCD (PSY + OCD; n = 13) and psychosis without OCD (PSY - OCD; n = 45) were compared in terms of socio-demographic and clinical features.

RESULTS

PSY + OCD patients displayed greater severity of depression before and after conversion to PSY + OCD, and increased rates of depressive disorders before exhibiting PSY + OCD. However, they only displayed greater severity of anxiety and increased rates of non-OCD anxiety disorders after psychosis. Further, PSY + OCD patients were more likely to report a positive family history for anxiety disorders than PSY - OCD.

CONCLUSION

Although depression and a family history of anxiety disorder may act as vulnerability markers for OCD in psychosis, the resulting anxiety may be a correlate or a consequence of PSY + OCD.

Predicting the development of schizophrenia in high-risk populations: systematic review of the predictive validity of prodromal criteria

BACKGROUND

There is a great deal of debate on the usefulness and accuracy of prodromal criteria in predicting schizophrenia. The risk of treating people who screen false positive with medication is considerable. Yet intervening during the prodromal stage of illness may reduce the burden caused by schizophrenia.

AIMS

To draw together the evidence base for the predictive validity of prodromal criteria in identifying individuals at high risk of developing schizophrenia.

METHOD

We conducted a systematic review of prospective studies investigating the predictive validity of prodromal criteria in schizophrenia.

RESULTS

Our study found two main criteria, ultra-high-risk criteria and basic-symptoms criteria, used in studies investigating the predictive validity of prodromal symptoms. The sensitivity and specificity of ultra-high-risk criteria was 0.81 (95% CI 0.76-0.85) and 0.67 (95% CI 0.64-0.70) respectively and for basic-symptoms criteria sensitivity and specificity was 0.97 (95% CI 0.91-1.00) and 0.59 (95% CI 0.48-0.70) respectively.

CONCLUSIONS

Both ultra-high-risk criteria and basic-symptoms criteria are useful in predicting the development of schizophrenia among high-risk populations.

A longitudinal study of obsessive-compulsive disorder in individuals at ultra-high risk for psychosis

BACKGROUND

We evaluated whether (1) a diagnosis of obsessive-compulsive disorder (OCD) at baseline, or (2) the persistence, remission or emergence of de novo OCD at follow-up, were associated with the development of different psychotic disorders in a cohort of individuals at ultra-high risk (UHR) for psychosis.

METHODS

Patients were assessed for OCD at baseline and after a mean of 7.4 years follow-up and classified into: (i) Non-OCD group - patients without OCD both at baseline and follow-up (n = 269; 86.2%), (ii) Incident OCD group - patients without OCD at baseline but with OCD at follow-up (n = 17; 5.4%), (iii) Remitting OCD group - patients with OCD at baseline but without OCD at follow-up (n = 20; 6.4%), (iv) Persistent OCD group - patients with OCD both at baseline and at follow-up (n = 6; 1.9%). Rates of different DSM-IV psychotic disorders at follow-up were compared across these groups.

RESULTS

Patients who displayed remitting OCD were not related to the development of any DSM-IV psychotic disorder. A diagnosis of incident OCD was associated with greater rates of psychotic disorders at follow-up, particularly mood disorders with psychotic features and psychotic disorders not otherwise specified (PDNOS), and greater baseline severity of general psychopathology, alogia, and avolition-apathy. Two of the six patients (40%) with persistent OCD developed schizophrenia, while only 12.5%, 5.0%, and 9.7% of incident, remitting, and non-OCD groups, respectively, exhibited the same condition at follow-up. Rates of antipsychotic use in the previous two years were not significantly different between the groups.

CONCLUSIONS

Our findings suggest that, in a cohort of individuals at UHR for psychosis, remission of OCD does not increase the risk of psychosis, while de novo OCD was associated with development of mood disorders with psychotic features and PDNOS.

Altered resting-state connectivity in subjects at ultra-high risk for psychosis: an fMRI study

Background

Individuals at ultra-high risk (UHR) for psychosis have self-disturbances and deficits in social cognition and functioning. Midline default network areas, including the medial prefrontal cortex and posterior cingulate cortex, are implicated in self-referential and social cognitive tasks. Thus, the neural substrates within the default mode network (DMN) have the potential to mediate self-referential and social cognitive information processing in UHR subjects.

Methods

This study utilized functional magnetic resonance imaging (fMRI) to investigate resting-state DMN and task-related network (TRN) functional connectivity in 19 UHR subjects and 20 matched healthy controls. The bilateral posterior cingulate cortex was selected as a seed region, and the intrinsic organization for all subjects was reconstructed on the basis of fMRI time series correlation.

