Estimated yield of early detection of prodromal or first episode patients by screening first degree relatives of schizophrenic patients

Understanding the schizophrenia prodrome

Schizophrenia is a neurodevelopmental disorder and its course is said to have an onset much before the presentation with psychotic symptoms. Even though the concept of prodrome in schizophrenia has been accepted, there is still an existence of a diagnostic dilemma. Various imaging studies and biomarkers have also been studied for confirmation of this diagnosis. The critical period of intervention when identified clarifies the doubts about faster and better outcomes.

Young people at risk for psychosis: case finding and sample characteristics of the Oulu Brain and Mind Study

AIM

Set within the general population-based Northern Finland Birth Cohort 1986, the Oulu Brain and Mind Study aims to explore the causes and pathogenesis of psychotic illness by following young people at risk for psychosis due to having a first-degree relative with psychotic illness or due to having experienced psychotic-like symptoms themselves. We report the study methods and explore the relationship between these definitions of high risk for psychosis and operational criteria for a prodromal psychosis syndrome based on interview.

METHODS

Prospectively collected data from earlier follow-ups of this cohort were combined with health register data to categorize subjects as those with familial risk (n = 272), symptomatic risk (n = 117), psychosis (n = 78), attention deficit hyperactivity disorder (ADHD) (n = 103) and a sample of controls (n = 193) drawn randomly from the remaining cohort. The Structured Interview for Prodromal Syndromes (SIPS) was applied to all, 295 participants together with questionnaires measuring psychosis vulnerability and schizotypal traits.

RESULTS

There were 29 (10%) current prodromal cases. Criteria for the current prodromal syndrome were fulfilled by 12% of the familial risk group and 19% of the symptomatic risk group, compared with 5% of the ADHD group and 4% of controls.

CONCLUSION

We successfully detected young people with a prodromal psychosis syndrome although relatively few subjects deemed to be at high risk met the full operational criteria according to the SIPS interview. Combining methods from familial, clinical and psychometric high-risk approaches provides a tractable method for studying risk of psychosis in the general population.

Diagnostic features of the cycloid psychoses in a first psychotic episode sample

INTRODUCTION

The cycloid psychoses have not been included in the modern classifications-what makes scientific research difficult. The aim of the present study is to investigate the presence and specific characteristics of the cycloid psychoses in a broad sample of first psychotic episodes.

METHODS

Seventy patients diagnosed with one-year first schizophrenia episode, schizophreniform disorder, or schizoaffective disorder were studied (mean age, 27.9 years old; SD±6.34). The detection of the possible cases of cycloid psychosis was done according to the Perris and Brockington operational criteria. Two groups of "cycloid" (n=11) and "non cycloid" (n=59) patients were compared according to demographic and clinical variables, and possible diagnostic variables were evaluated by the ROC curves.

RESULTS

Significant differences were found between cycloid and non cycloid groups for a number of clinical variables: prodromic symptoms (p<0.001), PANSS total score (p=0.003), PANSS-P (p=0.009), PANSS-GP (p=0.001), total score for mania by EVMAC (p=0.001), and CDSS for depression (p=0.004). ROC curves were significant for PANSS-GP (AUC=0.791, p=0.002), EVMAC (AUC=0.938, p=0.001), and CDSS (AUC=0.770, p=0.005). A sensitivity/specificity study demonstrated a negative predictive value for PANSS-GP (93.88%), EVMAC (96.30%), and CDSS (93.88%).

CONCLUSIONS

According to these results, cycloid psychoses might represent differentiated and well-defined clinical entity.

Early detection of psychosis: finding those at clinical high risk

AIM

In early detection work, recruiting individuals who meet the prodromal criteria is difficult. The aim of this paper was to describe the development of a research clinic for individuals who appear to be at risk of developing a psychosis and the process for educating the community and obtaining referrals.

METHODS

The outcome of all referrals to the clinic over a 4-year period was examined.

RESULTS

Following an ongoing education campaign that was over inclusive in order to aid recruitment, approximately 27% of all referrals met the criteria for being at clinical high risk of psychosis.

CONCLUSIONS

We are seeing only a small proportion of those in the community who eventually go on to develop a psychotic illness. This raises two important issues, namely how to remedy the situation, and second, the impact of this on current research in terms of sampling bias and generalizability of research findings.