Results

Default mode areas included the posterior/anterior cingulate cortices, the medial prefrontal cortex, the lateral parietal cortex, and the inferior temporal region. Task-related network areas included the dorsolateral prefrontal cortex, supplementary motor area, the inferior parietal lobule, and middle temporal cortex. Compared to healthy controls, UHR subjects exhibit hyperconnectivity within the default network regions and reduced anti-correlations (or negative correlations nearer to zero) between the posterior cingulate cortex and task-related areas.

Conclusions

These findings suggest that abnormal resting-state network activity may be related with the clinical features of UHR subjects. Neurodevelopmental and anatomical alterations of cortical midline structure might underlie altered intrinsic networks in UHR subjects.

Suicide attempt in first-episode psychosis: a 7.4 year follow-up study

BACKGROUND

Individuals with first-episode psychosis demonstrate high rates of suicide attempt (SA).

AIMS

1) To examine the prevalence of, and risk factors for, SA in a first-episode psychosis (FEP) cohort over a 7.4 year follow-up period. 2) To investigate differences between single versus multiple suicide attempters.

METHODS

This study reports baseline and follow-up data from a naturalistic, prospective follow-up of 413 FEP patients treated at a specialist early psychosis centre. Assessments were conducted at treatment entry, initial symptom remission or stabilization, and long term follow-up. Binary logistic regression models were used to assess unadjusted and adjusted associations between early illness and sociodemographic characteristics and two outcome measures: any SA during follow-up; and multiple SAs.

RESULTS

Follow-up data were available for 282 participants. Sixty-one (21.6%) made a suicide attempt over the follow-up period, including 12 successful suicides. The following baseline risk factors increased the risk of any SA: history of self-harm (OR=4.27; p<0.001), suicidal tendencies (OR=2.30; p=0.022), being depressed for >50% of the initial psychotic episode (OR=2.49; p=0.045), and hopelessness (OR=2.03; p=0.030). History of problem alcohol use increased the risk of multiple SAs (OR=4.43; 95% CI (1.05-18.7); p=0.043).

DISCUSSION

The prevalence of suicide attempt in this study exceeds reports from short-term FEP studies but is comparable to longer term follow-up studies, indicating that risk remains elevated for at least 7 years following commencement of treatment. The key predictor of future suicide attempt was previous self-harm, indicating that interventions for self-harm are required.

Anatomic abnormalities of the anterior cingulate cortex before psychosis onset: an MRI study of ultra-high-risk individuals

BACKGROUND

Abnormalities of the anterior cingulate cortex (ACC) are frequently implicated in the pathophysiology of psychotic disorders, but whether such changes are apparent before psychosis onset remains unclear. In this study, we characterized prepsychotic ACC abnormalities in a sample of individuals at ultra-high-risk (UHR) for psychosis.

METHODS

Participants underwent baseline magnetic resonance imaging and were followed-up over 12-24 months to ascertain diagnostic outcomes. Baseline ACC morphometry was then compared between UHR individuals who developed psychosis (UHR-P; n = 35), those who did not (UHR-NP; n = 35), and healthy control subjects (n = 33).

RESULTS

Relative to control subjects, UHR-P individuals displayed bilateral thinning of a rostral paralimbic ACC region that was negatively correlated with negative symptoms, whereas UHR-NP individuals displayed a relative thickening of dorsal and rostral limbic areas that was correlated with anxiety ratings. Baseline ACC differences between the two UHR groups predicted time to psychosis onset, independently of symptomatology. Subdiagnostic comparisons revealed that changes in the UHR-P group were driven by individuals subsequently diagnosed with a schizophrenia spectrum psychosis.

CONCLUSIONS

These findings indicate that anatomic abnormalities of the ACC precede psychosis onset and that baseline ACC differences distinguish between UHR individuals who do and do not subsequently develop frank psychosis. They also indicate that prepsychotic changes are relatively specific to individuals who develop a schizophrenia spectrum disorder, suggesting they may represent a diagnostically specific risk marker.

Prospective outcome of early intervention for individuals at ultra-high-risk for psychosis

AIM

Based on previous reports of second-generation antipsychotic agents having a beneficial effect on prodromal symptoms, we investigated the effectiveness and tolerability of atypical antipsychotic therapies in individuals at high risk for developing psychosis.

METHODS

We examined prodromal symptoms and functioning in individuals at ultra-high-risk for psychosis using an uncontrolled prospective design with pre- and post-treatment measures.

RESULTS

Of the 27 subjects taking antipsychotics during the study period, 15 took part in at least one follow-up assessment. Overall Comprehensive Assessment of At-Risk Mental States scores significantly improved at the last evaluation point, with a medium-size effect of Cohen's d = 0.54 (95% confidence interval, -0.02 to 1.08) (mean follow-up period = 8.8; SD = 8.3 months). Depression and anxiety symptoms were markedly reduced, and global and social functioning also significantly improved. Of the 27 subjects, two (7.4%) converted to psychosis and 16 (59.3%) experienced at least one treatment-emergent adverse event, but no subjects exhibited serious adverse events.

CONCLUSIONS

The results of this study support treating high-risk individuals with antipsychotics to reduce prodromal symptoms with adequate safety.

Social functioning deficits in young people at risk for schizophrenia

OBJECTIVE

Impairment in social functioning is a central feature of schizophrenia and is known to be evident before the onset of psychosis, acting as a potential vulnerability marker. The aim of the present study was to test the hypothesis that social impairment is simultaneously a state and trait marker of risk for schizophrenia and schizophrenia-related disorder.

METHOD

Social functioning was examined in three groups: ultra-high-risk subjects (UHR, n =32), genetic high-risk subjects (GHR, n =32), and age- and IQ-matched healthy controls (HC, n =30). Social functioning was assessed using the Social Functioning Scale (SFS), and prodromal symptoms were assessed in high-risk subjects using the Comprehensive Assessment of At-Risk Mental States (CAARMS).

RESULTS

Both the UHR and GHR groups exhibited significantly impaired social functioning compared with the HC group, and the UHR group was more impaired than the GHR group. In the UHR group, duration of prodromal symptoms was related to impaired 'interpersonal behaviour'. Positive and negative symptoms were not significantly associated with social functioning, whereas disorganized and general symptoms were significantly correlated with poor 'independence-competence' in UHR individuals.

CONCLUSION

The findings support the hypothesis that impairment in social functioning is both a trait and state marker of risk for schizophrenia and other psychotic disorders, implying that social impairment constitutes a mediating vulnerability indicator of psychotic disorders including schizophrenia.

Symptom rating scales and outcome in schizophrenia

BACKGROUND

Symptom rating scales are now well established in schizophrenia research but their scores are not the same as outcome.

AIMS

To appraise the usefulness of symptom rating scales in evaluating the outcome of people with schizophrenia.

METHOD

Literature on the use of the Brief Psychiatric Rating Scale (BPRS) the Positive and Negative Syndrome Scale (PANSS) and the Clinical Global Impression (CGI) in schizophrenia research was studied.

RESULTS

Scales were designed to make diagnoses, to categorise patients, syndromes or both, and to demonstrate antipsychotic efficacy, as well as to measure outcome. There is much redundancy both between and within scales. Early work suggests limited concurrent validity with external outcome variables. Data are at best ordinal and there are particular difficulties in equating outcome with percentage changes in scores. The concept of remission, which uses absolute item score thresholds with a duration criterion, is a promising outcome measure.

CONCLUSIONS

Symptom rating scale scores can only comprise a limited part of outcome measurement. Standardised remission criteria may present advantages in outcome research.

Schizophrenia: measurements of psychopathology

A key problem in schizophrenia research is how to assess the effects of treatment interventions given the spectrum of schizophrenia symptoms and patients' functioning. Measuring symptoms is complex, because these symptoms cover a wide variety of psychopathologic domains. The commonly recognized domains are the positive, negative, cognitive, excitement, and depression domains. This article critically reviews some of the available assessment tools of these domains together with other associated syndromes. The instruments discussed cover the broad range of psychopathology found in patients who have schizophrenia.

Symptomatic and functional outcome 12 months after a first episode of psychotic mania: barriers to recovery in a catchment area sample

OBJECTIVE

Recent studies have shown that outcome in mania is worse than previously thought. Such studies have been conducted in selected samples with restrictive measures of outcome. We aimed to explore outcome and its predictors in a catchment area sample of first-episode psychotic mania of DSM-III-R bipolar I disorder.

METHODS

Prospective 6 and 12 months follow-up was conducted with 87 DSM-III-R first-episode psychotic mania patients admitted to Early Psychosis Prevention and Intervention Centre between 1989 and 1997. Syndromic and symptomatic outcome were determined with the Brief Psychiatric Rating Scale; functional outcome with the Quality of Life Scale and Premorbid Adjustment Scale subitems.

RESULTS

Symptomatic outcome was assessed in 67 patients at 6 months and 61 patients at 12 months, and functional outcome in 56 patients at 6 months and 49 patients at 12 months. Logistic regressions were conducted on 46 and 43 patients, respectively, to explore predictors of outcome. While 90% of patients achieved syndromic recovery at 6 and 12 months, 40% had not recovered symptomatically at 6 and 12 months, still presenting with anxiety or depression. A total of 66% of patients at 6 months and 61% of patients at 12 months failed to return to previous level of functioning. Age at intake, family history of affective disorder, illicit drug use and functional recovery at 6 months predicted functional outcome at 12 months.

CONCLUSIONS

This study confirms poor symptomatic and functional outcome after first-episode psychotic mania. It suggests possible usefulness of early intervention strategies in bipolar disorders and need for developing specific interventions addressing anxiety, depression and substance abuse comorbidity.