The empirical status of the ultra high-risk (prodromal) research paradigm

Given the growth of prodromal research in the past 15 years, the time seems right for assessing whether the ultra high-risk (UHR) research paradigm has delivered on its promise as an approach to identification of individuals at risk for imminent onset of psychosis and as a platform for studies assessing protective benefits of early interventions and for elucidating predictive markers. As demonstrated by the 8 articles on this theme in the present issue, the empirical basis of the prodromal research area has advanced significantly. While there is a lower risk for transition to psychosis in recent studies compared with initial studies, most recent studies still show a 30%-35% risk for psychosis within 1-2 years of follow-up, a rate that is substantially higher than the incidence rate of psychosis among transition age youth in the general population. Moreover, the means with which to improve this predictive equation is rapidly developing, enabled by the collaborative integration of data across multiple sites, the employment of multivariate risk algorithms, and a longitudinal perspective on symptoms, cognition, and functioning. All the initial intervention studies have produced encouraging findings, albeit with small sample sizes and relatively large attrition rates. Nevertheless, the findings in this issue, together with others like them appearing at an increasing rate in the world literature, indicate that the prodromal research area is increasing in maturity and sophistication, providing a useful heuristic for early detection and intervention in those at risk for psychosis.

Metabolic abnormalities associated with second generation antipsychotics: fact or fiction? Development of guidelines for screening and monitoring

Epidemiological studies have demonstrated a relevant increased risk of diabetes in schizophrenic patients who are treated with many atypical antipsychotics, irrespective of concomitant weight gain. Numerous case reports and some large retrospective cohort studies have documented an increased risk of diabetes with some second-generation antipsychotics (SGAs), leading different authors to identify patients on SGA as another high-risk group for diabetes in their review articles. An American consensus conference dealing with this problem has proposed much awaited guidelines for the monitoring of patients on SGA and recommended acquiring additional data, especially from large-scale prospective studies. A more recent Belgian consensus on the screening and management of antipsychotic-related metabolic disturbances has proposed a more stringent approach. Here, we will cover the current diagnosis of metabolic problems, and provide a review of antipsychotic-related metabolic problems (diabetes, lipid abnormalities and the metabolic syndrome), as well as guidelines for the screening and management of metabolic abnormalities in people treated with antipsychotic medication.

ADHD and schizophrenia phenomenology: visual scanpaths to emotional faces as a potential psychophysiological marker?

Commonalities in the clinical phenomenology and psychopharmacology of ADHD and schizophrenia are reviewed. The potential of psychostimulants to produce psychotic symptoms emphasizes the need for objective psychophysiological distinctions between these disorders. Impaired emotion perception in both disorders is discussed. It is proposed that visual scanpaths to facial expressions of emotion might prove a potentially useful psychophysiological distinction between ADHD and schizophrenia. There is consistent evidence that both facial affect recognition and scanpaths to facial expressions are impaired in schizophrenia, with emerging empirical evidence showing that facial affect recognition is impaired in ADHD also. Brain imaging studies show reduced activity in the medial prefrontal and limbic (amygdala) brain regions required to process emotional faces in schizophrenia, but suggest more localized loss of activity in these regions in ADHD. As amygdala activity in particular has been linked to effective visual scanning of face stimuli, it is postulated that condition-specific breakdowns in these brain regions that subserve emotional behavior might manifest as distinct scanpath aberrations to facial expressions of emotion in schizophrenia and ADHD.

Psychosis: conceptual and ethical aspects of early diagnosis and intervention

PURPOSE OF REVIEW

Interest in the early identification and treatment of incipient first-episode psychosis is rapidly expanding. In the present review we discuss the major conceptual and ethical problem areas related to research and clinical work in detection and treatment of prepsychosis.

RECENT FINDINGS

The recent literature shows that conceptualization of early psychosis is often inconsistent and even misleading. Ethical discussions mostly concern 'false positives' risk assignments, stigmatization, informed consent and acceptability of treatment procedures.

SUMMARY

At present there is a lack of consensus regarding which concepts to use in describing prepsychosis in prospective studies, and new concepts are needed for prospective description of emergent psychosis.