Prospective investigations of the prodromal state of schizophrenia: review of studies

OBJECTIVE

The paper presents a comprehensive overview of prospective studies monitoring or intervening in the pre-onset phase of first episode psychosis.

METHOD

A systematic literature search was conducted and supplemented by a manual search. All relevant studies were ordered and intensively reviewed according to specified criteria. Methodological and conceptual issues are discussed.

RESULTS

Reports of 23 prospective studies were found, some describing subsamples of larger samples. Major methodological and conceptual divergences exist.

CONCLUSION

Applied criteria detect individuals with a significantly increased risk of psychosis within the schizophrenia spectrum, but these criteria are only validated on clinical populations. The significance of differences in sample-characteristics is unclear. Most study samples are small. Results are preliminary and in need of further research before they constitute a realistic knowledge base. Methodological and conceptual issues should not be underestimated.

Schneiderian first rank symptoms predict poor outcome within first episode manic psychosis

BACKGROUND

The validity of a sub-classification of affective psychosis according to the mood congruence of psychotic features has been questioned in the literature. While some authors have found a correlation between such symptoms and outcome, their predictive value was rather limited in these studies.

METHOD

Prospective study of 108 subjects presenting with a first DSM-III-R manic episode with psychotic features to determine the frequency of different types of psychotic symptoms and to measure the predictive utility of mood incongruent psychotic symptoms (MIPS) and first-rank Schneiderian symptoms (FRSS) during the first episode for a 12-month outcome. Outcome was measured by the level of positive, negative, depressive symptoms, and psychosocial functioning. Duration of affective and psychotic symptoms was also assessed.

RESULTS

Patients presented with a wide variety of psychotic symptoms. The presence of MIPS at baseline was significantly correlated with a longer persistence of psychotic symptoms, but not with poorer outcome at 12 months. By contrast, the presence of FRSS at baseline was significantly associated with earlier onset of psychosis as well as increased severity of negative symptoms and poorer psychosocial functioning after 12 months.

CONCLUSION

The presence of FRSS during a first manic episode with psychotic features identifies a sub-group of patients with more severe presentation and poorer short-term outcome. These results question the prognostic utility of MIPS.

LIMITATIONS

Despite the relatively large number of subjects compared with other studies, the statistical power to detect all but large effect sizes is limited by the sample size.

Risk factors for psychosis in an ultra high-risk group: psychopathology and clinical features

The identification of individuals at high risk of developing a psychotic disorder has long been a goal of clinicians because it is thought that early treatment of this group may prevent onset of the disorder. However, little is known of predictive factors of psychosis, even within a high-risk group. This study followed up 104 young people thought to be at 'ultra high risk' for schizophrenia and other psychotic disorders by virtue of having a family history of psychotic disorder combined with some functional decline or the presence of subthreshold or self-limiting psychotic symptoms. All subjects were therefore symptomatic, but not psychotic, at intake. Thirty-six subjects (34.6%) developed frank psychotic symptoms within 12 months. Measures of symptom duration, functioning, disability and psychopathology were made at intake, 6 and 12 months. Poor functioning, long duration of symptoms, high levels of depression and reduced attention were all predictors of psychosis. A combination of family history of psychosis, a recent significant decrease in functioning and recent experience of subthreshold psychotic symptoms was also predictive of psychosis. Combining highly predictive variables yielded a method of psychosis prediction at 12 months with good positive predictive value (80.8%), negative predictive value (81.8%) and specificity (92.6%) and moderate sensitivity (60.0%). Within our symptomatic high-risk group, therefore, it appears possible to identify those individuals who are at particularly high risk of developing a psychotic disorder such as schizophrenia. Given the very high PPV and low false positive rate with this two-step process, it may be justifiable to target these individuals for intensive monitoring of mental state and even low-dose neuroleptic medication or other biological and psychosocial treatments depending on clinical condition. This indicated prevention approach could be further developed and preventive strategies in the psychoses refined.

Outcome measurement in pharmacological trials: validity of the Routine Assessment of Patient Progress (RAPP)

The assessment of outcomes after treatment with antipsychotic medication is fundamental to clinical care and research. The Routine Assessment of Patient Progress (RAPP) is a reliable multidimensional scale that employs nurses' ratings of symptoms and functioning in psychiatric inpatients. The present study sought to extend validity evidence for the RAPP by examining its ability to reflect changes associated with treatment by antipsychotic medications. The use of a different sample in this study also provided the opportunity to replicate earlier validity data collected on the original set of patients. Ninety-seven separate trials were conducted, involving 65 consecutive admissions to a unit that specializes in the assessment and treatment of patients with long standing severe psychiatric disorders. The RAPP, along with the Positive and Negative Syndrome Scale and global measures of severity, were administered at baseline and at the end of each trial. Both factor scores and clinically-derived subscales were analysed for sensitivity to change. Patients were globally rated as improved, unchanged or worsened at the end of the medication trial. Results indicated that the RAPP factor, clinical scale and total scores compared favourably to other outcome measures in patients rated as improved or worse. In patients rated as unchanged, RAPP scores displayed significantly less change than did the PANSS scores. These findings support the validity of the RAPP as an outcome measure in treatment trials.

Recovery style and outcome in first-episode psychosis

Our study aimed to investigate how recovery styles influence 12-month clinical outcome in first-episode psychosis patients. We hypothesised that patients who use an integrative recovery style would have better outcome than those who seal over. A total of 196 first-episode psychosis patients from the Early Psychosis Intervention Centre (EPPIC) participated in the study. Each patient was interviewed at stabilization of their acute psychotic episode, and then again 12 months later, using an Integration/Sealing-over measure. Our results suggest that recovery style may be a useful predictor of outcome. Integrative patients had better outcome and functioning at 12 months. These results were influenced by diagnosis and, unlike previous studies, recovery style changed over time, suggesting it was not a stable trait. The capacity for recovery style to change challenges the suggestion it is a personality trait and raises the need for psychoeducation and other psychological interventions that could improve outcome.

Psychosis prediction: 12-month follow up of a high-risk ("prodromal") group

Intervention in the prodromal phase of schizophrenia and related psychoses may result in attenuation, delay or even prevention of the onset of psychosis in some individuals. However, a "prodrome" is difficult to recognise prospectively because of its nonspecific symptoms. This study set out to recruit and follow up subjects at high risk of transition to psychosis with the aim of examining the predictive power for psychosis onset of certain mental state and illness variables.Symptomatic individuals with either a family history of psychotic disorder, schizotypal personality disorder, subthreshold psychotic symptoms or brief transient psychotic symptoms were assessed and followed up monthly for 12 months or until psychosis onset. Twenty of 49 subjects (40.8%) developed a psychotic disorder within 12 months. Some highly significant predictors of psychosis were found: long duration of prodromal symptoms, poor functioning at intake, low-grade psychotic symptoms, depression and disorganization. Combining some predictive variables yielded a strategy for psychosis prediction with good sensitivity (86%), specificity (91%) positive predictive value (80%) and negative predictive value (94%) within 6 months. This study illustrates that it is possible to recruit and follow up individuals at ultra high risk of developing psychosis within a relatively brief follow-up period. Despite low numbers some highly significant predictors of psychosis were found. The findings support the development of more specific preventive strategies targeting the prodromal phase for some individuals at ultra high risk of schizophrenia.

Validation of the Routine Assessment of Patient Progress (RAPP) in patients with psychosis in South India

The aim of the study was to validate the Routine Assessment of Patient Progress (RAPP), an instrument for assessment by nurses, among patients with psychosis in South India. One hundred consecutive patients with psychosis admitted to the Department of Psychiatry, Christian Medical College, Vellore, India, were assessed on day five and day 19 using the RAPP, the PANSS, and the CGI scales. The correlation of the RAPP with the other scales, its change over time, the inter-rater reliability, and factor structure were assessed. The subscales of RAPP correlated significantly with those of the other scales at intake and at follow-up. The RAPP scores changed significantly after treatment. Its inter-rater reliability as measured by the intra-class correlation coefficient was 0.98. The Cronbach's alpha, used to measure the internal consistency of the scale, was 0.87. The split-half reliability (Spearman-Brown) was 0.89. Principal component analysis with varimax rotation revealed six factors, which explained 67.4% of the variance. Items related to life skills explained a major proportion of the variance. The good psychometric properties, concurrent validity, high inter-rater reliability and sensitivity to change make it a useful instrument for nurses to employ to assess patients with psychoses.

Prediction and prevention of transition to psychosis in young people at incipient risk for schizophrenia

The treatment of psychotic disorders, particularly schizophrenia, had been viewed with pessimism until a recent shift in focus from established or chronic illness to earlier phases of illness around the onset highlighted opportunities for enhanced recovery. Associated with this change in focus of research and clinical efforts has been the recognition that the biological and social changes underpinning the development of psychotic disorders may already be active in the pre-psychotic or prodromal phase. It has therefore been suggested that efforts toward the prevention of psychotic disorders should focus on the emerging illness. This article provides a review of work that has been conducted at the PACE Clinic in Melbourne, Australia since 1994. This clinical research program was established to develop strategies for the identification of young people at high risk of developing a psychotic disorder within a short period of time- primarily by virtue of recent mental state changes. Additionally, biological and psychological processes that have been proposed to underlie the development of illness have been investigated and potential preventive interventions have been evaluated.

Cannabis use is not associated with the development of psychosis in an 'ultra' high-risk group

BACKGROUND

The association between cannabis use and the development of a first psychotic episode was studied in a group of 100 young people identified as being at very high risk for the onset of psychosis.

METHOD

The 'ultra' high risk cohort was identified by the presence of subthreshold psychotic symptoms, or a combination of first-degree relative with a psychotic disorder and recent functional decline. Thirty-two per cent of the cohort developed an acute psychotic episode over the 12-month period after recruitment. As a component of a larger research study, the level of cannabis use by participants in the year prior to enrollment in the study was assessed at intake.

RESULTS

Cannabis use or dependence in the year prior to recruitment to this study was not associated with a heightened risk of developing psychosis over the following 12-month period and therefore did not appear to contribute to the onset of a psychotic disorder.

CONCLUSION

The results of this study suggest that cannabis use may not play an integral role in the development of psychosis in a high-risk group. While this study does not support a role for cannabis in the development of first-episode psychosis, we cannot conclude that cannabis use should be completely ignored as a candidate risk factor for onset of psychosis. A number of weaknesses of the study (the low level of cannabis use in the current sample, the lack of monitoring of cannabis use after intake) suggest that it may be premature to dismiss cannabis use as a risk factor for the development of psychosis and further research is urged in this area.

The PACE Clinic: identification and management of young people at "ultra" high risk of psychosis

Over the past decade, both clinical and research interest in the early stages of psychotic disorders has grown. This has been associated with research suggesting that early intervention in these disorders may limit their impact on the life of the affected individual and his or her family. It has also been recognized that the biological and psychological changes underpinning the development of psychotic disorders may already be active in the prepsychotic or prodromal phase. It has been suggested that efforts to prevent psychotic disorders should be focused on this phase of emerging illness. In this article, the authors review work conducted at the PACE Clinic in Melbourne, Australia since 1994. This clinical research program was established to develop strategies for identifying young people at high risk for developing a psychotic disorder within a short period. The program has also investigated biological and psychological processes thought to underlie the development of psychosis and evaluated potential preventive interventions.

Substance abuse among patients with schizophrenia

Substance use in the general population is a significant public health problem. Problems associated with substance use are aggravated by concomitant psychiatric illness, particularly schizophrenia and schizoaffective disorder. Although there is a general agreement on the need to address this problem, a wide range of opinions exists on exactly what is the best modality. In this article, we provide a brief overview of the etiology and consequences of substance use in individuals with schizophrenia, followed by a more detailed review of pharmacological and psychotherapeutic trends in the treatment of this population. Research studies indicate that, while some evidence supports the self-medication hypothesis, individuals with schizophrenia or schizoaffective disorder frequently use substances for the same reasons and in the same manner as the general population. In the pharmacotherapy section, we briefly discuss the rationale for current medication strategies, their efficacy, and directions for future research. This is followed by an assessment of current psychotherapeutic interventions, their limitations, and potential modifications to improve treatment outcome. The research literature suggests that integrated treatment and well-tailored interventions that take into account psychosocial factors and motivation offer the most promise for the future. More controlled trials are necessary to validate this hypothesis.

A structured interview guide increases Brief Psychiatric Rating Scale reliability in raters with low clinical experience

OBJECTIVE

To assess the beneficial impact of a structured interview on the reliability of BPRS ratings in raters with low clinical experience.

METHOD

Each patient was rated once a week in two separate interviews, conducted on the same day. The first interview was conducted by a rater with low clinical experience (recruited from a group of five residents in psychiatry and one clinical psychologist in training). All second interviews were conducted by the same highly experienced psychiatrist.

RESULTS

The number of items with full agreement between observers increased with the use of SIG. The value of intraclass correlation coefficients for individual items and the total score also increased, approaching reported studies with experienced raters.

CONCLUSION

These results suggest that the use of SIG reduces variability of information gathering in reliability testing of BPRS with less experienced raters.

A Nurse's Guide to Mental Health: Assessment Reference Sources

1. As the research base on psychological testing has proliferated across various disciplines, a comprehensive review of the testing literature is recommended. 2. In researching literature on psychological tests, nurses need to rely on traditional print as well as electronic databases and Internet sites. 3. In reviewing test items or in using a test, nurses need to be aware of test-user qualifications and publisher copyright restrictions.

Enduring negative symptoms in first-episode psychosis: comparison of six methods using follow-up data

Targeted intervention in the early treatment of enduring positive and negative symptoms in first-episode psychosis is contingent on adequate case-identification procedures. Six methods of determining enduring negative symptoms in a sample of 238 individuals with first-episode psychosis who were assessed at three time points over a 12-month period are described. Results were examined at each of the seven combinations of follow-up points, revealing a highly fluid pattern. The percentage of the sample achieving caseness varied dramatically, depending on the method used. Compared with non-cases, the enduring negative symptom group had significantly lower scores on quality of life, poorer premorbid adjustment, and longer durations of prodrome and untreated psychosis. Notwithstanding the 'ebb and flow' of negative symptoms in first-episode psychosis, the results suggest that early identification of enduring negative symptoms is a feasible goal.

Duration of untreated psychosis and 12-month outcome in first-episode psychosis: the impact of treatment approach

OBJECTIVE

Early intervention research is examining whether reducing the duration of untreated psychosis (DUP) leads to improved outcome from first-episode psychosis. Another key influence may be the quality of treatment after initiation of care. This study examined the effect of phase-specific treatment on 12-month outcome for different categories of DUP.

METHOD

A total of 250 first-episode psychosis cases were followed up 12 months after stabilization. The sample consisted of two historically sequential cohorts treated in the same region within different service models, one of which was more intensive and phase-specific. Outcome was compared according to four predefined categories of DUP.

RESULTS

Only patients with a mid-range DUP of 1-6 months who were treated within the phase-specific model experienced significantly better outcomes than patients treated within the previous model.

CONCLUSION

These data suggest that there may be a limited window of opportunity in which to influence outcome. However, the complexity of this relationship is emphasized.

Perceived social support and community adaptation in schizophrenia

Prompted by the continuing transition to community care, mental health nurses are considering the role of social support in community adaptation. This article demonstrates the importance of distinguishing between kinds of social support and presents findings from the first round data of a longitudinal study of community adaptation in 156 people with schizophrenia conducted in Brisbane, Australia. All clients were interviewed using the relevant subscales of the Diagnostic Interview Schedule to confirm a primary diagnosis of schizophrenia. The study set out to investigate the relationship between community adaptation and social support. Community adaptation was measured with the Brief Psychiatric Rating Scale (BPRS), the Life Skills Profile (LSP) and measures of dissatisfaction with life and problems in daily living developed by the authors. Social support was measured with the Arizona Social Support Interview Schedule (ASSIS). The BPRS and ASSIS were incorporated into a client interview conducted by trained interviewers. The LSP was completed on each client by an informal carer (parent, relative or friend) or a professional carer (case manager or other health professional) nominated by the client. Hierarchical regression analysis was used to examine the relationship between community adaptation and four sets of social support variables. Given the order in which variables were entered in regression equations, a set of perceived social support variables was found to account for the largest unique variance of four measures of community adaptation in 96 people with schizophrenia for whom complete data are available from the first round of the three-wave longitudinal study. A set of the subjective experiences of the clients accounted for the largest unique variance in measures of symptomatology, life skills, dissatisfaction with life, and problems in daily living. Sets of community support, household support and functional variables accounted for less variance. Implications for mental health nursing practice are considered.

Neuropsychological correlates of positive vs. negative schizophrenic symptomatology

This study attempts to further the validity of the subtype hypothesis in schizophrenia by testing the relationship of neuropsychological functions in schizophrenics with predominantly positive vs. negative symptoms. The Brief Psychiatric Rating Scale (BPRS) was used to parse schizophrenics into positive and negative symptom groups, while a neuropsychological test battery was administered to both types of patients. The results indicate that positive schizophrenic symptomatology is related to frontal executive tasks, whereas negative schizophrenic symptomatology is related to mental tracking tasks that require motoric and dexterous manipulation. However, the absence of non-overlapping symptomatic and neuropsychological functioning groups raises the possibility that a three or more factor model may be more reasonable for reflecting the variety of symptom and neuropsychological patterns in patients, rather than the two-type positive vs. negative dichotomy. The results further the hypothesis that schizophrenia is not a single disease entity.

Routine assessment of patient progress: a multiformat, change-sensitive nurses' instrument for assessing psychotic inpatients

A new instrument, the Routine Assessment of Patient Progress (RAPP), is a standardized scale with a unique format that allows trained nurses to incorporate both interview and observational data into a comprehensive assessment of psychiatric inpatients. The scale was developed to accurately document treatment effects, assist in treatment planning, and provide ancillary judgments of psychopathology that may affect diagnosis. The RAPP demonstrates satisfactory interrater reliability and internal consistency. The RAPP total score and its two subscales correlated highly, where expected, with an observation-based nursing scale, global measures, and an interview-based psychopathology scale. RAPP scores demonstrated sensitivity to change over time in patient functioning. It reliably discriminated among patients discharged to settings with varying degrees of independent living. The use of the RAPP over several years on a psychiatric inpatient unit has shown it to be a practical clinical tool that eases nurses' charting demands, helps create care plans, and facilitates interdisciplinary communication.

Initial experiences with clozapine at Kenmore Psychiatric Hospital

OBJECTIVE

To replicate overseas experience with clozapine, a new antipsychotic drug reputed to be effective in producing major improvement in a high proportion of patients with treatment-resistant schizophrenia.

DESIGN AND SETTING

A prospective clinical trial at Kenmore Psychiatric Hospital, Goulburn, NSW. This paper is a preliminary communication covering 14 to 18 weeks after commencement of clozapine.

PATIENTS

Twelve patients with treatment-refractory chronic schizophrenia, chosen on the basis of the severity of their disability.

INTERVENTION

After existing medication was changed to be compatible with clozapine, it was reduced to the minimum level acceptable for staff and patient safety. Clozapine was then introduced gradually while other medication was withdrawn.

OUTCOME MEASURES

Progress was monitored in terms of clinical presentation, side effects, use of supplementary medication and assessments by means of three standardised scaling systems.

RESULTS

None of the patients deteriorated. Of six patients aged 35 years or less, three showed dramatic improvement and three showed clinically significant improvement. None of the six older patients showed major improvement, except that extrapyramidal symptoms were reduced in all cases. Drowsiness and hypersalivation were the only common side effects.

CONCLUSIONS

These preliminary findings are consistent with results reported overseas.

Positive and negative symptoms in the psychoses: principal components analysis of items from the Scale for the Assessment of Positive Symptoms and the Scale for the Assessment of Negative Symptoms

The present study investigated the factor structure of the items contained in Andreasen's scales for the assessment of positive and negative symptoms (SAPS and SANS) by use of a series of principal components analyses (PCAs) with oblique rotations of the axes. It was found that the structure could be summarized by three major components labeled negative symptoms, thought disorder, and delusions/hallucinations. Dimensionality could meaningfully be increased to five components. Negative symptoms was found to separate into two components that we labeled negative signs and social dysfunctions. The delusions/hallucinations factor could be separated into two components, delusions and hallucinations, with "loss of boundary" delusions being related to both factors. Delusions of persecution were independent of other symptoms. The thought disorder factor did not decompose meaningfully within the investigated dimensionality. A two-factor solution did not explain the correlation between symptoms adequately. The results do not support the simple dichotomy between positive and negative symptoms in psychosis, but suggest that a wider dimensional concept may be more useful in future studies.

Assessment of contributions to disability in people with schizophrenia during rehabilitation

The aim of this study was to assess a number of the components of disability in patients diagnosed with DSM-IIIR residual schizophrenia. Forty-one patients undergoing hospital and community rehabilitation programs were tested. A range of disability levels was defined with a measure of global assessment of function. A large proportion of the patients also had poor results on frontal lobe testing, persistent positive symptoms, and high levels of emotional distress. There was a trend for higher levels of positive symptoms to be associated with increases in global levels of disability, frontal lobe impairment and emotional distress. The work suggests that rehabilitation programs could be more focused if patients were assessed not only for their overall level of functional disability but also for the level of treatment resistant positive symptoms, frontal lobe impairment and the amount and type of emotional distress and insight.

Use of the Brief Psychiatric Rating Scale by Nurses

1. Nurses are intimately involved in the assessment of patients in inpatient clinical settings and in community settings--and nurses have a role to play in the systematic rating of severe psychopathology. 2. The Brief Psychiatric Rating Scale (BPRS) provides a means of assessing mental health status from an interview using 16 rating concepts. Analysis of BPRS rating profiles obtained from a variety of patients and settings have consistently revealed four syndromes: withdrawal-retardation, anxious depression, hostile-suspiciousness, and thinking disturbance. 3. Once properly trained regarding the BPRS, nurses can use the scale effectively in the assessment and ongoing monitoring of patient conditions. The scale is an added tool for nurses to use in monitoring the effectiveness and outcome of both medical and nursing interventions.

Symptomatic response to antipsychotics differs between recent onset and recurrent chronic schizophrenic patients

The symptomatic response to standard antipsychotic treatment was assessed over the first 4 weeks of hospitalisation in 39 patients with DSM-III schizophrenia, active phase, using the Brief Psychiatric Rating Scale (BPRS). While highly significant improvement was noted overall, 36% of patients either did not improve or worsened. Furthermore there was no diminution in the withdrawal-retardation factor of the BPRS. Patients experiencing their first admission to hospital, all with recent-onset illness, were then compared with patients who presented with a recurrence and had illness of at least 3 years duration. Despite similarities in overall response, withdrawal-retardation scores did not diminish in recent-onset patients, in contrast to multiple admissions who demonstrated significant improvement. These findings suggest greater responsiveness of negative symptoms to treatment in patients with longstanding illness, and possibly a poorer prognosis in first admission patients with deficit manifestations.

Origins and establishment of the schizophrenia research programme at Royal Park Psychiatric Hospital

This paper documents the initial phase of a new research direction which began in 1984 at Royal Park Hospital. Attention is focussed on the place of the university and the research institute in the psychiatric hospital and on the perceived need for concerted research on the major psychoses in Australia. The focal point of the Royal Park research programme, the Aubrey Lewis Clinical Research Unit, has been open since October 1984. The development of the unit's research activities during the initial few years of its existence required an awareness of specific scientific, administrative and political issues. These are discussed in detail in order to convey something of the process, as well as the content of such development, and in an attempt to provide some assistance to others undertaking similar developments.